Genital herpes counselling tool

Introduction

Genital herpes is caused by herpes simplex virus (HSV). It is a chronic viral infection that occurs frequently among sexually active individuals. The diagnosis can trigger significant psychological, social, relationship and sexual distress for those affected. Adjusting to having genital herpes is key to managing the infection successfully and reducing the risk of transmission.^{Footnote 1Footnote 2} Both the management of the infection and the counselling messages given to an individual will be informed by the type of genital herpes he or she may have — either HSV-1 or HSV-2, or both. Ideally, a clinical diagnosis of HSV would be confirmed by type-specific laboratory testing (e.g., viral culture or nucleic acid amplification test [NAAT]).^{Footnote 3Footnote 4Footnote 5} Type-specific serology may be useful under certain circumstances, but because those results are an indirect marker of HSV infection, they are more complex to interpret than a positive viral identification test.

Research attests to the value of counselling for those diagnosed with a sexually transmitted infection (STI) in relieving their distress, helping them manage the infection and reducing the risk of transmission.^{Footnote 6Footnote 7Footnote 8} Therefore, providing supportive counselling to help affected individuals understand and cope with the infection is a pivotal role for practitioners in any practice setting.^{Footnote 2Footnote 9Footnote 10}

This tool aims to enhance practitioner comfort and skills in providing counselling to individuals diagnosed with genital herpes. It is complementary to the Genital herpes simplex virus (HSV) Infections chapter of the Canadian Guidelines on Sexually Transmitted Infections.

Impact of a genital herpes diagnosis

As a practitioner, you may encounter a variety of responses from individuals who receive a genital herpes diagnosis, ranging from indifference to devastation. Some may display strong emotions and anxiety due to how they perceive the infection and the stigma associated with it.

Common psychological, social and sexual distress reactions may include:

• shame, guilt, anger
• fear of ongoing transmission
• anxiety over impact on fertility/childbearing
• depression, low self-esteem and resulting isolation
• fear of being judged, stigmatized, rejected by partners
• confusion, denial (especially with atypical presentation)
• inability to disclose genital herpes status resulting in concealment

These emotional sequelae may deter individuals from seeking further care, disclosing their status to sexual partners, or even engaging fully in their everyday lives. For example, low self-esteem may decrease the feeling of desirability and adversely affects romantic and sexual relationships. Some feel they are no longer appealing or worthy of a loving relationship as a result of having the infection.^{Footnote 1Footnote 11Footnote 12}

The goal of supportive counselling is to help individuals:

• understand the infection, including its frequency and manage outbreaks
• understand options for treatment
• deal with psychosocial issues they associate with having genital herpes
• access resources for ongoing information and support
• disclose and discuss their infection with their sexual partners
• know how to reduce the risk of transmission and prevent neonatal herpes
• understand the psychosocial and behavioral risk factors for STBBIs

Approach to counselling

The counselling tool provides practitioners with best practice interventions and specific messages for individuals suspected of having genital herpes or for those diagnosed with genital herpes.

How a practitioner informs and counsels an individual with genital herpes often will influence the patient's long-term adjustment to the infection.^{Footnote 6Footnote 7Footnote 11Footnote 12} Explaining a positive HSV test result can be difficult, since many complex issues must be conveyed. Easing discomfort by first acknowledging it and then proceeding to educate the individual about the infection can greatly empower him or her to manage it effectively.

Take time to examine your own views about genital herpes. Become aware of any stigmatizing attitudes and beliefs that can undermine counselling efforts.

Key counselling activities^{Footnote 9Footnote 13Footnote 14}

• Reassure the individual that genital herpes is a manageable condition.
• Adopt a patient/client-centred approach and focus on the individual's feelings and the potential impact of the diagnosis.
• Engage the individual in conversation by listening actively, expressing empathy, and offering reassurance.
• Use simple, non-judgmental language that the individual can understand.
• Summarize information and check in throughout the consultation to ensure the individual understands.
• Help to dispel myths, anxieties and stigma related to HSV infection by answering questions (Refer to: "What it is" section in Discussion points/Pre-test counselling, below).
• Encourage the individual to discuss his or her genital herpes status with current and future sexual partners even though it may be difficult.
• Discuss the importance and limitations of serological testing to partners to determine their risk of HSV acquisition.
• Refer to other counselling professionals for individual or couples counselling (e.g., sexual health clinics, sex therapists, psychologists) as needed.

