Patient and Physician Partnerships in Managing Genital Herpes

Transcription

1 S57 Patient and Physician Partnerships in Managing Genital Herpes Linda Alexander 1,a and Barbara Naisbett 2 1 Digene Corporation, Gaithersburg, Maryland; 2 GlaxoSmithKline Research and Development, Greenford, United Kingdom Genital herpes simplex virus infections are widespread throughout the world and are characterized by stigma, myth, and anxiety by patients and the public but are perceived as trivial by most physicians. Surveys in the United States, Europe, Australia, and South Africa have measured the unfavorable effect of genital herpes on infected patients, health care resources, and workplace productivity. These surveys identified limited satisfaction of patients with current care and support (41% satisfied), although satisfaction scores were greater for patients receiving suppressive antiviral therapy (56% satisfied). Bridging the gap between patients and physicians is vital for improving the management of genital herpes. Key to facilitating patientphysician partnerships is education and recognition by physicians that patients with genital herpes may have expert knowledge. In effective partnerships, physicians and patients can have informed constructive discussions such that patients share in the responsibility for managing their disease and in therapeutic decision making. Patient involvement in disease management through associations and advocacy groups is becoming increasingly influential in health care. Patient advocacy (defined for this discussion as patient education and empowerment) is particularly important for sexually transmitted diseases (STDs) such as genital herpes simplex virus (HSV) infection. When partnered with health care provider education and public awareness, advocacy may prove integral to stopping the spread of genital HSV infection and to making life better for people with herpes [1]. With such a prevalent and socially stigmatizing disease as genital herpes, physicians should be aware of patient concerns and attitudes in order to manage the problem at both individual and community levels; the patient-physician partnership is essential for optimizing herpes management. The worldwide prevalence of HSV-2 infection has been extensively reviewed [2]. Seroprevalence is increasing in many regions of the world. Genital herpes must be viewed in terms of its effect on both the individual and the wider community. The scale and impact of genital herpes combine to define a Presented in part: 2nd European Congress of Chemotherapy and 7th Biennial Conference on Antiinfective Agents and Chemotherapy, Hamburg, Germany, May 1998; International Congress of Sexually Transmitted Infections, ISSTDR/IUSTI, Berlin, June The American Social Health Association (ASHA) does not endorse products or companies. As president of ASHA, L.A. does not accept personal honoraria for consultant work with industry. Financial support: GlaxoSmithKline (to ASHA for herpes programs; sixcountry telephone survey); ASHA (survey of health care providers on counseling and education provided to patients with genital herpes). a President, American Social Health Association, during preparation of this manuscript. Reprints or correspondence: Dr. Linda Alexander, Women s Health, Digene Corp., 1201 Clopper Rd., Gaithersburg, MD The Journal of Infectious Diseases 2002;186(Suppl 1):S by the Infectious Diseases Society of America. All rights reserved /2002/18608S-0007$15.00 disease of considerable medical and social importance [3]. Patient perspectives on genital herpes and participation in its management are now being acknowledged as essential. The importance of health care professionals partnering with patients is recognized in many countries [4] and continues to be the subject of lively debate, especially in settings where health care is government funded. This review encompasses the importance of physicians partnering with patients for improved understanding of the social and economic impact of genital herpes. Materials and Methods The views of patients and physicians toward genital herpes disease and its management have been identified in a number of studies and surveys. These include a qualitative survey by the US American Social Health Association (ASHA) [5] (information was gathered by staff at the ASHA national herpes hotline and national STD hotline); an international telephone survey of 597 patients with genital herpes in France, Greece, Italy, Sweden, Australia, and South Africa [6] (the aim was to ascertain the effect of genital herpes on patients lives and patients treatment preferences); and two studies that assessed physician attitudes toward genital herpes in Europe and the United States [7, 8]. The first study was designed to identify issues concerning management, treatment choices, and future therapies [7]. The second study [8] focused particularly on counseling and information provided to patients with genital herpes. A cross-sectional survey of 307 patients evaluated the impact of genital herpes on a patient quality of life and on society [9]. Patients attended specialist genitourinary or dermatology clinics in Australia, Denmark, Italy, The Netherlands, and the United Kingdom. The questionnaires included the generic Medical Outcome Study Short Form-36 (SF-36) [10] and the disease-specific Recurrent Genital Herpes Quality of Life (RGHQoL) questionnaire [11].

