Genital Herpes

Summary

Genital herpes is a sexually transmitted infection caused by the herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2). Once a person is infected with HSV, the virus stays in the body for life. Both HSV-1 and HSV-2 can be transmitted through sexual contact. Genital herpes is an HSV infection of the groin, pubic area, genital area, anus, rectum or buttocks.

All people who are sexually active may be at risk for genital herpes.

Many people with genital herpes have no symptoms or the symptoms are very mild so they go unnoticed or are mistaken for another skin condition. The most common symptoms of genital herpes are lesions, which appear as painful blisters in the genital area.

To test for genital herpes, samples are taken from the sites of suspected infection and tested for the presence of the virus. Blood tests can also be used to determine if HSV-1 or HSV-2 is present in the body.

Antiviral medications can reduce the severity and frequency of genital herpes outbreaks.

Genital herpes increases the risk of HIV transmission.

Correct and consistent condom use and antiviral medication can reduce the risk of genital herpes transmission.

The words we use here – CATIE is committed to using language that is relevant to everyone. People use different terms to describe their genitals. This text uses medical terms, such as vagina and penis, to describe genitals. Cisgenderi people can often identify with these terms. Some transgenderii people may use other terms, such as front hole and strapless. CATIE acknowledges and respects that people use words that they are most comfortable with.

Key messages on genital herpes for clients are available here.

What is genital herpes?

Genital herpes is a sexually transmitted infection (STI) caused by the herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2). Genital herpes is generally defined as an HSV infection of the groin, pubic area, urethra (the tube that allows urine and semen to pass out of the body), vagina, vulva, cervix, clitoris, labia, penis, perineum (the area between the anus and the scrotum or vagina), anus, rectum or buttocks.

HSV-1 usually infects the mouth or lips but can also infect the genital area.

HSV-2 usually infects the genital area. A person can be co-infected with both HSV-1 and HSV-2. HSV infects the epithelial cells (top layers) of the skin and the mucous membranes (the “wet” linings of the body). The virus then travels to a nerve root called a ganglion at the base of the spine. HSV stays in the ganglion for the rest of a person’s life. Periodically, the virus travels back to the skin or mucous membranes, which may or may not cause symptoms (lesions) to occur.¹,²,³

How is genital herpes transmitted?

HSV is transmitted through direct skin-to-skin contact with an HSV lesion and it can also be spread through contact with a partner’s infected oral or genital area. When the virus is shed (released) from infected skin it can be present in genital or oral secretions. Transmission can occur when the infected partner has no visible lesions and, in many cases, is not aware of the infection. HSV can be spread through sexual contact.

HSV-1 is usually transmitted by kissing. (Oral HSV-1 is a very common infection with or without symptoms. When HSV-1 symptoms appear on the lips they are referred to as “cold sores.”) HSV-1 can also be spread from the mouth to the genitals or anus during oral sex. Although it is less likely, HSV-1 can also be transmitted via genital-to-genital contact and anal intercourse.

HSV-2 is most often transmitted by vaginal and anal intercourse. HSV-2 can spread from a person’s genitals to another person’s mouth during oral sex, although HSV-2 infections of the mouth are rare.

Condomless vaginal and anal intercourse and oral sex are considered high risk for HSV transmission. Although lower risk, fingering, hand jobs and sharing sex toys can transmit HSV.

Genital HSV-1 or HSV-2 can be passed to a fetus or newborn during pregnancy or childbirth. The risk of transmission is higher if the pregnant person is experiencing a first (primary) HSV outbreak.³,,,,

Who is at risk?

All people who are sexually active, including people who experience sexual violence, are at risk for genital herpes. Because HSV stays in the body for life once a person has become infected, rates of genital herpes tend to be higher among older people. The Canadian Health Measures Survey indicated that about 19% of people aged 35 to 59 years had HSV-2 infection compared to 6% of people aged 14 to 34 years. The prevalence of genital HSV-1 infection is unknown but research in Canada suggests that many genital herpes infections are HSV-1.