Pre-test counselling

Some individuals may be shocked and distressed by even the possibility of having genital herpes. A practitioner who suspects HSV infection at the time of testing should be prepared to provide basic information and initial counselling.

Counselling should be patient/client-centered and based on their particular situation/needs. Depending on their initial presentation, you may be faced with counselling acutely affected individuals/couples, those with chronically recurring lesions, or those who may have a one-time episode with no recurrence.

Emergency care clinicians should refer individuals to primary care clinicians for follow-up.

Provide print and online resources for additional support (such as the Genital Herpes factsheet produced by the Canadian AIDS Treatment Information Exchange [CATIE]) and include contact information for counsellors, local support groups, sexual health info lines or sexual health clinics.

Many individuals benefit more from learning about the chronic aspects of genital herpes after their acute illness resolves or their level of initial distress lowers. Therefore, a follow-up appointment is recommended to discuss coping mechanisms for longer term self-management.^{Footnote 15}

Discussion points:

What it is

• There are two types of herpes simplex virus, HSV-1 and HSV-2. Either one can cause genital herpes. However, HSV-2 rarely causes oral herpes (i.e., cold sores).^{Footnote 16}
• The terms 'genital' and 'oral' refer to the sites of infection and not the types. For example, you can get genital HSV-1 by receiving oral sex from someone who has a cold sore.
• A first outbreak of genital herpes may take 2 to 3 weeks to heal without treatment. Later outbreaks, if they occur at all, often heal more quickly.^{Footnote 17}
• The first outbreak does not necessarily mean you have just been infected. Symptoms can appear anywhere from a few days, weeks, months or even years after being infected.^{Footnote 18} Individuals who experience lesions, swollen glands and other systemic symptoms such as fever, headache, aching muscles shortly after a sexual contact acquire most likely a primary infection. Others may never know when or from whom they got it. It is also important to note that patients with first presentations of localized symptoms and signs may represent recurrent rather than initial infection.
• Genital herpes is a common condition. One analysis estimates that 14% of people between 14 and 59 years of age in Canada have HSV-2.^{Footnote 19}
• Genital herpes is a recurrent, chronic infection; however it is a manageable condition. Your sores/blisters will heal, and you can have a fulfilling sexual life despite this variably recurring viral infection. However, immunocompromised patients are at risk for severe diseases and may benefit from the suppressive therapy. During pregnancy, genital herpes infection can cause severe consequences to the fetus and neonate.

Natural history

• Most people who have genital herpes don't know they have the infection because they have mild, short-lived or no symptoms, or they think the symptoms are due to another condition (e.g., yeast infection, boils, bug bites, friction burns).^{Footnote 13Footnote 15Footnote 19Footnote 20}
• Some people have an acute initial episode (outbreak) with 'flu'-like symptoms, swollen glands and obvious sores/blisters.

Transmission

• Herpes is transmitted through direct skin-to-skin contact with an infected partner. Most HSV-2 infections are acquired through penetrative intercourse such as vaginal and anal sex, but non-penetrative exposures including genital-to-genital rubbing are also ways to transmit the virus. With regard to type 1 infections, most of them are acquired through oral sex.

Prevention

• As for other STIs, condoms, if used consistently and correctly will reduce, but will not eliminate the risk of HSV transmission or acquisition. They need to protect or completely cover the infected area or the area of potential exposure. They can also be used as a barrier for oral-genital sex if your partner has a history of cold sores.^{Footnote 21Footnote 22Footnote 23}
• Until your follow-up appointment, you should abstain from having sex.

