The Herpes Simplex Virus (HSV) is part of a large family of Herpes viruses that include Varicella Zoster Virus (VZV – which causes chickenpox and shingles) and Epstein-Barr Virus (EBV – which causes infectious mononucleosis aka glandular fever aka kissing disease). We will use the term “Herpes” in this article to refer to the HSV virus. Although Herpes infections are exceeding common globally (some estimates showing up to 30% of the global population carry the virus) Herpes infections can still be very stressful for many patients. Particularly when they read articles on the internet likening HSV to HIV (Human Immunodeficiency Virus).
What is Herpes?
HSV (Herpes Simplex Virus) is a virus. It is a small particle that infects the human body. It is very contagious and most commonly spread via direct skin contact with infectious lesions on the skin caused by HSV like blisters and ulcers. However, people who carry Herpes can also shed the virus from normal skin that does not have any blisters or ulcers. That is why Herpes is often spread via sexual contact and kissing. Making Herpes one of the most common STDs in the world. Once Herpes infects a person, it goes into hiding inside the nerve bodies. It can never be fully eradicated from the body consequently earning its reputation of being “incurable”. However, even though it lives in the body, it does not cause any harm except for occasionally causing troublesome skin symptoms. These symptoms resolve with or without treatment.
Is HSV the same as HIV?
No.
Herpes is a lifelong Sexually Transmitted Disease like HIV that stays in your body. However, unlike HIV, Herpes persists in your system but does not progress while HIV if left untreated can progress to a life threatening state of Acquired Immuno-Deficiency Syndrome (AIDS). In other words, Herpes lives in the body and cannot be cured. However, aside from occasionally causing troublesome skin symptoms, it does not injure the body in any other way. So Herpes does not require any chronic treatment. HIV on the other hand will continue to damage the body ultimately resulting in death if left untreated. And it has to be chronically controlled with medications.
Will HSV become HIV?
Absolutely not.
HSV and HIV are 2 completely different viruses. They will never become each other.
That said, they are both sexually transmitted diseases. In other words, having one raises the possibility of having the other. Also, Herpes sores on the skin lowers the skin’s natural immune defenses and can increase the risk of getting HIV. Please click here for our article on HIV risks.
What is the difference between Herpes Type 1 and Herpes Type 2?
There are 2 subtypes of Herpes – Herpes Type 1 (HSV1) and Herpes Type 2 (HSV2), however there is little practical difference for patients as both subtypes have the same symptoms and are treated the same way. Herpes subtype classification was previously used to group patients into oral herpes or genital herpes based on the subtype of the virus – HSV 1 for oral herpes and HSV 2 for genital herpes. There is increasing evidence that this distinction is not as accurate as once thought, primarily because we know that sexual intercourse is seldom a static activity and hence you can detect HSV 1 in the genitals and HSV 2 in the mouth. In other words, you can catch either type of Herpes from any kind of sexual contact including oral sex.
In fact, a study found that up to 40% of Herpes blisters and ulcers in the genital region is actually caused by HSV 1.
The only practical difference between the 2 subtypes of HSV is that HSV 1 infections in the genital usually cause less severe and less frequent outbreaks compared to HSV 2.
What are the signs and symptoms of Herpes infections?
Herpes Infections switch between 2 phases:
- Acute (flare) phase characterized by painful blisters and ulcers on the skin
- Chronic (latent) phase in which the patient feels perfectly well and symptom free
Acute Phase
In an acute or flare phase, blisters filled with HSV virus appear on the skin. These blisters are surrounded by a ring of inflamed red skin earning them the very romantic description of “dew drops on a rose petal”. The commonest affected sites are around the mouth and genitals. Left untreated these blisters usually dry up over 3 – 4 weeks. However, this is when you are most infectious. Because when the blisters break, the fluid containing HSV can infect people who come into direct contact with it. Furthermore, as the blisters rupture, they become open sores that are painful. These sores can also become infected with bacteria, further complicating the recovery. Seeing a doctor early and starting antiviral medication can stop the flare and reduce the duration of symptoms to 1 week or less. You will continue to be infectious as the lesions heal because the virus is still present on your skin during the healing process. This means that until the blisters or sores dry up you are still infectious and “shedding” virus. Only until the skin is in the state where it was before the blisters can the acute phase be considered to be over.
Condoms do give SOME protection to your partner but because it may not cover all the lesions, your partner may still get infected.
Therefore my advice to my patients during an acute flare is
- Prompt treatment
- Take care not to let anyone come into contact with the blisters/ sores
- Do not share towels
- Abstain from sexual activity for at least 3 weeks or until the blisters have completely healed
Latent Phase
In the chronic or latent phase, the HSV virus remains in your system and does nothing. You feel completely normal during this phase. Like having Shingles after you have had chickenpox, it is not possible to predict when a HSV infection changes from a latent phase to an acute phase. Some patients have a long latent phase lasting years while others have recurrent acute phases every 1 – 2 months. The usual natural history is for the frequency of flares to reduce with time. In the first 12 months following infection with Herpes, the flare frequency is on the average every 1 to 2 months. This reduces to once in 3 to 4 months in the next 12 months. And continues to reduce until the patient reaches a stable phase. For most patients, this means a flare about once a year.