2 S58 Alexander and Naisbett JID 2002;186 (Suppl 1) Overview of Findings Personal and Social Impact of Genital Herpes Patients diagnosed with genital HSV infection usually have many questions and concerns. There is still considerable shame, embarrassment, and stigma associated with having herpes [12]. For many patients, the psychological impact is far more severe than the physical consequences of the disease [13]. Shock, anger, guilt, and depression are common. These feelings may be intensified by the lack of control that patients believe they have over the disease because of the unpredictable nature of recurrences. Problems with relationships ensue and feelings of low self-esteem, fear of transmission of the infection to others, and impaired sexual function are common [14]. How patients feel was reflected in results of an international six-country telephone survey [6]. Genital herpes had a profoundly negative effect on some infected persons; the anxiety of not knowing when another attack will occur had a significant impact on respondents lives. The survey showed that physical pain or discomfort and psychological strain resulted from genital herpes. Inhibition of sexual behavior was the main practical implication; 67% of respondents reported reducing or stopping sexual contact once they were diagnosed with genital herpes. This also led to social withdrawal and isolation, particularly in younger persons. Figure 1 illustrates patient attitudes toward genital herpes and figure 2 lists the psychological effects of recurrent genital herpes. When asked to describe the personal impact of recurrent genital herpes outbreaks, the most common aspect mentioned by patients was physical discomfort (18%) or pain (13%), particularly stinging and burning sensations [6]. Emotional strain or trauma was noted by 9% of patients. Pain and discomfort associated with herpes episodes were described in another study as moderate or severe by 47% of patients and mild by 48%; the remaining 5% reported no pain [9]. By using SF-36 analysis, mean scores for bodily pain, general health, vitality, social functioning, role emotional, and mental health were significantly lower (i.e., worse) for patients with genital herpes compared with a population norm (two-sample t test, P!.05) [9]. The mental health summary score (role emotional, social functioning, and mental health) was also significantly lower in the study population ( P!.01). The significant impact of genital herpes on mental health perceptions was further reinforced by a depression screen, which revealed that one-third of patients felt depressed or sad for much of the prior year or had sadness or depression on most days for 2 years [9]. Genital herpes patients recorded a mean score of 36.1 on the RGHQoL (maximum range, 0 60) [9]. Significant reductions in quality of life, as reflected by lower scores, were independently associated with increased recurrence frequency (Kruskal- Wallis, P p.002) and with more severe pain or discomfort during recurrences ( P!.001). Use of recurrence frequency as the sole criterion on which to base a therapeutic strategy is, therefore, inadequate for optimal care as patients who experience more painful recurrences, regardless of frequency, also have a significantly reduced quality of life. Economic Aspects Persons infected with genital herpes made an average of 1.9 physician visits in the 3 months prior to survey because of the Figure 1. Patient attitudes towards genital herpes [6]

3 JID 2002;186 (Suppl 1) Patients, Physicians, and Genital Herpes S59 Figure 2. Psychological impact of genital herpes. Direct quotations from respondents illustrate how genital herpes affects their lives [6]. herpes: about one-third in primary care and two-thirds to specialist clinics [9]. This medical resource usage adds a considerable burden on the health care system. Genital herpes has a measurable impact on workplace productivity [9]. The majority of patients surveyed (71%) were employed. Although patients only recorded 0.4 days absent from work due to genital herpes symptoms over the previous 3 months, they reported that symptoms attributable to genital HSV infection were present an average of 22.2 working days. Almost half (45%) estimated their effectiveness at work was reduced by 25% 50% when they had symptomatic recurrences. What Patients Want More than 50,000 people in the United States contact the Herpes Resource Center (HRC), staffed by ASHA, every year seeking reliable up-to-date information about genital herpes in order to obtain effective care and help in putting genital herpes in perspective. Consistent themes and concerns emerge and are summarized in figure 3. Diagnosis. With the more widespread availability of new type-specific serologic tests for genital HSV infection, the HRC has noted more people requesting information about diagnostic testing. Many patients want to know about the accuracy of the newer tests, how they differ from earlier versions, and how they compare with HSV culture and diagnosis by physical examination. They are also concerned when they learn that HSV culture may be of limited sensitivity and dependent upon the timing of the culture and transportation variables. While it may take time for physicians to explain testing