Screening, testing & diagnosis

• Based on your history and clinical findings, we can do a swab test for HSV. Testing is recommended to confirm/rule-out infection.^{Footnote 3Footnote 4Footnote 5}
• The test will be able to identify the type of infection (type 1 or type 2), which is important for you to know for long-term management. [Note to practitioner: Both clinicians and patients should be made to understand the importance of always determining the virus type, either virologically (lesion NAAT or culture) or serologically.]
• You may have to come back for more testing if your results are negative for HSV and symptoms return.
• Let's book an appointment for you to receive these results.
• Blood tests for HSV in people who have no symptoms of herpes are not generally recommended, although such testing sometimes is useful in asymptomatic persons whose sexual partners have herpes. These tests look for HSV antibodies (your immune system response), not the virus, in the blood. They can give misleading results. They can miss some HSV infections and sometimes can be falsely positive in uninfected persons.
  [Note to practitioner: Serologic testing for type-specific HSV antibodies may assist in diagnosing patients with recurring lesions, or in recommending prevention methods for a likely serodifferent couple. It is important to note that serological testing is not recommended for screening, given its associated high rates of false positive/negative results. The complexity of result interpretation may require consultation with an experienced colleague.^{ootnote 24} For example, there are cases where HSV seroconversion can be longer than 6 months and also there are problems with cross-reactivity between HSV-1 and HSV-2.]

Approaches to treatment

• Oral antiviral medications can reduce the duration and severity of a herpes outbreak.^{Footnote 15Footnote 25Footnote 26}
• All first episodes of genital herpes normally are treated with antiviral drugs, unless all lesions have already healed completely.
• In a recurrent outbreak, take medication at the prodromal stage or very early stage to be of benefit (i.e., may abort or shorten the episode). [Note to practitioner: two treatment options are available: episodic therapy or suppressive therapy. Both options result in clinically significant improvements in perceived quality of life.^{Footnote 27Footnote 28} Both options should be discussed with all patients. While some patients benefit from episodic therapy of recurrences, most do not. Because recurrent outbreaks are uncommon with genital HSV1, most people with HSV1 need not be offered the aforementioned option. The choice of episodic versus suppressive therapy should be individualized].

Post-test counselling for positive test results

Once HSV type-specific test results are received, more detailed information can be provided in the follow-up visit.

Individuals will often have concerns about the frequency and severity of outbreaks, the origin of their infection, their current and future sexual relationships, their likelihood of transmitting the infection to others, and the impact on future childbearing. Practitioners should set aside dedicated time for counselling and/or refer to another patient-support service.

Partner notification for genital herpes is not required as a public health measure; however, you should encourage individuals to disclose their genital herpes status to their sexual partners as a way to decrease transmission. Depending on the history, the most recent partner(s), the current partner(s) and new partners should be advised. Former or current partners should be encouraged to talk with healthcare providers who can evaluate their risk and the need for an HSV type specific serology if no history of lesion or viral testing if they develop signs and symptoms.

The individual's past, current and future partner(s) may benefit from having an evaluation, receiving counselling, and having HSV type-specific serologic testing to assess their potential infectiousness to help prevent neonatal herpes and decrease the risk of herpes transmission to new partners. Doing so will help couples make informed decisions about the level of protection they want to adopt. Suggest this option to your patient or client and, if possible, offer a counselling session with his or her partner to assist with disclosure and choosing their specific preventive activities (refer to Prevention section in Discussion points, below).

In couples where an asymptomatic partner is diagnosed with HSV-2 infection using type-specific serology , he or she should receive the same counselling as those with symptomatic infection. Advise these individuals that clinical manifestations can occur within a year^{Footnote 29} and they should return if/when lesions appear to allow for confirmatory testing using a culture or NAAT .

Some individuals may be too distressed to fully benefit from counselling at the time of getting their test result. Therefore, provide print and online resources for additional support (such as the Genital Herpes factsheet produced by the Canadian AIDS Treatment Information Exchange [CATIE]) and include contact information for counsellors, local support groups, sexual health info lines or sexual health clinics.

Discussion points:

Refer to the key counselling activities section for best practices.

About herpes

• Herpes is a common virus, and it's also common to feel emotional stress about having it – at first. Working with a counsellor can help you learn how to disclose your herpes status to a new partner, continue to enjoy sex and decrease the risk of transmission to your partner(s) and to a baby, if and when you want to have a baby.
• Most people who have genital herpes don't know they have it because they have mild or no symptoms, symptoms for a short time or they think they have something else. A Canadian study has shown that 94% of those with lab-confirmed HSV-2 infection didn't know they were infected.^{Footnote 19}
• HSV-1 and HSV-2 can live in your body for a long time undetected or unrecognized – for months or years – so it's very difficult to know how long you've had the virus and who might have given it to you. The first outbreak is often the worst, and may occur a long time after you were infected.
• Understanding how HSV is transmitted, when and if to take anti-viral therapy, consistent use of condoms, disclosure of your HSV infection status and testing of your partner(s) can give you peace of mind. All combined, these actions can also provide your sexual partner(s) with the greatest protection from getting genital herpes.

