Genital herpes (HSV): diagnosis, treatment, and the AU GP approach

Genital herpes is one of the most common sexually transmissible infections in Australia. Around 12% of Australian adults carry HSV-2 antibodies, and HSV-1 seroprevalence approaches 75% — with HSV-1 now accounting for 50–70% of new genital herpes diagnoses, particularly in younger women. Despite its prevalence, genital herpes is frequently underdiagnosed, partly because most people with the infection have unrecognised or very mild symptoms, and partly because of the persistent social stigma that surrounds the diagnosis.

The clinical impact of genital herpes extends beyond the physical lesions. Many patients describe significant psychological distress — anxiety about transmission, impact on relationships, and shame — that warrants the same attention as the antiviral prescription. The general practitioner plays a central role in accurate diagnosis, structured treatment, ongoing suppression management, pregnancy safety planning, and destigmatising counselling.

The primary Australian clinical reference is the Australasian Sexual Health Alliance (ASHA) STI Management Guidelines, with supporting guidance from eTG, RANZCOG for pregnancy management, and ASHM for STI-HIV interactions.

A. Core clinical — the AU general-practice framework

Definitions and clinical presentation

Primary infection is the first-ever HSV infection in a person without prior HSV antibodies. It tends to produce the most severe clinical picture: multiple painful vesicles or shallow ulcers in the genital or perineal area, significant dysuria, inguinal lymphadenopathy, and systemic features including fever and malaise. Primary episodes typically last 2–3 weeks without treatment.

First-episode non-primary infection is the first symptomatic genital episode in someone who already has antibodies to the other HSV type (e.g., first genital HSV-1 in a person with existing HSV-2 antibodies). It is typically milder.

Recurrent episodes are reactivations from the sacral dorsal root ganglia where HSV establishes lifelong latency. HSV-2 recurs genitally on average four times more frequently than HSV-1. Recurrences are usually shorter and milder, often preceded by a prodrome of tingling, burning, or paraesthesia in the perineal or buttock area — the trigger to initiate patient-held episodic treatment.

Asymptomatic shedding is the release of infectious virus without visible lesions. It is responsible for approximately 70% of transmission events and is why complete risk elimination remains impossible even with strict lesion-avoidance.

History and examination

History should cover: lesion onset and character, prior episodes and prodrome pattern, sexual history (partners, practices, prior STIs), pregnancy status, immunosuppression (HIV, transplant, biologics, corticosteroids), and psychological and relationship impact.

Examination: inspect the genital, perineal, perianal, and adjacent skin for vesicles, ulcers (shallow, painful, erythematous base), and inguinal lymphadenopathy. In women, include speculum examination for cervical or vaginal involvement. Look for atypical distributions (buttock, thigh) in sacral nerve territory, and examine for other STI signs simultaneously.

Diagnosis

Per ASHA guidelines and eTG:

• HSV PCR swab from the base of an unroofed lesion — gold standard. Sensitive, specific, rapid, and identifies HSV type (1 vs 2). This is the test of choice when an active lesion is present.
• Type-specific IgG serology (HSV-1 and HSV-2 IgG separately) — useful when no active lesion is present, for atypical presentations, for past-exposure assessment in sero-discordant counselling, and for partner counselling. IgG has a window period of 12–16 weeks after primary infection.
• Avoid IgM serology — poor specificity; do not use.
• Avoid Tzanck smear — low sensitivity, non-specific; largely obsolete.

Offer a full STI screen at initial diagnosis: NAAT for chlamydia, gonorrhoea, and trichomoniasis; syphilis serology; HIV; hepatitis B and C.

B. Treatment evidence — aciclovir, valaciclovir, and suppressive therapy

All three licensed antivirals — aciclovir, valaciclovir, and famciclovir — inhibit HSV DNA polymerase and are well-evidenced. Per eTG and AMH:

Primary or severe first episode

Commence within 5 days of onset, or while new lesions are still forming:

• Aciclovir 400 mg orally three times daily for 7–10 days — first-line, effective, low cost.
• Valaciclovir 500 mg twice daily for 7–10 days is an alternative with simpler dosing.
• IV aciclovir for severe disease (urinary retention, proctitis, immunocompromised, neurological involvement).