considerations and limitations, the HRC has found that patients generally appreciate the time and attention provided. The international six-country telephone survey of genital herpes patients confirms the findings of ASHA s HRC; in particular, that one main requirement for patients is an accurate diagnosis [6]. For participating patients, the initial diagnosis of genital herpes was made by a primary care physician (38%), a gynecologist (27%), or dermatologist (20%) and varied by country. Most respondents (68%) said their doctor gave them a definitive diagnosis of genital herpes at their first visit. For those not receiving a diagnosis at the first visit (32%), there was an average wait of 15 days for a test result; a minority of respondents waited 1 month before diagnosis. In 73% of patients, diagnosis was based on clinical suspicion after physical examination; only 41% had a swab taken for viral culture and 21% said they had a blood test. Many (39%) were anxious during the diagnostic process and 38% were embarrassed; women were affected more than men. When asked to rate the importance of six factors involved in diagnostic testing for genital herpes, the respondents main priority was for an accurate diagnosis (figure 4) [6]. Counseling and information on the disease and treatment options were also highly ranked. Although patients found the idea of new typespecific, rapid, office-based tests for diagnosis of genital herpes

4 S60 Alexander and Naisbett JID 2002;186 (Suppl 1) Figure 3. Predominant patient and physician views about genital herpes and its management [5 8] appealing, they emphasized that accuracy of diagnosis was of utmost importance, although the speed of availability of results was perceived as a major advantage (81%). A minority (8%) felt that a speedy diagnosis could enable earlier treatment, thus relieving symptoms, and 6% thought the test would remove the stress of waiting for the diagnosis. Management expectations. All patients want an absolute cure for genital herpes a treatment that would eradicate HSV from its latent state and completely prevent recurrent genital herpes [5]. Once they learn such a drug does not exist, they want to know the advantages and disadvantages of available antiviral therapies and which are most effective. There is disparity in the management of genital herpes throughout the world and, although effective treatments are available, not all patients appear to be informed about them [6, 7]. Treatment strategies. Patient acceptability of a treatment strategy is critical, and the patient and physician should discuss options together and tailor therapy to suit the individual and his/her circumstances. In Western countries where oral antiviral drugs for recurrent genital herpes are widely available, the relative merits of suppressive versus episodic treatment are a common topic of discussion among physicians and patients [5]. For many patients, suppressive therapy helps them take control of genital herpes but for others it can be a daily reminder that they have genital herpes. Thus, some patients prefer episodic therapy while others prefer long-term suppressive therapy (e.g., those who do not cope well with the discomfort and stigma of recurrences or whose outbreaks are especially frequent). Patient preferences for treatment may vary over time from suppressive therapy to episodic, or vice versa, with changes in disease natural history, lifestyle, or life events. From numerous interactions with genital herpes patients, ASHA and the HRC found that, for many, suppressive therapy brings the most consistent relief from repetitive herpes outbreaks and frees them from constant anxiety and worry. For others, common concerns about long-term suppressive therapy revolve around safety and viral resistance. No definitive evidence suggests that long-term suppressive therapy with acyclovir is associated with waning efficacy, the development of resistance, or side effects [15 17]. The same is expected of its prodrug, valacyclovir. The international telephone survey [6] highlighted the wide range of treatments used for genital herpes. Treatment varied according to local prescribing practices, but the most common prescribed therapy was oral acyclovir (used by 46% of patients; table 1). At the time of the survey, 55% of all respondents were using episodic antiviral therapy compared with 22% on continuous suppression; 17% alternated between these two antiviral strategies. Of those receiving suppressive therapy, most had treatment for!1 year (72%); however, the majority of those alternating treatments had been doing so for 11 year (57%); the largest proportion (39%) used the treatments for 1 3 years. Satisfaction with therapy. Survey participants were asked to rate their current therapy in terms of satisfaction on a scale