Natural history & recurrences

HSV-2 is the main cause of recurrent genital herpes. [Note to practitioner: substantial information should be conveyed to patients, so they understand clearly the very different natural courses of genital HSV-1 and HSV-2, with implications for symptomatic management, the potential for sexual transmission, and treatment, particularly suppressive therapy.]

• Most people who experience a first episode of HSV-2 will have recurrences, but they are often milder and may decrease in frequency over time. Within one year after initial infection recurrence is observed in about 70 to 90% of HSV-2 individuals and in 20-50% of HSV-1 individuals^{Footnote 30Footnote 31Footnote 32}
• It's common for HSV-1 to be a cause of initial genital herpes, but HSV-2 is still the most common cause of recurrent genital herpes. Genital HSV-1 tends to cause fewer recurrences.^{Footnote 32Footnote 33}
• Genital HSV-1 infection recurs about once per year, whereas in absence of antiviral therapy after first episode HSV-2 infection recurs about four to five times per year with about 40 percent of patients having at least six recurrences and 20 percent having more than 10 recurrences in the first year.^{Footnote 34Footnote 35} Although after an outbreak, the herpes virus goes into state of latency^{Footnote 36}, it may still continue to replicate in both mucosa or skin and in neural tissue.
• Before a recurrence, you may experience warning sensations, called prodromal symptoms. These feelings arise hours to a few days before the sores/blisters appear. Prodromal symptoms can include itching, burning, tingling or discomfort at the site where the sores/blisters appeared during the first outbreak.^{Footnote 37} They indicate that the virus is reactivating, and during this period, you are infectious and able to spread the virus even without visible lesions.
• The triggers that reactivate the virus are often not obvious, but they can be physical (e.g., sun exposure, hormonal changes, sexual activity), emotional (e.g., stress) or anything that may affect your immune system. We do not know if triggers that are reported by patients are coincidental or causal.
• When the virus reactivates, it replicates and travels the nerve pathways to the surface of the skin. When HSV reactivates, it may do so with or without any signs or symptoms.

Transmission

• Even without any visible signs or symptoms, you can be contagious and transmit the virus. This is because the virus sheds from your skin before any sores/blisters appear (what's called "asymptomatic viral shedding").
• Asymptomatic viral shedding occurs when enough virus is present to be contagious but not enough to cause sores on your skin. Understanding the concept of not knowing when you may be shedding the virus is very important in reducing the risk of transmitting HSV.
• You can infect a partner when you have prodromal symptoms, during an outbreak when sores/blisters are present, during healing periods after outbreaks, and at random times when you have no symptoms. The risk is higher during prodromes or outbreaks.
• During initial herpes, you may be able to spread herpes to other parts of your own body, called auto-inoculation. For example, you can spread HSV-1 from a cold sore to your hands and then to your eyes, arms, thighs or to your genitals. An important point to keep in mind is that auto-inoculation is not a significant risk in recurrent herpes [Note to practitioner: Discuss importance of hand hygiene. To be extra safe, wash your hands after touching an outbreak, either oral or genital.]
• If you have HSV-2, your risk for getting HIV from an HIV-infected partner increases two-fold over those who don't have HSV-2.^{Footnote 38Footnote 39Footnote 40}

Prevention

• Avoid having sex when you have warning symptoms (itching, burning, tingling or discomfort at the site) or when you have an outbreak (blisters/lesions) to reduce (but not eliminate) the risk of transmitting the virus to your uninfected partner(s).^{Footnote 25Footnote 26Footnote 41Footnote 42}
• Use a condom during vaginal intercourse and anal intercourse, and a condom or oral dam during oral sex.
• When you and your partner(s) use condoms consistently and correctly (i.e., the infected area or site of potential exposure is covered / protected), you may reduce (but not eliminate) the risk of transmitting the virus to your uninfected partner(s).^{Footnote 21Footnote 22Footnote 23}
• Consider taking suppressive antiviral therapy, which may reduce, but not eliminate, the risk of transmitting the virus to your partner, if taken exactly as prescribed. Some evidence suggests that higher adherence to medications have been associated with transmission risk reduction of HSV-2.^{Footnote 25}

HSV & HIV co-infection

• If you are HIV co-infected, taking daily suppressive antiviral therapy for HSV may not reduce your risk of transmitting HSV to an uninfected partner.^{Footnote 43}
• [Note to practitioner: Consultation with, or referral to, a colleague experienced in HIV care may be required.]

