COUNSELLING A DIAGNOSIS

Genital herpes is a common condition in people who are sexually active, and is usually a relatively minor condition from a medical perspective. However, societal conditioning means that individuals often have a range of emotional responses when given a diagnosis of genital herpes.(1-4)

Emotional impact of a genital herpes diagnosis

Some people cope well without any problems. However, for others, a diagnosis of genital herpes (whether it be primary, non-primary or first symptomatic reactivation) may be the most challenging health disruption that they have experienced due to the associated stigma and societal conditioning. As a result, a diagnosis of genital herpes can trigger confusion and a grief reaction, including feelings such as guilt, anger, fear, shock, denial and a sense of injustice. Common concerns for people diagnosed with genital herpes include the social stigma, transmission, fear of rejection upon telling potential sexual partners, and the impact that having genital herpes might have on their sex life and social activities.(3, 5) Individuals with genital herpes are often very concerned about the potential impact of the diagnosis on their relationships.(6, 7) It is therefore important that the diagnosing clinician addresses as many of these concerns as possible at the time of diagnosis, even if the person is referred elsewhere for counselling.(8) In addition, it should not be assumed that another clinician has spoken with the person about genital herpes.(6, 9) 

Successful psychosocial management of genital herpes is time-intensive. The impact of the diagnosis in any individual is influenced by their coping strategies, level of social support, and underlying beliefs about sexuality and sexual health. A diagnosis of herpes can also trigger worries about the acquisition of HIV or other sexually transmitted infections (STIs), and whether the individual is seen as promiscuous and is being judged by their
doctor.(10) 

It is important to reassure people with genital herpes that they are not alone. The NZ Herpes Foundation website and Herpes Helpline provide specialist support, education and counselling in both acute and non-acute situations. In addition, they can refer individuals for specialist counselling at their local sexual health clinic. People need to be advised to consult reputable internet resources and that they should be wary of online ‘cure’ claims that are not scientifically supported. Although not all people will take up the offer of counselling and support initially, it is very important to provide them with information about all available resources because these are often accessed at a later date, such as when establishing a new relationship or wanting to conceive. 

The above section is based on internationally accepted standards of practice. GRADE C

Key information to convey during counselling

The following list of information can help people to understand and normalise the meaning of having a viral STI. When providing this information, it would be helpful if health professionals can convey that they understand that having what may be a relatively innocuous infection in medical terms could actually be life changing for the affected individual. 

• Herpes is common, manageable and treatable. 
• Herpes simplex virus (HSV) causes cold sores on the mouth and cold sores (herpes) on the genitals. It is caused by two strains of the same virus. HSV-1 causes most oral cold sores and about half of all cases of genital herpes. The  other half of genital herpes cases are caused by HSV-2. 
• Infection with HSV is very common and is usually quite mild, but a diagnosis can cause significant psychosocial distress when the genital area is affected. 
• As many as one in three people have genital herpes (caused by HSV-1 or HSV-2), but only one in five of affected individuals have symptoms. This means that most people (4/5, or 80%) who have a genital HSV infection will not have any symptoms or will have such mild symptoms that they will not be recognised or diagnosed as genital herpes. Three-quarters of herpes infections are acquired from partners who were unaware that they were infected.
• For most people with symptoms of genital herpes, this is like a cold sore on the genitals that comes and goes. It does not affect a person’s overall health or life expectancy.
• A small percentage of people who get genital herpes may experience problematic recurrences. 
• There is effective oral antiviral treatment available to treat genital herpes. 
• People who experience a first episode of genital herpes will get better, lesions will heal and there will be no evidence of the initial lesions left.
• Most people who experience a first episode of genital herpes caused by HSV-2 will have recurrences, but these are generally milder than the first episode. Genital herpes caused by HSV-1 tends to have fewer recurrences.
• Getting genital herpes while in a long-term relationship does not mean that the other partner has been unfaithful. However, a full sexual health screen may be reassuring.
• Genital herpes does not stop you having sex.
• Use of condoms reduces the risk of transmission. The use of condoms in a long-term relationship should be a matter of discussion between the individuals. It is advisable to avoid genital-to-genital contact, even with a condom, until any lesions are completely healed.
• Where both partners in a long-term relationship have the virus, use of condoms is not necessary because they cannot reinfect each other. However, it is advisable to avoid sexual contact when lesions are present because friction may delay healing.
• Oral to genital transmission of HSV-1 during oral sex is very common, and this can happen even when cold sores are not causing symptoms.
• Genital herpes does not affect fertility or prevent you from having children, and most pregnant people with genital herpes can have a vaginal delivery.
• Anybody with genital herpes, whether they get symptoms or have never had symptoms, may shed the virus from time to time without having any symptoms.
• There is no evidence that genital herpes causes cervical cancer.
• Even if the virus is passed on to a sexual partner, the most likely outcome is that the person will never experience symptoms.
• Ensure patients have access to the NZHF patient pamphlets, and have the details for The NZ Herpes Foundation www.herpes.org.nz and Herpes Helpline (toll free 0508 11 12 13 or 09 433 6526 from a mobile).

Herpes in pregnancy and neonates 

It is important to notify the health professional(s) managing the pregnancy if there is any history of genital herpes, or if infection occurs during pregnancy. Most pregnant people with a history of genital herpes can still have a vaginal delivery. 

Neonatal herpes is serious but extremely rare, affecting about one in 10,000 live births. Nevertheless, it is important that parents are instructed on the symptoms to look out for if there is any possibility of transmission. Knowledge of the early symptoms of neonatal herpes will facilitate early identification and management of neonatal infection, which increases the likelihood of a good outcome for the infant. The most common cause of neonatal herpes infection is a woman experiencing a first episode (often asymptomatic) in the last trimester of pregnancy. The risk of transmission during an episode of recurrent herpes during pregnancy is much lower because maternal antibodies help to protect the baby and viral shedding during recurrences is low. Please refer to the Genital Herpes in Pregnancy and Neonatal HSV Infection chapters for more detailed information.