5 JID 2002;186 (Suppl 1) Patients, Physicians, and Genital Herpes S61 Figure 4. Importance of specific factors in diagnosis of genital herpes: rank order of patient priorities [6] of 1 10, where 1 represented not at all satisfied and 10 represented extremely satisfied [6]. Overall, a mean score of 6.8 was achieved for satisfaction with current treatment: 41% scored satisfaction at 8, 9, or 10. The mean satisfaction score was higher (7.4) among those who used suppressive therapy than for all therapies combined (episodic treatment, 55%; suppressive therapy, 22%; episodic/suppressive switch, 17%; no treatment, 6%). Respondents were also asked to consider their satisfaction with specific aspects of their treatment; highest satisfaction ratings were for lack of side effects and relief of symptoms. Patients were least satisfied with the impact of (predominantly episodic) therapy on frequency and severity of attacks. When the scores of those using suppressive and episodic therapy were compared, those on suppressive therapy were more satisfied regarding all aspects of treatment than those on episodic therapy (figure 5). Patients treated with suppressive therapy used mainly a once or twice a day dosage regimens (39% and 42%, respectively). When satisfaction with current treatment was examined by dosage regimen, more of those using the once a day regimen claimed to be satisfied (60%) than those on a twice a day regimen (44%). Prior research [5] identified self-management as important for patients. The ability to manage one s own treatment provides empowerment and gives personal responsibility over an infection that is life long. This often helps to offset some of the initial shame and stigma associated with herpes. Genital herpes patients today are not completely satisfied with their care. Education should inform them that the ideal of HSV eradication is not yet achievable but that oral antiviral therapy plays a major role across a range of aspects of patient well being [14]. Transmission issues. Many patients are concerned about transmitting genital herpes to their sex partner and are particularly interested in knowing if antiviral therapy will prevent or reduce sexual transmission risk [5, 18]. Because antiviral therapies (valacyclovir, famciclovir, and acyclovir) all reduce the frequency of asymptomatic HSV shedding, they would be expected to reduce the risk of transmission [19]. Prospective evidence will be forthcoming from the ongoing randomized clinical trial evaluating suppressive valacyclovir on transmission risk in discordant couples. The risk of transmission of genital HSV infection is one factor affecting a patient s preference for episodic or suppressive therapy [18]. During the first year after initial acquisition of genital HSV infection, a time when virus shedding is at its highest [20] and a patient s knowledge about the disease and awareness of transmission risk is lowest, suppressive therapy may be expected to have the greatest effect on asymptomatic shedding and also on the psychological impact of a herpes diagnosis [21]. In the international telephone survey [6], 73% of respondents agreed strongly that one of the biggest fears is passing genital herpes on to someone else. However, when patients considered their current therapy, the lowest satisfaction ratings were given to impact on the risk of transmitting virus to partner. Ratings were lower for patients on episodic versus suppressive therapy (figure 5). Research among Physicians Attitudes toward genital herpes. In contrast to patient attitudes, the overall view of 400 physicians [7] was that genital herpes is a trivial disease and very easy to manage. On the whole, most would treat the physical symptoms but not address the psychological impact of genital herpes (figure 3). The physician s choice of treatment for genital herpes was driven by the severity of clinical recurrences and the cost of therapy [7]. Improvements in personal hygiene, saline baths, and analgesia were often advocated as first-line management; suppressive oral antiviral therapy was restricted to patients with severe or frequent recurrences. Some physicians realized that the stigma associated with genital herpes had a psychological impact on the patient and, although only a minority of physicians offered counseling, its value was recognized. The primary therapeutic considerations of the physicians were relief of symptoms and patient education or reassurance. Disease transmission was not a major concern. There was a firm belief that educating patients about safe sex and condom use, particularly during an acute attack, was effective and the only way to stop transmission [7]. Prescribing habits. Four groups of doctors were identified

6 S62 Alexander and Naisbett JID 2002;186 (Suppl 1) Table 1. Commonly used genital herpes treatments [6]. Therapy Total (n p 597) Australia (n p 96) France (n p 100) Greece (n p 101) Italy (n p 100) South Africa (n p 100) Sweden (n p 100) Zovirax/acyclovir tablets 46% 38% 62% 49% 77% 24% 29% Zovirax cream 36% 21% 51% 46% 59% 38% 3% Valtrex/zelitrex/valacyclovir 20% 26% 17% 20% 8% 23% 27% Stress management 8% 20% 8% 14% 6% Famvir/famciclovir tablets 6% 17% 5% 6% 8% 1% Complementary medicine 6% 15% 4% 2% 3% 13% Lysine 2% 6% 2% Vaginal/genital wash 2% 8% 1% 1% Vitamins 2% 6% 4% Xylocaine/xylocaine cream 2% 12% Betadine 2% 7% 3% 1% Over-the-counter creams (e.g., Vaseline, zinc) 2% 3% 2% 2% 3% No treatment 6% 2% 5% 27% with differing attitudes towards genital herpes [7]. Half had no particular interest in the disease, did not often offer any treatment to patients, and were not interested in offering counseling. The second group (20%), who considered genital herpes to be trivial and not