Treatment

• There are safe and effective treatment options available.^{Footnote 44} You can take episodic oral antiviral therapy — as soon as you feel the warning symptoms — and this may shorten or prevent an outbreak, or reduce the severity of your sores/blisters.
• You can choose to take daily oral suppressive antiviral therapy that may reduce, but not eliminate: the number of times the sores/blisters come back, the length of time you shed the virus without symptoms, and the risk of transmitting the infection to your sexual partner(s) — as long as you take it as prescribed.^{Footnote 15Footnote 25Footnote 26Footnote 28Footnote 41Footnote 42Footnote 45Footnote 46}
• Topical treatment may help some patients but it is not generally recommended for use with initial or recurrent outbreaks. [Note to practitioner: Topical antiviral medications have poor efficacy and are of little clinical benefit.^{Footnote 47}]

Disclosure and partner testing

It is strongly encouraged that you disclose your genital herpes status to your most recent, current and future sexual partner(s). Telling your sexual partner(s) about your herpes infection may be difficult or challenging, but it can also have beneficial outcomes. It is an important strategy to prevent the spread of the virus. It has been shown that disclosure of the herpes infection to sexual partner may reduce risk of transmission by approximately 50%.^{Footnote 48}

[Note to practitioner:

• Depending on the history, initial vs recurrent episodes, the most recent, current and future partners(s) should be advised.
• Genital HSV-1 recurrences are less frequent than genital HSV-2 recurrences; therefore the risk for HSV-1 transmission is less than that for HSV-2. It may be appropriate to consider suppressive therapy for those with frequent and /or severe recurrences. This may keep the partner from being infected.]
• To prepare for disclosing your status to your partner(s), you may find it helpful to join a support group or get additional individual or couples' counselling or the health clinics may assist you as much as they can to facilitate a successful disclosure.
• Disclosing your status can help you reduce the risk of transmitting the virus to your partner(s). It may lead to openly talking about what you need to do to be safe, such as periodically abstaining, making choices about the use of condoms, taking daily oral antiviral medications and finding out if you are in a serodifferent relationship.
• If your current partner is asymptomatic, he or she may want to consider having an HSV type-specific blood test to determine if he or she has already been exposed to your serotype of HSV. These test results can help you decide on what prevention methods to use to keep you and your partner safe from further transmission.^{Footnote 24}
• Asking your current or future sexual partners to get tested will let you both know if they're already infected or whether they're at risk for being infected.
• Most people with HSV are highly resistant or entirely immune to new infections with the same virus type they already have, anywhere on the body. Therefore, if both members of a couple are infected with the same HSV type, then there is no concern about re-infection or transmission of that type of HSV to each other and no precautions are necessary.

Pregnancy

• Genital herpes does not prevent you from having children. Women who have the virus, or women with male partners who have the virus, should tell their practitioners who care for them during pregnancy about their or their partner's HSV infection to prevent transmission to the newborn. Both parents should be involved in any strategy to prevent neonatal herpes.
• HSV can be spread to an infant in the birth canal during delivery, causing neonatal herpes that is a serious and sometimes fatal condition.
• The greatest risk for neonatal herpes is if a woman gets infected with genital herpes late in pregnancy. This is because a newly infected mother doesn't have antibodies against the virus, will likely be in active infection, and therefore more liable to have the virus in the birth canal during delivery.
  [Note to practitioner: The evidence regarding the comparative prevalence of HSV by type in pregnant women is inconsistent; one Canadian study showed that the majority of infant HSV cases were HSV-type 1, whereas previous studies indicated greater prevalence of HSV-2.]^{Footnote 49}
• If you are infected and your pregnant partner is not:
  • the healthcare provider may order an HSV type-specific blood test for your pregnant partner. [Note to practitioner: healthcare providers need to be aware of the HSV serological tests limitations and the lack of recommendations or consensus on the use of the test for screening and the best timing for testing. For further information related to serology testing, refer to the section "Screening testing & diagnosis" under Discussion points/Pre-test counselling].
  • If you have genital herpes, abstain from oral, vaginal or anal sex or use condoms for all penetrative sexual activities, especially during the last three months of pregnancy. Suppressive antiviral therapy should be considered in the male infected partner even when condom is used.
  • If you have oral herpes, avoid performing oral sex during the last three months of pregnancy;
• If you have recurrent genital herpes, suppressive antiviral therapy may be prescribed during the last few weeks of pregnancy, in order to reduce viral shedding (symptomatic and asymptomatic) and prevent an outbreak that may otherwise require you to deliver by Caesarean section.^{Footnote 17Footnote 50}