Situations that weaken the immune system also puts the patient at risk of getting a Herpes flare. For example falling ill with another illness, even the common cold. Or taking medicines that weaken the immune system like steroids. Or even many sleepless nights.
A person who carries Herpes is still infectious during the latent phase. This is due to asymptomatic viral shedding. This means the person will continue to shed the Herpes virus from the skin while not showing any signs or symptoms and feeling completely well. Albeit the level of infectivity during the latent phase is much much lower compared to the flare phase.
How do I get tested for Herpes?
There are 2 ways to test for HSV
- Blood test
- Swab test of blisters or ulcers
Herpes Blood Test
A blood test detects Herpes antibodies. After getting infected by HSV, your body develops antibodies (though ineffective) towards HSV. This process takes time. Which means although most people infected with HSV will test positive for HSV antibodies only after 4 weeks Some patients take up to 16 weeks to develop detectable antibodies. Detecting HSV antibodies tells us that you have been infected with HSV about 1 month or more ago. The antibody test cannot tell you exactly when you were infected. It could even have been 10 years or more ago.
There is also a risk of false positive tests with Herpes blood tests. Having a previous chickenpox infection or chickenpox vaccine can increase the risk of a false positive result.
Also, not all Herpes Blood tests are able to differentiate well between the HSV 1 and HSV 2 subtypes. A unique Herpes blood test known as a Type Specific Serology Test (TSST) is required for this. Even lab reports that appear to report HSV 1 and HSV 2 results separately do not necessarily mean they are running proper TSST tests.
HSV Swab Test
A swab test can only be done during the acute phase of the infection. When there are blisters/ ulcers present. The test is a Polymerase Chain Reaction (PCR) analysis for any HSV genetic material. A positive test confirms a HSV infection.
Swab tests for Herpes are a lot more specific. In other words, it is much less likely to have false positive results. Also, it can accurately differentiate between HSV 1 and HSV 2.
However, since swab tests for Herpes can only be done where there are actual skin blisters and/or ulcers, it cannot be used as a screening test.
How do you treat Herpes?
Herpes is not curable. Once a patient has been infected, he will carry the virus in his body for the rest of his life.
That said, not everyone with Herpes needs to be treated. There are people who live with Herpes who have very infrequent flares. Or who have flares so mild that even without treatment, goes away in a few days and does not bother the patient. Many people choose not to actively treat the Herpes flares and this is perfectly OK.
Anti-viral medicines are the mainstay of Herpes treatment. There are anti-viral tablets and anti-viral creams.
There are 2 strategies to treat Herpes.
- Ad-Hoc
- Suppressive
Ad-Hoc Treatment for Herpes
This treatment strategy involves taking anti-viral medications only after Herpes flare symptoms have started. The aim of therapy is to minimize the number of symptomatic days.
The main goal of HSV treatment is to stop/ reduce frequency of acute flares and prolonging the chronic phase. Anti-viral medication is used to halt the production of new HSV particles in your body and therefore are useful in speeding up recovery when you are experiencing a HSV flare. The earlier you start Anti-viral medication in a flare the better, studies have shown that starting within 24 hours is able to limit the duration of the HSV flare to 5 days as compared to 3 weeks if left untreated.
Getting control of a HSV flare early on also has the advantage of preventing the sores that develop after the blisters burst not becoming infected. This will prevent the need for using antibiotics in addition to the antiviral medications.
Another benefit of early treatment of Herpes flares is to reduce the risk of Post-Herpetic Neuralgia (PHN). Because the Herpes virus travels along the nerves, it can irritate the nerves and cause pain or a variety of uncomfortable sensations long after the skin blisters and ulcers have resolved. This is called PHN and can be very troublesome and takes a long duration of treatment to get under control.
Suppressive Treatment for Herpes
Suppressive treatment for Herpes involves taking a low dose of anti-viral medication regularly even when there are no symptoms. This is to prevent flares from occurring in the first place. This treatment strategy is helpful for patients who have very frequent flares. Or for patients who just do not want to experience any flares. Or for patients who wish to minimize the risk to their partners.
This suppressive treatment is not meant to cure the virus but to reduce the chance of a recurrence.
In conclusion
HSV is a very common virus and remains in the body for life. Aside from occasional acute flares of the infection, there are minimal long term side effects of the infection. The most important thing to do is to seek medical advice early, arrive at a diagnosis and plan how best to manage flares when they come.