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What's New and What's Not
Current Thoughts for People Living with Herpes
by Dr. H, Medical Director
www.herpes.org
A Revised Paper for January, 2018
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I received a question from a nice person the other day who noted that some of my pages had not been updated in awhile. I had to agree, and I thought for a bit about how the stresses and strains of clinical practice make it hard for me to get to the Web as often as I should. I promise to do better, though!
I spent several hours researching a number of current topics over the last week, and I wanted to share with you some of my current findings. These are issues that I have monitored over the years, principally through the published literature available through the National Library of Medicine as well as through scientifically-refereed medical journals available around the world. I then weigh my judgments and recommendations based upon the apparent scientific validity of these papers and my own experience as a clinician, researcher, and patient advocate.
In answering a number of your questions over the last couple of weeks, I thought it would be useful to return to some recurring themes that I am asked, time and time and time again. These are questions such as, "will there ever be a cure", or "Is there a vaccine that will protect my partner", and "how do I keep the virus under control". Here are some thoughts.
The issue of a herpes vaccine that will be both preventative for a partner as well as therapeutic for an infected person remains one of the hottest topics in research today. The distressing fact, though, is that there really has not been a vaccine to date that has convincingly offered protection to partners. I discuss some of these efforts elsewhere on the website, such as the pioneering work of Skinner et al from the 1980's to the Herpevac Trial whose results were recently published (Herpevac Trial for Women finds experimental vaccine ineffective in prevention of genital herpes disease, October 2010: "An experimental vaccine intended to prevent genital herpes disease in women, although generally safe and well-tolerated, proved ineffective when tested in the recently concluded clinical study known as the Herpevac Trial for Women.").
For some reason that is not understood (according to my research), the DNA virus known as herpes simplex remains elusive to the immune system. It strikes me as a bit odd that another member of the "herpesvirus hominis" family, namely Varicella zoster (which causes chicken pox), can be successfully immunized against, rendering a modest infectious disease scourge - that many of us older physicians treated for many years - much, much less of a problem in medicine today. What is it about herpes simplex virus (HSV) that is eluding the efforts of the makers of vaccine today? Some day we'll know the answer, but we don't know it today. Similar problems linger for Hepatitis C, tuberculosis, and HIV: We just don't have an effective vaccine yet. It is odd that vaccination efforts have been so successful in so many other ways: Tetanus, polio, smallpox (completely eradicated), rabies, mumps, measles, rubella, Hepatitis B, and hemophilus (one of the serious causes of meningitis in years past). But, not so yet for HSV. I find it interesting that so many researchers and so much funding have gone into this effort without success.
A fellow named Halford has made the news recently (http:www.herpesvaccineresearch.com) as regards his work on HSV ICP0 mutant virus vaccine. The theory seems to be that a strain of HSV virus can be made that will not cause the disease but that will generate an immune response and possibly be protective for uninfected partners, even possibly being therapeutic for infected persons. A description of the patent can be found here: Halford Vaccine Patent . You might find this interesting reading. The bottom line is really this: CAN the immune system actually locate the virus, "wall it off", and possibly either eliminate the virus from the infected nerve cells or stop these cells from reproducing virus? To date, the answer seems to be "no". Perhaps the Halford model will work. Only time will tell.
WHAT TO DO ABOUT RECURRENT OUTBREAKS?
Anybody who has recurrent herpes simplex infections should have a doctor somewhere who is sympathetic, understanding, and informed. I had a letter recently from someone who told me that in that country (it was not in America), that apparently typical treatment custom for HSV does NOT include suppressive therapy to prevent transmission to un-infected partners. I deeply hope that this is not true (I only have the letter to back this statement up). But, if it IS true, that is a serious misunderstanding that seems to be widespread in that medical community.
Acyclovir, valacyclovir, and famciclovir are the three antiviral medications that are approved for the treatment of HSV infections. They work for new outbreaks, for recurrent outbreaks, and (at least valacyclovir, but I suspect applies to all three) to decrease the incidence of transmission of the virus to a partner. These drugs are very non-toxic. Studies going out over ten years examining the daily use of acyclovir to prevent recurrences has found the drug to be safe and effective, and the resistance of HSV to acyclovir remains very small (one study in immunocompetent patients found resistance to be as low as two cases in a thousand patients).
