Herpes Complex
Cornelis A Rietmeijer; Nicola Low

In a blood-red splatter, the word "Herpes" adorned the cover of Time Magazine of 2 August 1982 along with the tagline : "Today's Scarlet Letter". It appeared to herald an era of heightened public interest for herpes simplex virus (HSV) as a "new" sexually transmitted infection (STI). Of course, this attention was quickly overshadowed by increasing awareness of a really new, but much more serious STI: HIV. In the past 25 years, although perhaps less sensational than the progress in HIV research, studies into HSV, especially the genital variant HSV-2, have yielded many important insights that are now leading to renewed efforts to push the prevention of genital herpes to the foreground, inviting the question as to whether aggressive HSV-2 control efforts are now feasible and, from a public health view, warranted.

First, HSV-2 is much more prevalent than was previously thought. Among the general US population, 17% show serological evidence of infection; up to 40% in the African-American subpopulation. The article by Glynn and colleagues shows that HSV-2 infection was widely spread in parts of sub-Saharan Africa even before the HIV epidemic and that HSV prevalence over time does not seem to have been strongly influenced by the co-occurrence of HIV.

Second, controlling HSV-2 has been seen as a potentially important tool in HIV prevention because of the ample evidence that HSV-2 is an important co-factor in the acquisition of HIV. Third, control of HSV may reduce the incidence of neonatal herpes, a cause of severe morbidity and mortality. Fourth, antiviral HSV-2 therapy is not only effective in treating symptomaticHSV-2 infections, but also reduces HSV genital shedding and reduces HSV transmission to uninfected partners. With more anti-HSV drugs coming off-patent, these drugs are increasingly affordable.

Fifth, type-specific serological tests for HSV are increasingly sensitive and specific and have a high positive predictive value in high prevalence populations. Rapid HSV tests are currently being marketed at prices that will allow them to be considered for routine use in certain clinical settings, for example STI clinics. Finally, clinical trials into preventive HSV-2 vaccines have yielded mixed results thus far and condom use might be only partly effective in preventing HSV transmission. Testing and suppressive treatment for those infected have thus emerged as the mainstay of a possible intervention to prevent the ongoing transmission of HSV.

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