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Note: All
these questions were posed on this forum.
The wording in both the questions and replies have been edited here and
there for grammar, spelling, etc. Many
thanks to frequent forum user Daisyjoy who compiled the first draft, which I
then modified.
Q1. What is the difference between HSV-1 and
HSV-2?
A.
Herpes simplex virus HSV type 2 (HSV-2) is the usual cause of genital herpes
and is always acquired by genital (or anal) contact with another person. HSV
type 1 (HSV-1) is the cause of herpes sores on the lips and in the mouth (often
called fever blisters or cold sores).
It also causes up to 50% of initial genital herpes infections, usually
acquired during oral sex. Genital HSV-2
infection almost always recurs frequently, with or without symptoms, whereas
HSV-1 genital herpes reactivates infrequently.
Therefore, the large majority of recurrent genital herpes is due to
HSV-2.
Q2. I visited a sex worker at a massage
parlor. She performed unprotected oral
sex on me. What are my chances of
contracting herpes?
A.
On average, the risk of acquiring genital herpes simplex type 1 (HSV-1)
infection is very low for any single episode of oral-genital exposure. However,
it is impossible to know for sure without more information. The risk of course depends on whether or not
the sex worker has an oral HSV-1 infection and whether or not she had an
outbreak at the time; the risk would be quite high if she had an active cold
sore. But it also depends on whether or
not you already are infected with HSV-1 (of any part of your body)—as does half
the population. If so, there is no
risk; you are immune to catching it again.
There is no risk of acquiring genital HSV-2 infection from oral sex.
Q3. What are the symptoms of herpes? How soon do they show up?
A.
The symptoms of a first outbreak of genital herpes usually appear 2 to 10 days
after exposure to herpes and last an average of 2 to 3 weeks. With the first infection, without treatment
the sores typically are active (that is, red, irritated, perhaps painful) for
1-2 weeks, then take another 7-10 days to heal completely, so total time from
onset to complete healing generally pmtis 2-4 weeks. Recurrent outbreaks are
briefer, typically 7-14 days. Symptoms
of a first genital herpes infection vary widely and may include any of the
following: blisters or other sores on the penis, vagina, cervix, anus,
buttocks, or (rarely) elsewhere on the body.
Small red bumps usually appear first, then develop into blisters, and
then become painful, open sores. Over a
period of days, the sores may scab over.
Finally, they heal. In moist
areas, such as around the vaginal opening, labia, or around the anus, lesions
often rapidly develop into open sores that can be especially painful. First episodes often cause lesions
bilaterally, that is on both sides of the genitals, anal area, etc swollen
lymph glands in the groin. Recurrent
outbreaks almost always are limited to once side or the other—up to but not
across the body’s midline and lymph gland swelling usually is absent. Often symptoms are mild or nonspecific, such
as itching, irritation, or scratch-like sores, or painful urination, so that
herpes can easily be mistaken for other problems, such as yeast infection, jock
itch, urinary tract infection, and others. Not everyone has all these symptoms
and many infected persons have no symptoms at all. However, everyone with genital HSV-2 infection has periods of
“asymptomatic shedding of the virus, when they can transmit herpes to their
uninfected sex partners.
Q4. So if I think I contracted herpes but I have
no symptoms. Does that mean I never
will have symptoms?
A.
You might or might not. Genital herpes
often first causes recognized symptoms a long time after acquisition. In fact,
40% of persons with the first known outbreak of genital HSV-2 infection have
been infected for several months or years.
Some infected people never develop symptoms, or have such mild or
atypical ones that they don’t notice them.
Q5. How early can I take a test to determine if
I caught herpes?
A. If there are fresh herpes lesions, the best
diagnostic method is to take a sample from the sores to test for the virus,
usually by culture. But when the
culture is negative or if there are no lesions at the time, a blood test can
detect antibodies to HSV – that is, the body’s reaction to the virus. However, it takes a few weeks for antibodies
to develop. Most infected people have
positive blood tests by 4 weeks after infection, but it can take up to 12 weeks
and, rarely, up to 4-5 months. But
about 90% of infected people become positive by 6 weeks. All this depends on having the right test;
see Question 6.