a true STD, indicated it would be inappropriate to inform patients that the disease could be sexually transmitted as this could cause undue worry and concern. This group would prescribe topical treatment and offer oral therapy for more severe cases. The third group (17%) was composed of physicians who did not want to be involved in the treatment of genital herpes. They believe that providing patients with information on the disease and treatment options would increase the likelihood of people asking for treatment and help, thereby increasing demands on their time. Drug treatments are prescribed but no practical support is offered. Physicians in the smallest group (13%) believe genital herpes is trivial and not particularly challenging to manage. Symptoms should be treated but no psychological intervention offered. Doctors in this group felt that over-the-counter medications would be a more effective way of managing the disease. Counseling. In an earlier US survey, more than 60% of patients with genital herpes rated the health care provider who made the diagnosis as fair or poor [22]. Particular areas of weakness appeared to be the providers lack of appreciation of the impact of a diagnosis of genital herpes on sexual relationships and behavior. Preliminary findings from a new survey of US genital herpes specialist health care providers, some with continuing herpesvirus medical education training, show a consistent disparity between what the physicians said should be covered as compared with what was actually covered in patient counseling sessions [8]. The disparity was greater for psychosocial than for biomedical aspects (table 2). The most common barriers cited by health care providers offering to discuss the broader range of genital herpes-related issues were lack of time, staff, or anticipated emotional reaction. Although the providers clearly recognized the importance of addressing a wider range of topics when counseling patients, especially on transmission and psychological aspects, this does not appear to be achieved in practice [8]. Patients and Physicians: Facilitating Links There is a gap between patient and physician perceptions about genital herpes [5 8, 22]. Closing this gap is of paramount Figure 5. Patient satisfaction with aspects of current therapy for recurrent genital herpes [6]

7 JID 2002;186 (Suppl 1) Patients, Physicians, and Genital Herpes S63 Table 2. Topic Physician counseling of patients with genital herpes. Think topic important to discuss Physicians who (%) Actually discuss topic Asymptomatic shedding Transmission Suppressive therapy Genital herpes in pregnancy Emotional impact of genital herpes Correct use of condoms importance if the medical profession is to provide patients with the most appropriate treatment and help in living with genital herpes. A number of hurdles need to be overcome for successful patient-physician partnerships in health care management [4]. Effective partnerships depend on mutual respect and recognition of the advantages of combining skills to achieve maximum benefit. Successful partnerships are nonhierarchical and share decision making and responsibility. For physicians, this means that patients should be considered as experts too. While the physician should be well informed about disease, diagnosis, and treatment options, only the patient has the personal experience of the illness. Younger patients tend to be better informed on health care matters and, therefore, more critical of the care they receive [4, 23]. They actively search for information and, for many, surfing the Internet is routine. Information available via the Internet can often form a reliable common source on which to build patient-physician relationships [23, 24]. Organizations such as the US ASHA and the French Association Herpès have been working to bridge the gap between Table 3. Resource Resources and support for patients with genital herpes and for physicians who treat them. ASHA National Herpes Hotline: (919) Ebel C. Managing herpes: how to live and love with a chronic STD Other US Web sites Outside USA providers and patients. STDs bring with them stereotypes, stigma, emotions, and fears in a way that few other medical conditions do, and health care providers may hesitate to discuss genital herpes in depth because of these issues and may not have the time to do so. Patients may be reluctant to discuss genital herpes because it may bring into question their sexuality and their own misconceptions about STDs. When helping patients prepare to discuss genital herpes and other STDs, it is important to emphasize education. Education and empowerment balance the scales of knowledge and power between patient and provider, creating a less fearful, more proactive and interactive relationship. Educated patients ask more constructive questions and are more comfortable with their providers, which, in turn, can make the providers more comfortable with patients and the topic. The most important thing providers can do for patients newly diagnosed with genital herpes is to give information, support resources, and help in defining the options. Table 3 summarizes a range of educational resources, telephone hotlines, and Internet sites that specifically focus on genital herpes. Education: