The
other
epidemic

Genital herpes rages among women and devastates some newborns

 Fifteen years ago, genital herpes had the sexually permissive in a panic. One in 10 adults was thought to be stricken with this ancient, incurable venereal disease and its accompanying blisters and sores. Suddenly, "free" sex seemed very costly; here was a consequence of a one-night stand that the pill couldn't avert and penicillin couldn't remedy. Then herpes seemed to vanish, eclipsed in the public's mind by the swift, deadly rise of AIDS. 

 But the virus didn't go away: It surged to create an epidemic. According to a study published last month in the New England Journal of Medicine, since the late 1970s, the proportion of Americans infected with the herpes simplex type 2 virus (HSV-2) has increased by almost one third. Today, 45 million people over the age of 12 carry it--about 1 in 5. Women generally are more susceptible to sexually transmitted diseases (STDs), so the numbers climb even higher for women. One in five white women is infected, versus one in seven white men. One in two black women has the virus, compared with one in three black men. 

 To Anna Wald, medical director of the Virology Research Clinic at the University of Washington in Seattle, "Herpes has become a major public health problem." In addition to causing sufferers periodic pain and discomfort, genital herpes is potentially devastating to newborns exposed during delivery. Herpes has also been shown to confound the lives of people with suppressed immune systems, such as burn victims and transplant patients. Recent studies show that people with herpes are more susceptible to a variety of STDs, including HIV--the virus that causes AIDS. 

 Dangerous myths. Several misconceptions about herpes are fueling the epidemic, according to public-health experts. Most Americans think the virus is uncommon, for instance, afflicting 1 percent or less of the population, says Peggy Clarke, former president of the American Social Health Association in Research Triangle Park in North Carolina. "People just don't know how likely they are to pick it up [from a prospective partner] unless they take precautions." 

 Many people also hold the mistaken belief that the herpes virus that infects the mouth is benign (herpes simplex type 1 or HSV-1) and that the one that infects the genitals is malevolent (HSV-2). There are differences between the two: HSV-1, which is far more prevalent, infecting about 7 in 10 people, often is acquired in childhood and usually infects the mouth; HSV-2 is typically acquired sexually and usually infects the genitals. But the two are clinically indistinguishable and can inhabit each other's territory. Oral-genital sex is an increasing source of infections, with perhaps 15 percent of genital sores really a manifestation of an HSV-1 infection. "People need to think of [lip] cold sores as infectious to newborns and sexual partners, too," says virologist Rhoda Ashley of the University of Washington in Seattle. 

 In addition, studies have shown that 2 out of 3 people with the virus don't know they are infected and potentially contagious. How can they miss clusters of itching, painful blisters? For many, a first outbreak is hard to ignore--like a bad case of the flu plus lesions. But others, especially individuals who already harbor HSV-1, often experience only a mild primary infection with HSV-2--with symptoms more like paper cuts or pimples than blisters. According to Ashley, the symptoms can be so variable that "even skilled practitioners can miss [herpes]." Some people also may be refusing to face facts. According to one study, 40 percent to 75 percent of the people with genital herpes who claim to have never experienced symptoms are able to identify them after a doctor delivers the news that they are infected. 

 No "safe" time. Many believe that people who carry herpes are infectious only during acute episodes, when blisters erupt. Yet infected people can shed virus particles from the genital area--and enough of them to infect a sexual partner--even when they are lesion free. Recent research with a new, sensitive test reveals that even when women with HSV-2 have no visible symptoms, they are shedding the virus "subclinically" about 1 in every 6 days. This "subclinical" shedding is generally greatest in the first six months after a person contracts the virus. The shedding rate declines slightly over the next six months and appears to fluctuate thereafter. Most people today with a first-time infection appear to have contracted it from sexual partners who were not aware of any symptoms. (Similarly, people with recurring cold sores in the mouth can transmit the virus between outbreaks.) "It's a tough message to have to tell people, but there's no `safe' time [for people with the virus] to have [unprotected] sex," says one counselor at the National Herpes Hotline (919-361-8488). 
 

The herpes virus can be devastating to newborns, as Barbara Wilkop of Birmingham, Mich., knows too well. Her 10-year-old son, Jimmy, has an IQ of 35 as a result of contracting herpes from his mother at birth. Jimmy can hear, but he can't understand words. He can ride a bicycle, but he can't always figure out what to do at the end of a dead-end street. He has to be reminded to zip up his pants whenever he goes to the bathroom, and he has so little impulse control that at one family gathering he bit a cousin on the

shoulder. "Sometimes I get so sad," says Wilkop. "Jimmy will never get a chance to drive a car, get married, buy a house, or see his first child born."

Barbara Wilkop signs, "I love you," as Jimmy heads to school.  He grasps few symbols of sign language, gets frustrated trying to express himself, and calls for attention by grunting.

 
 About 1 in 3,000 infants nationally contracts the herpes virus during delivery, says David Kimberlin of the University of Alabama at Birmingham. Women who have had herpes for several years before having children rarely infect their infants during delivery, thanks to protective antibodies passed from mother to child in the womb. Only about 2 in 100 such infants pick up the virus during birth, and, in most instances, it infects only the skin, eyes, or mouth. 

 Infants at high risk. But one third to one half of infants delivered to women who contract the virus for the first time late in their pregnancies contract herpes. In these cases, herpes often attacks the brain, causing death or severe neurological impairment, ranging from blindness and deafness to mental retardation. Because the consequences of infection can be so severe, obstetricians usually recommend delivery by Caesarean section if they spot even the hint of a lesion at the time of delivery. "The general rule is: `No lesion, vaginal delivery; lesion, C-section,' " according to Larry Gilstrap, chairman of the committee on Obstetrics at the American College of Obstetricians and Gynecologists. As a result, genital herpes is one of the leading causes of C-sections nationally. Although precise figures are not available, Gilstrap estimates that herpes may be fourth or fifth on the list. 