Q6. What blood tests are available to diagnose
HSV infections?
Several
blood tests are offered by various laboratories, and many health care providers
don't know the differences between them. The accurate ones are the HerpeSelect
test, produced by Focus Technologies; biokit-HSV-2, produced by Biokit USA; and
the Western blot HSV test, which is used by research labs and isn't very often commercially
available. Be sure that one of these was used; if not, then your result might
be falsely positive. As of this writing
(May 2005), no other test commercially available in the U.S. accurately
distinguishes HSV-1 from HSV-2 infection.
Happily, more and more laboratories in the U.S. now do the HerpeSelect
test routinely. But if in doubt, ask
the health care provider and be sure the right kind of test was done. (A common
clue that the right kind of test wasn’t done is a result for “IgM” [immunoglobulin
M] antibody. The accurate tests are
only for IgG antibody; contrary to earlier beliefs, the presence or absence of
IgM antibody to HSV-2 has no diagnostic value.)
Q7. How reliable is the HerpeSelect test? If I test negative should I still worry I
have herpes?
A. Once enough time has passed for antibodies
to develop – that is, 6-12 weeks, rarely up to 4-5 months - either a positive
or negative result for HSV-2 in over 95% of people.
Q8. Will I have reoccurring outbreaks of my
genital herpes?
A.
In most people with genital herpes due to HSV-2, the virus reactivates from
time to time and causes symptoms. The frequency and severity of the recurrent
episodes vary greatly. Most persons
with HSV-2 have 3-6 outbreaks a year, but some people have 10 or more episodes
annually. Over several years, the
frequency of outbreaks tends to decline.
HSV-1 genital infection recurs much less frequently than HSV-2. Among people who acquire genital infection
with HSV-1, about 40% have no recurrences at all and most of the rest
experience just 1 or 2 outbreaks over the next 1-2 years, then none at
all. Fewer than 10% of people with
genital HSV-1 have continued outbreaks after that. For genital herpes due to either virus, recurrent episodes occur
most often in the first year after initial infection.
Q9. What about asymptomatic shedding? How frequent is it and how long does it
last?
A. The frequency of asymptomatic shedding
parallels that of symptomatic outbreaks.
There is little asymptomatic shedding in people with genital herpes due
to HSV-1 (and therefore not much risk of transmitting herpes to their
partners). For genital herpes due to
HSV-2, every infected person sheds virus without symptoms from time to time. Just as symptomatic outbreaks are most
common in the first months or years after catching the infection, asymptomatic
shedding is most frequent in the first year.
It isn’t known how long asymptomatic shedding goes on, but in most
infected it probably continues for at least several years. Asymptomatic shedding isn’t present all the
time, but occurs on and off (and unpredictably). This is why every person with genital herpes due to HSV-2 needs
to inform his or her sex partner or partners, so that those persons are aware
of the risk.
Q10. What treatments are available and how good
are they?
A.
No available drugs or other treatments cure herpes, i.e. eliminate the virus
from the body. However, three drugs are
highly effective in speeding healing of the first infection, preventing
recurrences, and, to a lesser extent, healing recurrent outbreaks. These are acyclovir (trade name Zovirax,
also available generically); valacyclovir (Valtrex), which actually is a
variation of acyclovir that produces higher levels of the drug in the system;
and famciclovir (Famvir). They are all
about equally effective; the differences are in dosing frequency and cost.
(Actual cost varies widely, and the drug that is least expensive in one city or
pharmacy might be the most expensive in another.) There are topical versions of acyclovir and famciclovir
(actually, penciclovir, the active ingredient in the latter drug) – that is
creams or ointments to put directly on herpes lesions. However, they have little effect; most
people who need treatment should take one of the drugs by mouth. Do not be tempted by other products sold in
health food stores, over the counter, or online. Such things like Blistex, lysine, or various vitamins or
“immunity boosters” have no effect whatsoever and are a waste of your money. To
my knowledge, there are no drugs in the research pipeline that are likely to
truly eradicate HSV infection, and none that are likely to be any better than
acyclovir, valacyclovir, or famciclovir.
