Susan ayers cambridge handbook of psychology he

Background
Herpes
John Green
St. Mary’s Hospital
Genital herpes is an extremely common infection caused by one
of the two related Herpes simplex viruses, HSV-1 and HSV-2.
HSV-1 is the cause of cold sores around the mouth but can
infect the genitals and be transmitted either oro–genitally or by
genital–genital contact. HSV-2 is mainly a genital infection although
orolabial infection can occur. Both viruses establish lifelong infections
in the nerve roots and can be periodically reactivated causing
recurrent episodes. During episodes small blisters appear which are
itchy or painful and which break down in about a day to leave an
open sore, which usually heals in about a week in those who
are immunocompetent. However inapparent lesions are common
and asymptomatic shedding, production of virus in the absence of
lesions, also occurs in the absence of frank episodes. Most infections
are believed to result from inapparent lesions or asymptomatic
shedding since avoidance of sex during obvious episodes is
common.
Genital recurrence rates are higher on average for HSV-2 than for
HSV-1. Some individuals have only a single obvious episode, others
can have episode rates up to one per fortnight. While episodes
usually diminish in frequency over the years there is considerable
variation. Infection is lifelong and cannot be eliminated. Treatment
is by antivirals which, when used on a continuing basis, largely or
completely suppress episodes during active treatment but do not
affect natural history.
Most people with genital herpes have never been diagnosed
and are unaware that they are infected. Estimates of incidence are
based on serology but are limited because they are based on HSV-2
antibodies only. Orolabial HSV-1 infection is very common and
serology cannot distinguish the site of infection. Since in many
countries HSV-1 accounts for half or more of clinical cases, as a
rough rule of thumb rates for HSV-2 might to be doubled to estimate
overall genital infection rates. On this basis the incidence of genital
infection with the HSV viruses in the USA and Europe in adults
under 35 is probably in the 15–25% range with some populations
showing rates in excess of 50%. HSV infection is a common cause
of genital ulcer disease in developing countries. Rates are rising
worldwide, particularly rapidly for HSV-1.
Fortunately the disease causes little in the way of long-term
physical morbidity. The main risk is transmission to the neonate
at birth where disseminated herpes of the neonate can cause blindness,
brain damage or death. Transmission to neonates is unusual
except where the mother is infected late in pregnancy. Cases of
disseminated herpes of the neonate are rare in Western Europe
although they are more common in areas of social and relationship
instability, for instance some inner city areas of the USA.
Risk of transmission can probably be reduced by antiviral treatment
of the mother (RCOG, 2002). Caesarian section is sometimes used
where risk or transmission is thought particularly high. Otherwise
the main problem is psychological morbidity and reduced quality
of life.
Psychological effects
Psychological morbidity is very common at the time of diagnosis
with half of patients being clinically anxious and about a tenth
clinically depressed on the HADS (Carney et al., 1994). In those
who do not get an (apparent) recurrence these symptoms usually
resolve over a few months. In those with recurrences, psychological
distress remains high for several months or even years. Distress does
usually resolve eventually and by 5–6 years most patients report
that their sexual and interpersonal function are similar to before
they were infected and their levels of anxiety and depression
are not different from population norms (Brookes et al., 1993;
Cassidy et al., 1997). A few patients however fail to adjust over
many years.
There is little systematic information on non-adjusters. There is
no way at present to predict who will have difficulty in adjusting.
Such evidence as is available suggest that non-adjusters are more
likely to be women, although not exclusively so. Possibly this is in
part because episodes are usually more painful in women.
Frequency and severity of episodes are related to level of psychological
distress and hence those with higher levels of reported
distress might be more likely to be women. Higher initial levels
of distress might be associated with more problems adjusting,
although this is not established. However the infection may
also feed into negative societal stereotypes of women’s genitalia as
‘contaminated’. Additionally there is some evidence that even
amongst adjusters the experience of a chronic condition outside
the patient’s control may have a broader impact on the patient’s
thinking about the world (Green & Kocsis, 1997).
Data on the impact of antiviral treatment on psychological
well-being is surprisingly limited as most early drug trials used
episode frequency as their endpoint. However available evidence
suggests that suppression of episodes can reduce psychological
distress and improve quality of life. (Carney et al., 1993; Patel
et al., 1999). Clinical experience suggests that the effects may persist
after treatment cessation, possibly because stopping episodes allows
patients space to adjust psychologically.
While many patients report unfounded concerns about casual
household transmission and transfer to other sites on their own
bodies (very rare and then probably only shortly after infection) 727