Introduction
Just like diamonds and true love, herpes is forever.
Herpes is a common STD frequently encountered by clinicians in HIV STD clinics in sun-drenched Singapore. In clinics dealing with HIV PEP (post exposure prophylaxis) and STDs, herpes infection tops the charts together with gonorrhea and Chlamydia.
Herpes is also sometimes found in famous celebrities, sportsmen, and even certain high profile divorces.
In the infamous divorce of Oscar-winner Liza Minnelli, her husband David Gest accused Mennelli of infecting him with herpes six months after their marriage. Of course, such lack of disclosure of health status can be perceived as a form of deception in marriage.
The Ethics of Disclosure
In moral philosophy and ethics, this divorce case can be argued as person A using person B for his/her purported ends (e.g. marriage). If we presume a certain state of affairs where A desires some kind of sexual interaction with B, then this sexual interaction with B is A’s purported ends. It may further be perceived that A sexually used B if there is either some form of coercion or deception (such as the lack of informed consent).
Thus, A sexually uses B if and only if A deliberately behaves in a way that violates the obligation that B’s sexual interaction with A be based upon B’s voluntary and informed consent. One can think of several cases in which one person sexually uses another because the former employs deception in a way that undermines the informed nature of the latter’s consent to sexual interaction. For example, Ms A knows she has herpes or some other STDs, and is very well aware that Mr B would never consent to sexual activities if he were to know of her condition. So when questioned by Mr B, Ms A denies that she has any HIV, STD or herpes.
If a person’s consent to sexual interaction is predicated on false beliefs that have been deliberately and misleadingly inculcated by his or her sexual partner in an effort to acquire the former’s consent, the resulting sexual intercourse involves one person sexually using another person. In the aforementioned divorce case, David Gest can argue that Mennelli has deceived him and therefore, sexually used him for her own ends. The outcome wouldn’t be very pleasant for the Oscar-winner if the allegations were true.
Genital Herpes
Herpes cause by the Herpes Simplex Virus is the leading cause of genital ulcers, and infection with Herpes Simplex Virus type 2 (HSV-2) at least doubles the chances of acquiring HIV through sexual intercourse. Having HSV-2 infection also increases the risk of HIV transmission to the HSV-2 patient.
As mentioned, herpes is forever. It is a chronic, lifelong affliction. Affected patients shed viruses, not only during symptomatic periods, but also when they are feeling well. Herpes is highly contagious, and it has been shown that seventy-five percent of sexual partners of HSV-2 patients eventually contract the disease.
Herpes can be transmitted via contact with infected tissues or body secretions, but the primary route of transmission of HSV-2 is genital-to-genital skin contact with a herpes patient who is shedding the virus. In fact, most genital infections are acquired from partners with subclinical infection, that is, partners who have herpes but are feeling well. In serodiscordant couples, about seventy percent of herpes transmission occurred when the infected partner was asymptomatic.
Case Study
In our case study today, the protagonist is Ms Bublé, a young, bubbly and vivacious 25 year-old accountant. She presented to me with a complaint of genital and perianal rash and pain. It was accompanied by fever, malaise, vaginal discharge and headache for the last few days. She revealed that she had been sexually intimate with her boyfriend of 2 years. It had been made known to her that her boyfriend suffered from recurrent genital herpes, but they chose to avoid sexual intercourse when her boyfriend had obvious symptoms of herpes.
She recalled that she had numerous “bubbles” in her nether region that subsequently broke down and produced a painful rash and several ulcers. Physical examination revealed multiple bilateral tender ulcers of the labia and perianal region (i.e. ulcers and rash on both sides of her private parts). Vaginal examination showed ulcers and purulent discharge from the cervix. Palpation revealed tender bilateral inguinal lymphadenopathy (i.e. painful lymph nodes on both her groins). Her oral temperature was 38.5 degree Celsius.
She had a classical picture of primary genital herpes. Other STDs that commonly produced ulcers include syphilis and chancroid – both of which are unlikely in this clinical presentation. Swabs taken from her lesions (vaginal and cervical ulcers) were positive for HSV-2. Nucleic acid amplification tests (NAAT) for gonorrhea and Chlamydia, as well as HIV serology, were all negative.
She was advised to return with her boyfriend for a thorough STD HIV testing and screening. Preventative measures like safe sex and HIV PEP were taught.
She was treated with Valacyclovir for 10 days, and her symptoms resolved very well. She had significant pain relief after 4 days, and her rash healed completely after 2 weeks. She was also warned that repeated crops of lesions might reappear 2 to 6 weeks later.
When she and her boyfriend returned the next day, they were counseled about the possibilities of asymptomatic viral shedding and disease transmission, which would explain how she acquired her very first episode of herpes outbreak. There is also risk of transmission of herpes to all her future sexual partners, but not to her current boyfriend. In this case, her boyfriend did not seem to have withheld information. He was truly ignorant of the fact of asymptomatic transmission of herpes infection. On an ethical note, the charge of person A “sexually using” person B is therefore a moot point in this scenario.
Herpes Suppressive Therapy
The couple was also educated about the availability of suppressive therapy for recurrent genital herpes. Suppressive therapy is especially recommended for those who have 6 or more outbreaks per year, those with clinically severe outbreaks, or those who are psychologically affected by the outbreaks. Suppression reduces recurrences by about eighty percent, and the antiviral drug Valacyclovir has been shown in clinical trials to reduce frequency of transmission by almost 50%. Therefore, suppressive therapy of herpes is effective in reducing frequency of outbreaks as well as risk of transmission to sexual partners.
Although herpes is forever, the torment need not be. If you think you have herpes, or if there are unexplained bubbles or ulcers down below, consult our board accredited Family Physician concerning HIV and STD testing, or get yourself educated on HIV Post Exposure Prophylaxis (HIV PEP).
Do come to sunny Singapore to get yourself tested.