 Doctors are debating whether pregnant women should be screened for herpes at their first prenatal visit to the doctor, as most are for syphilis, German measles, and a host of other diseases. Zane Brown of the University of Washington in Seattle contends that adding a blood test for herpes to the list makes good sense. "I can go from one end of a decade to the other and not see [a case of] syphilis or gonorrhea, but 35 percent of my patients have genital herpes," he says of his largely middle-class practice. It's especially important to identify high-risk couples, in which the man is infected and the woman isn't. Typically, he tells such couples to use condoms and prescribes for the men an antiviral drug, such as acyclovir or famciclovir, to suppress outbreaks and subclinical shedding, or he counsels couples to abstain from intercourse for the duration of the pregnancy. 

Physicians who oppose prenatal screening for herpes argue that test results aren't that useful clinically. Even women who test positive in early pregnancy won't necessarily be shedding the virus during delivery, Gilstrap says. And a woman who tests negative at the start of her pregnancy could have picked up the virus by the end.
	At Jimmy's workstation, his sister Sarah helps him to sort objects by shape and color and learn how to concentrate, which is very hard for him.

 There are dramatic reasons why all health care providers should deal with the topic. Besides inflicting health problems on infants, adults can find themselves in a fierce struggle with the virus. People with compromised immune systems are the most vulnerable. In burn victims, a herpes skin infection can spread bodywide. "Though rare, it's a well-recognized complication that can kill you," says University of Washington's David Koelle. Bone-marrow-transplant patients and people with lupus can succumb to herpes infections too, although hefty doses of antiviral drugs usually will keep the virus in check. Most AIDS patients--particularly in the disease's early stages--have sufficiently intact immune systems that lesions stay localized. But outbreaks can become the size of silver dollars or larger and be slow to heal. 

 Public-health experts are deeply concerned about studies finding that getting herpes sores puts sufferers at a much greater risk of contracting HIV--up to nine times as great--by providing portals for HIV to enter the body. "Especially in inner-city populations [which have a high incidence of herpes], it's plausible that herpes is fueling the spread of HIV," says Sharilyn Stanley at the National Institute of Allergy and Infectious Diseases (NIAID) in Bethesda, Md. 

 Despite the many health threats posed by herpes, few weapons are available to fight the disease. The diagnostic tests commercially available today are unreliable. People with active lesions can have them swabbed and cultured, but such "viral culture" tests are accurate only when lesions are newly formed and teeming with virus particles. Because many people don't get in to see their doctors until their blisters are partly healed, about half the herpes-infected people who take the test are falsely assured that they don't have the virus. 

 Testing the blood. Doctors can give patients with no current symptoms a blood test for antibodies to HSV. But the tests currently on the market can't diagnose a case of genital herpes because they don't distinguish between HSV-1 and HSV-2. An accurate, reliable blood test that can tell HSV-1 from HSV-2 is being reviewed by the Food and Drug Administration, however, and may be available by early next year. 

 Several studies of couples in which one person is infected and the other isn't have shown that transmission is not inevitable, even after years of sexual contact--although often it takes only a few months for the uninfected partner to catch the virus. Herpes is a "very serious infection," according to Penelope Hitchcock, chief of the division of Microbiology and Infectious Diseases at NIAID, but "[it] is not the most infectious disease in the world." 

 Still, there is no reliable way to prevent transmission of the virus. Condoms provide only partial protection because the virus can be shed from parts of the body not covered by condoms. "Condoms work pretty well for HIV [which is found in body fluids], and not so very well with HSV," says André Nahmias of Emory University School of Medicine in Atlanta. Until recently, researchers hoped that nonoxynol-9, a spermicide often used with condoms and diaphragms, would prove to be an effective chemical barrier, wiping out virus particles as handily as it does sperm cells. But recent studies have shown that nonoxynol-9 is so irritating to the mucosal membranes of the female genital tract that it may increase a woman's susceptibility to infections by damaging these protective membranes. "This is the frustration of clinicians," says Nahmias. "What do you tell people to do?" 

 To reduce the risk of contracting herpes, Hitchcock of NIAID recommends a few sensible precautions. If a person is not in a monogamous relationship with an uninfected person, he or she should always use condoms. If one partner carries the virus, the couple should never have sex when the partner has lesions, and they should use condoms at other times. If a partner has recurring lip sores, unprotected oral sex should be avoided. Women should abstain when they have vaginal yeast or bacterial infections, which can wipe out healthy microbes. 

 NIAID has begun funding a host of research projects aimed at developing new tools for stemming the epidemic. A promising area of inquiry is whether daily doses of acyclovir can help carriers of genital herpes protect their partners and infants from infection. A preliminary study published last year by Laurie Scott, then of the University of Texas Southwestern Medical Center in Dallas, and her colleagues suggests that women may be able to protect their babies from infection by taking acyclovir during the last month of pregnancy. Similarly, a study by Anna Wald and colleagues last year showed that acyclovir therapy reduced viral shedding between outbreaks in women by 94 percent. Wald says, "The transmission study hasn't been done yet, but these results do suggest that the drug may interrupt transmission [between sexual partners]." 

 Many herpes experts say that only a safe, effective vaccine will be able to decrease the number of people infected each year. But while many potential vaccines are being developed, all are at least a decade away.