If you or a loved one have recurrent HSV outbreaks, that person should have access to a physician that will provide - at minimum - anti-viral therapy to decrease the incidence and severity of these outbreaks. If the physician will not make this therapy available - and if the physician cannot provide a logical reason for being unwilling to prescribe therapy - then I suggest getting a second opinion. Antiviral therapy is effective, limiting the duration of outbreaks and limiting their severity. Indeed, antiviral therapy taken in the right dosage can abort an outbreak and prevent it from developing into a full-blown relapse.
Medical therapists have examined the use of antivirals in novel ways. A recent paper found that famciclovir taken in a dosage of 1000 mg twice daily for one day was effective in aborting outbreaks of HSV (Aoki FY. HERPES, 14:3, 62-65. 2007). My direct observational experience has confirmed this. The only reason NOT to make such a therapy available to an informed patient/consumer would be in the risk of increasing the resistance of the virus to the medication. At this writing, I am not currently aware of such a risk. A seminal paper was written regarding this matter (Gupta R, Wald A. Expert Opin Pharmacother. Genital herpes: antiviral therapy for symptom relief and prevention of transmission. 2006 Apr;7(6):665-75), and followup in 2010 with a paper looking at acyclovir resistance in another population (HSV infected patients who also were HIV+) confirmed this.
As a practicing clinician, I believe that patients with recurrent HSV outbreaks should have a prescription antiviral available. Find a physician that either IS informed or who will BECOME informed, and get under therapy. You will find dosages in my Treatments paper elsewhere on the website. Remember that being on therapy does not protect the partner a hundred percent. Remember also that being on therapy does NOT mean that you can have intimate relations without informing the partner.
COST OF ANTIVIRALS
The cost of antiviral mediction has plummeted over the last few years. Suppressive therapy can be purchased at low-cost pharmacy chains now for around a hundred dollars a year. That is cheap compared to the stress that frequent outbreaks can bring. I strongly encourage the readers to have a dynamic relationship with a caring and concerned clinician who will make long-term suppressive therapy available.
One bright note now is that Valtrex has gone generic! Valacyclovir is the valine ester of acyclovir. It is better absorbed than acyclovir when taken by mouth, and it is then converted in the liver to acyclovir in the bloodstream. Valacyclovir taken by mouth gives levels of acyclovir in the bloodstream comparable to acyclovir given by intravenous injection. What this means is that valacyclovir is a bit of a better drug.
I saw valacyclovir available by prescription through a Canadian online pharmacy recently for under a dollar a pill for the 500 mg dosage, when bought in a year's supply. This means that for $300 +/- per year, very effective control of outbreaks is available.
Now, that said, I have NO information that says that valacyclovir at 500 mg per day is more effective than, say, 800 mg of acyclovir taken once a day to suppress outbreaks. Let me suggest that you consult your private physician as regards these decisions. Very little research is available to guide the motivated consumer, unfortunately.
DOES NONPRESCRIPTION THERAPY WORK?
This week I spent quite a lot of time looking at current research on propolis, prunella vulgaris, algae, and a number of other products that have scientific evidence of antiviral activity but whose clinical effects have not been verified through rigorous scientific testing. I also do not know what happens if these products are consumed by mouth. Thus, I am always very cautious about the taking of substances internally by anyone. It is certainly true that a website can claim that a medication taken internally - ozonated water or peroxide or colloidal silver - have specific effects. However, absent rigorous scientific testing, it is impossible to know if a substance taken internally by mouth actually is safe. Thus, I always urge caution.
A good example of what I just said is very recent evidence that suggests, quite strongly, that calcium supplementation taken in the absence of Vitamin D supplementation may increase the incidence of heart attacks in adults. This is concerning enough to me that I have stopped taking calcium supplements by mouth but am rather increasing the amount of fat-free milk that I drink. It is easy for a health products vendor to make claims about some substance that is for sale, but it is only through carefully conducted scientific studies that proper conclusions can be drawn.
CONCLUSIONS
My recent reflections draw me back to some of the earlier work that I posted on the website. It is important to learn to live with a chronic viral infection, keep it dormant, and adopt a style of living that helps keep the infection under control. The protection of a partner, and the honesty required to be revealing of an infection in advance so that proper precautions may be taken, are essential. Having a caring, informed physician is essential. Understanding new work that reveals "abortive therapy" opportunities is really important.
I would now ask you this: Do you think that creating a list of physicians for the website who would be available to evaluate and treat for chronic HSV infections is a good idea? Send me a note at the website to let me know your thoughts.
Above all: Be of good cheer. Know that you are loved by many. Do not freak out or panic regarding an HSV infection. Get the right advice to keep it under control.
Best regards,
Dr. H.
January, 2018
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