FAQs: Quick reference tool

Common questions raised by individuals following their genital herpes diagnosis are listed below, along with sample responses. This information is intended to give practitioners additional options for advising individuals following an HSV diagnosis.

Frequently asked questions/concerns	Approaches and possible responses
This is awful. I don't know what to do.	Take an empathic approach and tailor messages to the individual's needs. Reflective listening: "I understand you may be feeling upset and concerned about this information. Do you want to ask any questions?" Reassure: "We know from hearing from others that this is a lot to handle and might be confusing and affect how you see yourself. You will likely go through a wide range of emotions."
Where did I get this? Who gave it to me?	"HSV-1 and HSV-2 can live in your body for a long time undetected/unrecognized – for months or years – so it's very difficult to know how long you've had the virus and who might have given it to you."
I was never with anyone who had sores or blisters.	"Genital herpes can be passed on from a person with no visible signs of the virus. It's common for people to be symptom-free but still contagious."
How often will I get outbreaks?	"The first time a person has symptoms is often the worst experience, and then over time the sores and blisters are less intense and less frequent."
Will I pass it to others?	"It's really important that you use condoms for sex with uninfected partners. If you and your partner(s) use condoms consistently and correctly, you can reduce (but not eliminate) the risk of transmitting genital herpes to your uninfected partner(s)." "There's also antiviral drug therapy that's taken every day, which may help reduce the risk of transmission. You may want to think about this as an option."
Am I contagious every day?	"No, you're not. But you won't know what days you are, or are not, contagious except when you feel the prodromal symptoms or see blisters/sores. Asymptomatic shedding will occur randomly, which means there will be days when you are contagious but you won't feel or see any indication of shedding the virus."
What does this mean for my sex life?	"You can have a fulfilling sex life. HSV is a chronic infection, but you can adapt to having it. With time, you'll be able to self-manage and cope. Using condoms, disclosing your status, couple's counselling, ask your partner(s) to undergo testing, and considering the use of antiviral therapies will help you manage the risks of transmission to your partner(s)." "There's support from other local resources available to you. You may benefit from working with a sex therapist, psychologist or couples counsellor. If you want, I can discuss what's available."
Do I have to tell my partner?	"It's really important to let your current sex partners know about your genital herpes and any future partners before you have sex." "Try to be casual and direct. Let the topic come up in conversation. Just say you have the virus that causes genital herpes, and that it's very common and most people who have the virus don't know it. If you start with, 'I have really bad news for you…' or 'Don't freak out, but...', your partner will interpret it as something serious." "Ask if your partner knows about it. Be prepared to talk about how the virus works and how you prevent it from spreading (e.g., condom use, oral suppressive antiviral medication, abstaining during outbreaks and prodromal phase). Explain that having genital herpes is only one small part of your life and that you deal with it." "Disclosing your status is the right thing to do, so feel good about doing it."
I heard that medication for HSV can cause liver disease.	"The studies show that antiviral medications have been proven to be safe and effective to treat and suppress genital herpes over long periods of time."
I want to conceive; is it safe?	"Having genital herpes does not affect fertility. But you should tell your obstetrician or midwife about your or your partner's HSV infection, so you can prevent transmission of the virus to your newborn."

Acknowledgement

The Government of Canada would like to thank the following individuals for their contribution to the development of this tool.

• Genital herpes Sub Working Group: Dr. Marc Steben, M.D., Dr. William A. Fisher, Ph.D.,
• External Reviewers: Dr. H. Hunter Handsfield. M.D., Geneviève Boily, B.Sc.N, M.Sc

References