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A Conversation with Charles Ebel Co-Author of Managing Herpes: Living & Loving with HSV

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Since its original publication in 1994, Managing Herpes, by Charles Ebel and Anna Wald, M.D., M.P.H., has been consistently cited by readers and reviewers as an invaluable resource for information on genital herpes. From transmission and treatment, partner communication, pregnancy concerns and vaccine development, this comprehensive guide offers a balanced perspective on both the medical and emotional issues surrounding herpes. On the eve of the release of the latest edition, fully revised and with the new title Managing Herpes: Living & Loving with HSV, The Helper spoke with co-author Charles Ebel to talk about changes in the new edition and his thoughts about advances in treatment, the issue of stigma, and more. Dr. Ebel

It’s been five years since the last edition of Managing Herpes was published. What would you say are the most significant updates in this latest edition?
The topic of prevention-or risk reduction-is probably the key area. We have known for decades that fear of transmitting herpes was really the toughest issue and, for most people, the biggest concern. And while experts have had advice about this before, much of it was based on scant evidence. Since 2002 we have much more data to work with. The biggest change, in my opinion, are studies showing that people can effectively reduce the risk of transmission of HSV to sexual partners. Perhaps the most important one is the valacyclovir study showing that daily suppressive therapy can cut the risk in half. In addition, we now have good information on condoms -they also reduce the risk by 50%, as does disclosure of having genital herpes to partners. So that becomes something quantifiable that people with genital herpes can make decisions about. We are no longer talking in vague generalities about these options.

Certainly one area where there have been new developments is in the area of treatment—how much has the discussion of treatment changed in this edition?
We did make a change in emphasis here and devoted an entire chapter to three oral antivirals—acyclovir, famciclovir, and valacyclovir. In doing so we were able to address more thoroughly new uses for these drugs, new dosing regimens, and other comparative information. This is now a more thorough discussion. Previously, our text on the three frontline antivirals had shared a chapter with all other treatments, including various topicals, over-the-counter medications, and alternative medicines. In this edition, these other approaches are addressed in a separate chapter. To me, the new structure is a more logical way to group these, largely because the vast majority of people are going to want information about an oral antiviral, and the hard science in support of these is far more extensive.

Do you believe in universal screening?
I don’t think anyone is trying to make a case for universal screening today. The emphasis instead is on serologic testing in a specific set of clinical scenarios. For example, if someone thinks they are at risk for a sexually transmitted infection and want to be worked up for that, then testing for HSV should be part of the workup. And there are other scenarios like this where serologic testing seems to hold great value, but in all too many clinical settings, it isn’t being done. There has been progress, to be sure, but we still have a ways to go. On the other hand, universal screening —having everyone tested—raises all kinds of controversies, including serious resource issues. The solution to the epidemic is probably going to have to come from a different direction-most likely from some kind of vaccine.

A good deal of recent research in the field has focused on HSV/HIV coinfection. How did you approach this emerging topic in the book? As new research about the increased risk of HIV acquisition for those with genital herpes comes out, what do you think is the best way to publicize this without further stigmatizing those with GH?
This is a very good question. We explained the latest thinking on both testing and treatment as it relates to persons who are HIV-positive. And we also covered the topic of how HSV-2 infection interacts with HIV. This has implications for transmission risk. But we tried to present this information in a way that makes it crystal clear that the average person with HSV-2 is not a walking magnet for HIV. The risk is measured and highly individual. For those who have sexual partners with HIV, the interaction is definitely a concern. For others this may be more theoretical. Managing Herpes

Speaking of stigma—do you think we’ve made any progress on that front (confronting and reducing stigma) in the five years since the previous edition?
It’s hard to quantify, but yes I do. Reviewing the text from previous editions on psychosocial adjustment, for example, I found there were subtle implications I did not like—almost an assumption that the diagnosis would be traumatizing. Today we know that for lots of people it isn’t, so we tried to reflect that in the book. At the same time, of course, we did address the fact that there are often adjustment issues. Hopefully it now strikes the right balance. But overall, I’d have to say that there is evidence that clinical care is better, people are better educated, and stigma should be slowly but surely diminishing.

Finally, while I realize that the ink isn’t even dry on this edition of Managing Herpes, I wonder if there is anything you’d hoped to include but didn’t, or couldn’t. Any thoughts toward future editions?
Nothing omitted, really, but I would hope that we will have more data on novel treatments in 3 to 5 years, including complementary and alternative treatments. Right now there just isn’t much hard science to go on. Even more than this, I look forward to seeing some innovative vaccines.

Order your copy of this book here!

 

What's safe?

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I recently started a relationship with a wonderful woman who has genital herpes (HSV2). She’s taught me a lot about this (including the fact that I may also have HSV2 and not know it!), but I want to know more about transmission. I should mention that I have had cold sores since I was a child, which I now know are also herpes. So basically, I want to know how we can protect each other. Are condoms enough? Is it okay for me to perform oral sex (seems like a risk for both of us)? What’s safe? Dr.

First off, you and your partner are to be commended for talking about herpes and looking for more information. This says a lot about both of you and the relationship. For her, having the discussion shows honesty and trust on her part and both are good for any healthy relationship. You’re also taking an important step by educating yourself. Rest assured that we talk with couples each day for whom herpes has become nothing more than a minor thing in their relationship.

If you have ever had sex/genital contact before, you could already have genital herpes (as you mention) and therefore it would be a good idea for you to get tested. When you speak with your healthcare provider about testing, make sure to request a “type specific IgG blood test.” If the test is positive for HSV-2, you are unlikely to need any therapy, as you have mild disease and would not have to be concerned about getting HSV2 from your partner. If you find out you don’t have HSV-2, there are ways to reduce the risk of contracting it.

Simply abstaining from sex when your partner has genital symptoms would reduce the risk somewhat, and using condoms at times when she is not having any genital symptoms would reduce it even further. In addition, if your partner is taking antiviral therapy, the risk would also be reduced-one study showed reduced risk with once daily valacyclovir (500 mg). While condoms and valacyclovir reduce the risk by about 50%, neither guarantees that you will not get HSV-2. However, men are at lower risk for contracting HSV-2 than women, and these strategies can help you reduce your risk even further.

In terms of you getting HSV-2 orally or her getting HSV-1 genitally (with you likely having HSV-1 orally) from oral sex-it’s possible. It’s best if you avoid kissing or contact with her geital area when you are having a cold sore. We have not seen people with genital HSV-2 acquire genital HSV-1, perhaps because HSV-2 appears to protect against HSV-1. HSV-2 orally is unusual without genital acquisition, and if so acquired, it almost never causes outbreaks.

Regarding the relationship overall, know that you can have the same level of intimacy and sexual activity that any couple can. It is true, though, that in an intimate sexual relationship with a person who has herpes, the risk of contracting the infection will never be zero. While there is a possibility of you contracting genital herpes, that’s a possibility for any sexually active person. That’s why not having sex when genital symptoms are present and using latex condoms are good recommendations for any sexually active couple regardless of whether herpes is part of the equation.

Remember, all relationships face challenges, most far tougher than herpes. Good relationships stand or fall on far more important issues—including communication, respect and trust. Good luck!

 

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