Adjuncts: adequate analgesia (paracetamol or ibuprofen), topical lignocaine 5% gel for dysuria, sitz baths.

Episodic recurrent episodes

Best initiated at the prodrome or first sign:

• Aciclovir 800 mg three times daily for 2 days (short-course).
• Valaciclovir 500 mg twice daily for 3 days.
• Famciclovir 1 g twice daily for 1 day (most convenient single-day regimen, PBS Authority Required).

Providing a patient-held supply for prompt self-initiated treatment reduces episode severity and duration.

Suppressive therapy

The evidence base is robust. Valaciclovir 500 mg once daily reduces recurrence frequency by approximately 80% and, in sero-discordant couples, reduces transmission to the negative partner by approximately 50% per the landmark Corey et al. NEJM 2004 RCT. Aciclovir 400 mg twice daily is an equivalent alternative. Review annually and consider cessation if recurrence frequency has reduced or life circumstances have changed (stable relationship, completed family planning).

PBS prescribing: aciclovir tablets are general schedule for genital herpes. Valaciclovir and famciclovir carry Authority Required listings for specific indications (initial, recurrent, and suppressive). Confirm current PBS criteria at pbs.gov.au.

C. Pregnancy, neonatal risk, and sero-discordant couples

Pregnancy — risk stratification

The neonatal risk depends on the timing and type of maternal infection:

• Primary HSV in the third trimester: highest risk (neonatal transmission approximately 30–50%); recommend caesarean section and consider IV aciclovir at delivery — per RANZCOG.
• Recurrent genital herpes (pre-existing infection before pregnancy): much lower neonatal risk (~1–3%) because maternal antibodies are protective. Vaginal delivery is appropriate if no active lesions or prodrome at the onset of labour.

Prophylactic aciclovir 400 mg three times daily from 36 weeks is recommended for all women with known recurrent genital herpes. This reduces the likelihood of active lesions or prodrome at delivery and may reduce the caesarean section rate, per RANZCOG and ASHA guidelines.

Mode of delivery: caesarean section is recommended when active genital lesions or prodromal symptoms are present at the onset of labour, regardless of whether the infection is primary or recurrent. Avoid invasive monitoring (foetal scalp electrode) if there is any concern about active lesions.

Sero-discordant couples

When one partner has genital herpes (HSV-positive) and the other does not, the risk of transmission warrants shared decision-making about: daily suppressive therapy for the positive partner, consistent condom use, avoiding sex during prodrome and active lesions, and timing of sexual activity to minimise risk. Partner type-specific serology can establish whether the HSV-negative partner is actually already seropositive (common given HSV-1 prevalence) and therefore not at risk of the same type.

Neonatal herpes

Although rare (~1 per 30,000–50,000 live births in Australia), neonatal herpes is devastating. Presentations include skin-eye-mouth disease, encephalitis, and disseminated infection. Any neonate with vesicular lesions, irritability, poor feeding, or seizures should be evaluated urgently with HSV PCR of surface swabs, blood, and CSF, and empirical IV aciclovir commenced pending results.

D. Australian operations

MBS items

Standard GP consultations: MBS items 23/36/44. A Level C or D consultation is appropriate for the initial genital herpes consultation, which typically involves diagnosis explanation, treatment planning, STI co-screening, partner notification counselling, and pregnancy or contraception discussion.

Mental Health Treatment Plan (items 2715/2717): Significant psychological distress following a genital herpes diagnosis is common. A Mental Health Treatment Plan with referral to psychology via Better Access (items 80000–80020) is appropriate and valuable for patients with significant anxiety, depression, or relationship difficulties attributable to the diagnosis.