Genital herpes is more common among cisgenderi women and transgenderii men than cisgender men and transgender women.¹,,

Symptoms

Many people with genital herpes have no symptoms or the symptoms are very mild so they go unnoticed or are mistaken for another skin condition. As a result, most people with genital herpes are unaware that they have the infection. Transmission can occur when the infected partner has no symptoms. If noticeable symptoms do occur, they usually appear two to 12 days after infection (the incubation period). The first appearance of symptoms is known as the primary outbreak and subsequent outbreaks are known as recurrences. Genital herpes infections can involve a number of different symptoms:

  • painful blisters in the genital area; these crust over and heal within one to two weeks. Genital herpes lesions can appear individually or in clusters.
  • itchy, tingling, burning or painful skin in the infected area
  • pain in the legs or buttocks
  • swollen and tender lymph nodes in the groin area
  • thin watery discharge from the vagina
  • fever, headache or muscle ache
  • fatigue

For people with genital herpes who do have noticeable lesions, the primary outbreak is usually the most severe. Subsequent outbreaks are usually less severe and for many, but not all, people will decrease in frequency over time. Some people with genital herpes never have a recurrence after the primary outbreak. For genital herpes infections caused by HSV-1, recurrences are less frequent than for infections caused by HSV-2. Recurrent outbreaks are often preceded by tingling, burning or itching in the infected area up to several days before the lesions appear. Genital herpes lesions may be more painful and persistent in people with suppressed immune systems, such as those who are HIV positive. A number of factors, including stress, illness, menstruation, or injury to the infected area, may trigger an outbreak.¹,²,³

Complications

In addition to the common symptoms of genital herpes, both HSV-1 and HSV-2 can also cause rare but serious complications such as encephalitis (inflammation of the brain), meningitis (inflammation of the lining of the brain) and blindness.

Neonatal herpes resulting from HSV transmission to the fetus or newborn during pregnancy or delivery can result in very serious complications including death. All pregnant individuals should talk to their doctor or midwife about HSV.

For many people with genital herpes, the most serious complications are psychological. Many people feel embarrassment, shame and stigma after a medical diagnosis of genital herpes and are concerned about the implications of the infection for current and future sexual relationships.¹,²,³

Testing and diagnosis

Cell cultures are the most common method currently used in Canada to test for genital herpes. A swab is taken from a lesion or blister or the skin surface and sent to a lab for testing. The culture test is more likely to detect the virus if the swab is taken within 72 hours after symptoms appear. This test can detect whether a genital herpes infection is caused by HSV-1 or HSV-2 or both.

There are also blood tests that can determine if a person has an HSV-1 or HSV-2 infection. However, the blood test cannot determine when a person was infected or where in the body a person is infected. (Many people will test positive for HSV-1 because of an HSV infection on the lips or mouth.) HSV blood tests are not covered by provincial or territorial health insurance plans.¹,²,³

Notification of partners

The Public Health Agency of Canada (PHAC) recommends that people with genital herpes be encouraged to inform all sexual partners from the preceding 60 days before symptoms appeared or the date of diagnosis if the infection was diagnosed in the absence of symptoms so that partners can be aware of the risk of infection. However, this is a recommendation only. Partner notification is not required as a public health measure, unlike with a diagnosis of chlamydia, gonorrhea, syphilis or HIV.¹

Treatment

Treatments for genital herpes can reduce symptoms but cannot cure the infection. PHAC recommends that treatment for a first outbreak be started as soon as possible after symptoms appear. Antiviral medications that are prescribed by a doctor include acyclovir, valacyclovir and famciclovir, which are taken for five to 10 days.

These same medications can be used to treat recurrent outbreaks to reduce the severity and duration of symptoms and should be taken as soon as symptoms appear. People who have frequent recurrences (several outbreaks a year) can be prescribed suppressive therapy, where antiviral medications are taken on a daily basis to reduce the frequency and severity of outbreaks and to reduce the risk of transmission to partners.

People experiencing an outbreak of genital herpes may be able to reduce discomfort by taking acetaminophen or ibuprofen, applying ice packs to the lesions, taking warm baths with salt or baking soda, and wearing loose-fitting clothing and cotton underwear.

According to PHAC, psychosexual counselling is an important aspect of the treatment and management process for people diagnosed with genital herpes. Many people experience feelings of loneliness, fear of rejection, depression, low self-esteem and anxiety upon learning that they have a chronic STI. Once diagnosed with HSV infection, people should become educated about the natural history of genital herpes (that is, basic information about the infection and the disease course) and the role of antiviral medication and condom use in reducing the risk of transmission to partners. People with genital herpes should also be counselled about communication with past, current and prospective sexual partners.¹,²,³

What about HIV?

