Herpes treatment in Africa: time for a rethink?

Giving people with genital herpes an advance supply of anti-herpes medication and instructions on how to recognise the early signs of a herpes attack may be the most effective way of limiting the spread of HIV in Africa through herpes lesions, doctors from the United Kingdom and South Africa argue in a recent edition of The Lancet.

In settings where infection with HSV-2, the virus that causes genital herpes, is widespread, up to half of HIV transmission may be facilitated by the presence of genital herpes, or by herpes virus shedding in the genital tract that is not causing symptoms.

Despite its key role in the HIV epidemic, especially in settings where the epidemic is long-established, treatment of genital herpes in Africa is limited. This is partly due to a perception that herpes is incurable, the authors say, and little attention has been paid to the logistics of providing treatment for a chronic sexually transmitted infection that may be responsible for huge numbers of HIV infections.

Instead, patients who seek medical treatment for genital ulcers will first receive antibiotic treatment for syphilis or chancroid, following guidelines from the World Health Organization that recommend treating the presenting symptoms without diagnostic tests, on the assumption that since syphilis is common and antibiotic treatment relatively cheap, this approach is the most cost-effective means of reducing the prevalence of genital ulcers.

But when the majority of genital ulcers are caused by HSV-2, the syndromatic approach is ineffective, and may actually cause patients to seek help from traditional healers when the ulcers do not go away. The opportunity to counsel about herpes and HIV transmission, and even better, to offer aciclovir treatment for herpes is thus lost.

Treatment for recurrent episodes of herpes, which are especially frequent in the first year after infection, and more likely to occur in people with suppressed immune systems, is not being offered due to cost, despite the fact that it may have an important role in preventing HIV transmission.

Continuous suppressive treatment, which requires people to take aciclovir every day, is used in the developed world to control herpes and prevent transmission of the virus to sexual partners, but a study carried out in Tanzania has shown that adherence to continuous treatment is difficult. Only 50% of HIV-positive women who received aciclovir in the study took at least 90% of the prescribed doses, which may explain why the study found no significant benefit to suppressive treatment in HIV-positive women when judged by levels of HIV and HSV-2 in genital fluids of the women participants.

But prolonged suppressive treatment may not be necessary, either from the individual’s point of view or a public health viewpoint. HSV-2 was isolated in genital fluids in less than 5% of women who had no symptoms of genital herpes in two studies, and HSV-2 levels are at least 100 times higher in herpes lesions than in the genital fluids of people without symptoms.

Training patients to recognise the early signs of an attack, and giving them aciclovir to take away for use when the signs appear, may be a better way of controlling HSV-2, argue Dr Nigel O’Farrell and colleagues.

Six episodes of herpes treatment each year would work out ten times cheaper than continuous suppressive therapy, they say (aciclovir treatment costs around $3 a day in South Africa but is more expensive elsewhere due to poor availability of generics). But prices could come down enormously if policies towards HSV-2 suppression changed.

“Management of herpes in Africa needs to shift from syndromic management,” they argue, calling for efforts to train health care workers to recognise herpes better and counsel patients on how to control it with medication.