The Key to Successful Partnerships Despite the increasing availability of information, the recent patient survey showed there was almost no awareness of genital herpes support groups among respondents in countries outside the United States (e.g., France, Italy, Greece, and South Africa) [6]. An exception was Australia where almost half (47%) of respondents were aware of groups and 18% belonged to a support group. Of those not in support groups, 47% said they Description ASHA Web site Information on sexual health and STDs for teenagers Information center Herpes Resource Center Web site The Helper, ASHA s quarterly newsletter HELP support groups for people in the US, Canada, and Australia with genital herpes Published by ASHA CDC Web site with fact sheet on STDs NIAID Web site with fact sheet on STDs AHF Web site, linked to IHMF; provides information and offers CME credit Site for patients and physicians with information about diagnosing genital herpes IHMF Web site for health care professionals International Herpes Alliance Web site, nonprofit patient support organization GlaxoSmithKline-sponsored Web site, information for patients and health care professionals Novartis-sponsored Web site, information for the general public and health care professionals Association Herpès Web site (in French) GlaxoSmithKline-sponsored Web site (in Swedish) Australia NOTE. AHF, American Herpes Foundation; ASHA, American Social Health Association; CME, continuing medical education; IHMF, International Herpes Management Foundation; NIAID, National Institute of Allergy and Infectious Diseases.

8 S64 Alexander and Naisbett JID 2002;186 (Suppl 1) would be interested in receiving information from a group. Use of the Internet for information about genital herpes was highest in Australia (20%), Sweden (16%), and South Africa (8%). With the support of the International Herpes Alliance (IHA), patient advocacy groups are now emerging worldwide including Australia, Canada, France, The Netherlands, and Sweden. The IHA was formed by patients and health care professionals with several goals: achieving the best possible care for people with genital herpes, addressing the stigma by informing the general public about herpes, its prevalence, transmission, diagnosis, and treatment, and attempting to reduce the rising trend in genital herpes infection worldwide by promoting protection and prevention. Raising awareness about genital herpes among the general public is also important. Most people who are HSV-2 seropositive do not know it because they either do not recognize the symptoms of genital herpes or they have no symptoms [25, 26]. Raising awareness of the prevalence of genital herpes should encourage diagnostic testing. Many people are also not aware that they are at risk for herpes or any STD. Increasing awareness may help this group acknowledge their own risks and encourage them to take appropriate prevention measures. Increased public awareness in parallel with effective patientphysician partnerships should over time help decrease the rate of herpes transmission. Conclusions Genital herpes remains at epidemic proportions in many countries. It is a disease shrouded in confusion and anxiety for patients and health care providers. The management of genital herpes should aim to alleviate both the patient s physical discomfort and psychological distress. At diagnosis, patients should be offered information, counseling, and support. Oral antiviral therapy should be discussed and considered. Most patients do not receive counseling or help about how to live with genital herpes and many are given inappropriate treatment. Education efforts are essential in reaching patients and providers together to aid in understanding the complex emotional and social associations, the options, and the resources available. Patients want to be more involved in managing and controlling their disease. They can achieve this if they are empowered with information and are ready for an informed and constructive discussion with their physician. Physicians, likewise, should recognize the basis of the expertise of patients with herpes and adapt their communication style so that choices in disease management are truly shared. Acknowledgments We thank Jane Shirley and Esther Mustchin of Insight International, London, for conduct and analysis of the six-country telephone survey of patients and their preferences for genital herpes care and information [6]. We also thank the ASHA Herpes Resource Center staff for review and comments for the manuscript. References 1. Ebel C, Wald A. Managing herpes: how to live and love with a chronic STD. 3d ed. Research Triangle Park, NC: American Social Health Association, Smith J, Robinson NJ. Age-specific prevalence of infection with herpes simplex virus types 2 and 1: a global review. J Infect Dis 2002;186(Suppl 1): S3 28 (in this issue). 3. Cusini M, Ghislanzoni M. The importance of diagnosing genital herpes. J Antimicrob Chemother 2001;47(Suppl T1): Coulter A. Paternalism or partnership? BMJ 1999;319: Alexander L. Optimizing the management of genital herpes patient s perspective. In: Whitley RJ, ed. Optimizing the management of genital herpes. Round Table Series. 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