People with genital herpes infection are at increased risk of HIV infection. Research has demonstrated that HSV-2 increases the risk of HIV twofold. This association between HSV-2 infection and increased risk for HIV is maintained even when there are no symptoms (such as lesions).

People who are HIV positive and also have genital herpes can more easily transmit HIV to a partner during sexual activity. HSV-2 infection can increase the amount of HIV in the genital area and the increased risk of transmission remains even when the person with HSV-2 has no symptoms (such as lesions).¹,²,¹⁰

Prevention

People with genital herpes should avoid sexual contact when they are experiencing symptoms before an outbreak (such as tingling or burning in the infected area) and when they are having outbreaks because this is when they are at highest risk for transmitting HSV to sex partners.

Correct and consistent condom use reduces the risk of transmitting genital herpes. There are two types of condoms available. The external condom (sometimes called the “male” condom) is a sheath made from polyurethane, latex or polyisoprene that covers the penis during sex. The internal condom (sometimes called the insertive or “female” condom) is a pouch made of polyurethane or a synthetic latex material called nitrile that can be inserted into the vagina or rectum. Condoms only provide protection against genital herpes transmission when they cover infected skin areas. Because internal condoms may cover more infected skin areas, they may provide more protection.

Some transgender men may cut a condom or oral dam to fit their genitals.

For people with genital herpes, suppressive therapy using valacyclovir can reduce the risk of transmitting HSV-2.

The use of oral dams or other barriers can reduce the risk of HSV transmission during oral sex or rimming.

Using a new condom for each partner with sex toys can reduce the risk of HSV transmission by preventing the exchange of bodily fluids.¹,²,³

Footnotes

i Cisgender – someone whose gender identity aligns with the sex they were assigned at birth

ii Transgender – an umbrella term that describes people with diverse gender identities and gender expressions that do not conform to stereotypical ideas about what it means to be a girl/woman or boy/man in society

(Definitions taken from Creating Authentic Spaces: A gender identity and gender expression toolkit to support the implementation of institutional and social change, published by The 519, Toronto, Ontario.)

Credits

This fact sheet was developed in partnership with the Sex Information and Education Council of Canada (SIECCAN).

Resources

Condoms for the prevention of HIV and STI transmission – CATIE fact sheet

References

  1. Public Health Agency of Canada (PHAC). Canadian Guidelines on Sexually Transmitted Infections: Genital Herpes simplex virus (HSV) infections. 2013. Available at: http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-5-4-eng.php [Accessed December 23, 2015.]
  2. BC Centre for Disease Control. Herpes is? Clinical Prevention Services, BC Centre for Disease Control. 2012. Available at: http://www.bccdc.ca/resource-gallery/Documents/Educational%20Materials/STI/Med%20Handouts/STI_handout_Herpes_20120905.pdf [Accessed December 23, 2015.]
  3. Garland SM, Steben M. Genital herpes. Best Practice & Research Clinical Obstetrics and Gynaecology. 2014;28:1098-1110.
  4. University of Maryland Medical Center. Herpes simplex. Available at: http://umm.edu/health/medical/reports/articles/herpes-simplex [Accessed December 23, 2015.]
  5. WebMD. Genital Herpes Health Center. Available at:
  6. http://www.webmd.com/genital-herpes/default.htm [Accessed December 23, 2015.]
  7. BC Centre for Disease Control. Smart Sex Resource. Know Your Chances. Available at: http://smartsexresource.com/about-stis/know-your-chances-0 [Accessed December 23, 2015.]
  8. Centers for Disease Control and Prevention (CDC). Genital herpes – CDC Factsheet (detailed version). Available at:  http://www.cdc.gov/std/herpes/stdfact-herpes-detailed.htm [Accessed December 23, 2015.]
  9. Rotermann M, Langlois K, Severini A, Totten S. Prevalence of chlamydia trachomatis and herpes simplex virus type 2: Results from the 2009 to 2011 Canadian Health Measures Survey. Health Reports. 2013;24:10-15.
  10. Gilbert M, Li X, Petric M, et al. Using centralized laboratory data to monitor trends in herpes simplex virus type 1 and 2 infection in British Columbia and the changing etiology of genital herpes. Canadian Journal of Public Health. 2011;102:225–229.
  11. Romanowski B, Myziuk L, Walmsley S, et al. Seroprevalence and risk factors for herpes simplex virus infections in a population of HIV-infected patients in Canada. Sexually Transmitted Diseases. 2009;36(3):165-169.

Published: 2016