ATSI Health Assessment (item 715): Proactive STI screening including herpes where clinically indicated.

Pathology: HSV PCR swab from active lesion (item 69496 range); type-specific serology; STI screen NAAT (item 69486 range); syphilis, HIV, hepatitis B/C serology.

GP Chronic Condition Management Plan (GPCCMP, items 965/967): applicable if recurrent genital herpes is accompanied by significant comorbidities (HIV, immunosuppression) warranting allied health coordination.

Notification

Genital herpes is not nationally notifiable under the National Notifiable Diseases Surveillance System (NNDSS) in Australia. Neonatal herpes may have specific notification requirements in some states and territories — verify with your local health department. Clinicians are not required to notify sexual partners directly, but should counsel patients about disclosure and provide resources to support those conversations.

Telehealth

Follow-up for suppressive therapy review, results discussion, and ongoing counselling is appropriate via telehealth where the existing 12-month treating-relationship criterion is met.

E. Special populations

Immunocompromised patients (HIV, transplant recipients, patients on biologics or high-dose corticosteroids): HSV reactivates more frequently and with greater severity. Suppressive aciclovir is standard. Aciclovir-resistant HSV (thymidine kinase-deficient strains) occurs in heavily immunosuppressed patients and requires foscarnet — specialist infectious disease input is needed.

HIV co-infection: HSV-2 increases HIV acquisition risk approximately three-fold. Suppressive aciclovir reduces HSV shedding but does not significantly reduce HIV transmission per the HPTN 039 trial. HIV pre-exposure prophylaxis (PrEP) is a separate and important consideration for people at high risk.

Adolescents and young adults: Genital herpes is most commonly acquired in early sexual life. Destigmatising the diagnosis and providing accurate information about transmission and treatment is especially important in this group. First-episode management is identical to adult treatment. Pregnancy counselling should be offered to all young women of reproductive age at diagnosis.

Mental health impact: The psychological burden of a genital herpes diagnosis is significant and often underestimated. Studies document high rates of depression, anxiety, reduced self-esteem, and relationship disruption at the time of diagnosis. Brief screening with PHQ-9 and GAD-7, empathic counselling, and referral to psychology via a Mental Health Treatment Plan should be part of routine management. Family Planning Australia and ASHA resources provide peer support information for patients.

When to escalate

Refer urgently or seek specialist input when:

• Severe primary infection with systemic features, urinary retention, or neurological involvement (meningism, encephalitis) — hospitalisation and IV aciclovir.
• Neonatal herpes is suspected — paediatric infectious disease urgently.
• Suspected aciclovir-resistant HSV in an immunocompromised patient — infectious disease specialist.
• Primary HSV acquisition in the third trimester of pregnancy — obstetric input required.
• Complex sero-discordant pregnancy counselling with conflicting patient values — sexual health physician or obstetrician.

Refer to a sexual health clinic for: complex cases, partner notification support, or access to comprehensive free STI services.

What this article is and is not

This is general health information drawn from Australian clinical guidelines — ASHA STI Management Guidelines, eTG, RANZCOG, and AMH. It is not personal medical advice and does not create a doctor–patient relationship. Treatment decisions, including antiviral selection and suppression duration, are made with your own GP or sexual health clinician.

For consumer resources: HealthDirect — Genital herpes, Better Health Channel, and Family Planning Australia.

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Sources cited

1. ASHA / Australasian Sexual Health Alliance — STI Management Guidelines
2. Therapeutic Guidelines (eTG) — Antibiotic / STI
3. Australian Medicines Handbook (AMH)
4. RANZCOG — Herpes simplex virus in pregnancy
5. ASHM — HIV and STI clinician resources
6. Family Planning Australia
7. CDC — STI Treatment Guidelines: Genital herpes
8. Corey L et al. — Once-daily valaciclovir to reduce transmission of genital herpes. NEJM 2004;350:11–20
9. HealthDirect — Genital herpes
10. Better Health Channel — Genital herpes
11. MBS Online