INTRODUCTION

INTRODUCTION, KEY MANAGEMENT POINTS, AND WHAT'S NEW IN 2024


Download Introduction here and download the Summary of Guidelines here.

This edition has been reviewed by Dr Anne Robertson, Consultant Sexual Health Physician and Gynaecologist, Dr Min Karen Lo, Sexual Health Physician, Dr Heather Young, Sexual Health Physician, Dr Silvana Campanella, Paediatrician, Katie McCullough, Nurse Practitioner and Clinical Lead, STIEF. Edited by Nicola Ryan.


Previous Editions; 1994, 1995, 1996, 1998, 2000, 2002, 2004, 2007, 2009, 2012, 2015, 2017.


New Zealand Herpes Foundation (NZHF)


The NZHF aims to provide support, current educational material and management options for people with genital herpes in a caring, friendly, confidential environment; to liaise with health professionals, providing a support network to assist in the responsible management of genital herpes; and ultimately, to improve the social context in which people with genital herpes live their lives.


Sexually Transmitted Infections Education Foundation Aotearoa (STIEF)


Promoting optimal sexual health outcomes for all peoples in Aotearoa New Zealand.

E whakatairanga ana i ngā putanga hauora onioni papai mō ngā iwi katoa o Aotearoa.


STIEF resources:

New Zealand HPV Project: www.hpv.org.nz

New Zealand Herpes Foundation: www.herpes.org.nz

Just the Facts: www.justthefacts.co.nz

HPV and Herpes Helpline - Toll Free 0508 11 12 13 from a landline or 09 433 6526 from a mobile

Guidelines for the Management of Genital Herpes in Aotearoa New Zealand: www.guidelines.stief.org.nz 


Other useful resources:

New Zealand Sexual Health Society (NZSHS) resources: Comprehensive STI Management Guidelines and Patient Information handouts are available on https://www.nzshs.org/guidelines/ 

Herpes Viruses Association UK: https://herpes.org.uk/ 

Dermnet NZ: www.dermnetnz.org/topics/genital-herpes

Australasian Society for the management of infectious diseases: Guidelines for the management of perinatal infections - https://asid.net.au/publications


How to cite this document: 

Sexually Transmitted Infections Education Foundation. Guidelines for the Management of Genital Herpes in Aotearoa New Zealand: 13th Edition. 2024. Available at: https://guidelines.stief.org.nz/herpes.


Introduction


The Aotearoa New Zealand Genital Herpes Guidelines were first developed in 1994 and regularly updated by the Professional Advisory Board until 2017. This 13th edition of the guidelines presents the previous chapters in individual documents to improve online accessibility. The authors and review team of these guidelines includes representation from patients, and medical and nursing disciplines involved in the management of people with genital herpes. Contemporary international literature has been evaluated to develop best practice regarding the diagnosis, treatment and evaluation of patients with genital herpes in Aotearoa New Zealand. The recommendations are based on strong evidence in the literature or reasonable supposition and expert opinion.


The information contained here is accurate at the time of publication.


The recommendations made in the guidelines have been rated using the following evidence-based categories:


GRADE A: Very strong evidence

Based on well-designed prospective randomised controlled clinical trials.


GRADE B: Fairly strong evidence

Based on evidence from case-control or cohort studies, or clinical trials lacking one or more of the above features.


GRADE C: Weak evidence or firmly held opinion

Based on published case reports, well-written reviews or consensus.


What’s new in 2024?


Since 2017, there have been no significant advances in the management of genital herpes. The World Health Organization (WHO) has emphasized the importance of quality of life for individuals with long-term and recurrent sexually transmitted infections. The 2024 European Guidelines for the management of genital herpes(1) have lessened the criteria for the prescription of suppressive therapy to include patients who have problematic recurrences, those who are adversely psychologically impacted by herpes recurrences and patients who wish to decrease the risk of transmission to their sexual partners. Likewise, the requirement to have a suppression free trial at the end of 12 months has been changed to ‘review prescribing’ after 12 months. This more patient centred approach to genital herpes management has been adopted by this edition of the Aotearoa New Zealand Guidelines for the Management of Genital Herpes. 


Other changes in 2024 guidelines include:

  • Guidance around second stage treatment for patients who are poorly controlled on suppressive therapy;
  • Specific information on herpes proctitis;
  • Recently pharmacists have been able to upskill to provide valaciclovir for episodic treatment for a recurrence of previously diagnosed HSV;
  • Changes to advice on active herpes during labour - As caesarean section is still recommended if ROM has already occurred, and genital lesions are present. Data from 50 years ago suggesting reduced benefit if ROM >4 h is not high quality.
  • Commercial point of care (POC) tests available online are not supported for the diagnosis of HSV-2. They are not reliable and should not be used. See NZSHS Position statement.



Key Points - Genital Herpes
HSV is a common, opportunistic infection. Most people (>80%) will eventually host a herpes virus which could result in genital herpes.
Genital herpes is a common infection caused by herpes simplex virus type one (HSV-1), most commonly associated with facial herpes commonly called cold sores) and/or herpes simplex virus type two (HSV-2).
Most facial herpes is HSV-1 mediated.
Up to 50% of first episode genital herpes is due to HSV-1 through oral to genital contact.
As many as one in five adults in Aotearoa New Zealand are serologically positive for HSV-2.
HSV-2 is more common in women than in men, and the prevalence of HSV-2 infection increases with age.
Genital herpes often presents atypically and is under-recognised and under-treated.
Minor lesions are common; any recurring, localised, genital symptoms or lesions should be tested with a polymerase chain reaction (PCR) HSV swab.
Laboratory confirmation of the diagnosis and typing based on the findings of HSV PCR swab testing is important, but should not delay treatment.
HSV serology is not recommended and is only indicated in specific clinical situations.
Oral antiviral treatment is safe and effective, and generic brands are not expensive.
Oral antiviral treatment of the first clinical episode (without waiting for the results of any testing) should always be offered, regardless of the time of symptom onset. The ’72-hour’ herpes zoster rule does NOT apply.
Antiviral therapy for recurrent genital herpes may be suppressive or episodic.
An individual diagnosed with HSV-2 should be informed about the availability of suppressive therapy and offered it as appropriate.
Suppressive therapy is invaluable for individuals with frequent and/or severe recurrences and/or psychosocial morbidity.
Episodic antiviral therapy requires anticipatory prescribing, as treatment needs to be commenced at the first signs of a recurrence.
Neonatal HSV infection is rare but potentially fatal, and occurs within the first 4–6 weeks of life. Symptoms are nonspecific and a high index of suspicion is required. Most neonatal HSV infections are acquired at birth, generally when the mother has an unrecognised first genital herpes infection that was acquired during pregnancy.
Specialist advice on management is needed for a pregnant woman who has a history of genital herpes and active lesions at term, OR especially in the high-risk situation of a first episode of genital herpes in the 6 weeks leading up to delivery.
Preventative and therapeutic vaccines for HSV continue to be developed but none are available at present.(2)
Herpes positive individuals need the following: To be given accurate, up-to-date information; to be provided with the best treatment available; to be involved in decisions about their treatment and management; to be referred for specialist care of advice where appropriate.



References


  1. International Union Against Sexually Transmitted Infections. 2024 European guidelines for the management of genital herpes. Available at: https://iusti.org/wp-content/uploads/2023/10/IUSTI-Guidelines-2024-Final-version-for-Circulation-.docx. Accessed 1 Oct 2024. 
  2. Malik S, Sah R, Ahsan O, et al. Insights into the novel therapeutics and vaccines against herpes simplex virus. Vaccines (Basel) 2023; 11 (2): 325.
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