An evolving understanding of genital herpes pathogenesis: is it time for our approach to therapy to change as well?

In this issue of the Journal, Tata and co-workers present data from a small, intensively studied group of women with genital herpes due to herpes simplex virus (HSV) type 2, demonstrating that during a 30-day period these women experienced both symptomatic and asymptomatic genital viral shedding bilaterally and at areas innervated by dorsal root nerve ganglia on both sides of the midline [1]. These findings challenge widely held beliefs that genital HSV infection resides in solitary or adjacent dorsal root ganglia on just one side of the body, suggesting that the infection may occur on both sides of the midline and in more ganglia than previously thought. Although the data need to be validated by additional investigations, they encourage conceptualization of genital herpes as a chronic, nearly continuously active infection rather than an infection characterized by periodic recurrences interspersed with periods of disease inactivity. Tata et al studied a small number of patients and did not include any men; moreover, as they acknowledge, 3 of their 4 patients had become infected within the preceding year and were thus were in a period of infection when both recurrences and asymptomatic viral shedding are more frequent than in persons with older infections. Nonetheless, the data are of great potential importance, because they further challenge widely held beliefs regarding genital herpes and, by extension , its management. They also suggest that it is time to use these sorts of data to guide the evolution of our approach to genital herpes management and prevention. Thirty years ago there were no easily taken, highly effective medications for genital herpes treatment and no reliable serological tests to help diagnose infection with the virus. In 1982, herpes was characterized as " Today's Scarlet Letter " in a cover story in Time magazine [2]. Much has changed since that time. We now know that about 1 in 5 American adults has genital herpes but that only ∼10% of them are aware of their infection [3, 4]. We know that " classic herpes " is not typical herpes and that in many persons with genital herpes the manifestations of initial and recurrent genital infections are subtle, varied, and frequently overlooked [5]. Furthermore, we have learned that the vast majority of HSV transmission occur through contact with sexual partners who are unaware of their infections and are asymptomatic when the infection is transmitted [6, 7]. Our tools for herpes diagnosis …