Q11. I have herpes and want to be careful not to
transmit it to anyone else. What can I
do?
A.
There are three main strategies to prevent transmission of genital herpes to
sex partners. First, avoid sex when
having an outbreak. For people with
mild or subtle symptoms, this means being on the lookout for even mild
symptoms. Second, use condoms. Condoms aren’t perfect, but provide
substantial protection. The third approach is to take suppressive antiviral
therapy, which not only helps control symptoms, but helps prevent transmission.
Suppressive treatment with alacyclovir (Valtrex) has been proved to prevent
transmission, and therefore is the drug of choice for this purpose. However,
the other anti-herpes drugs, acyclovir (Zovirax and others) and famciclovir
(Famvir) probably are helpful as well.
By itself, none of these strategies to prevent transmission is
perfect. However, using two or more of
them probably is effective the large majority of the time. Because prevention isn’t perfect, even if
they take all these precautions, people with genital herpes have a moral obligation
to tell any and all partners they have the infection, before having sex with
them. At the same time, using one or
more of these methods, some couples go for several years without transmission
despite frequent intercourse.
Q12. Is there a vaccine to prevent herpes?
A.
Research has been going on for many years on vaccines to prevent HSV-2
infection. An experimental vaccine is
currently in clinical trials. At best,
this vaccine will be only partly effective in preventing infection. If the research results are positive, it
will be at least another 3-4 years before the vaccine is available.
Q13. Can I transmit oral herpes to my own
genitals, eyes, or elsewhere?
A.
During an initial HSV infection, sometimes the virus is transmitted by the
hands to another part of the body, such as they eye (herpetic keratitis, which
if untreated can seriously damage the cornea and lead to blindness) or a
fingertip (herpetic whitlow). However,
once the infection has been present a few weeks, it is almost impossible to
auto-inoculate the virus to another part of the body. For example, people with oral cold sores do not transmit the
virus to their genitals by masturbation; and persons with recurrent genital
herpes almost never self-infect the eye or other body parts. However, because eye infection is so
dangerous, to be extra safe, persons with oral or genital herpes are advised to
wash their hands frequently and to try to avoid touching their lesions and then
their face. But even so, the risk is
extremely low.
Q14. Do people catch genital herpes through other
means other than sex?
A.
No. You need not worry about catching
genital herpes by sharing the bathroom, toilet, shower, etc with an infected
person. On common-sense grounds, it is wise to avoid using the same moist towel
immediately after someone whom you know to have genital herpes dries
themselves, but even there the risk is extremely low. The folklore about toilet seats and other kinds of nonsexual
acquisition originated before we knew that HSV could be transmitted when a
person had no symptoms, and before we knew that people could catch herpes then
show no symptoms for a long time. So
when herpes appeared in a person who hadn’t had sex for a long time, or in a
monogamous person whose partner apparently didn’t have herpes, it was assumed
the infection was acquired by non-sexual means. But it just doesn’t happen.
There is one important exception:
babies born to infected mothers can catch neonatal herpes, a very
dangerous infection that sometimes is fatal.
Q15. Is herpes a lifelong virus or will it ever
go away?
A.
Once a person has HSV-2, the virus is believed to persist for life.
Q16. You tell people who have HPV that it’s not
necessary to forever inform future partners long after their warts/symptoms go
away. So that means I don’t need to
inform future partners about my herpes, right?
A.
Wrong. Human papillomavirus (HPV)
usually goes away after several months; although the virus may persist, it
generally does so in amounts that cannot be transmitted to sex partners. Herpes is different; the virus persists for
life and is transmissible to partners (on and off) for many years. Whether infectivity lasts for a whole
lifetime, however, isn’t known. Therefore, anybody who has reason to believe
s/he may have genital herpes has an ethical obligation to inform current and
future sex partners before having sex, even if s/he isn’t having an outbreak at
the time, intends to use a condom, or is taking antiviral therapy.
Q17. I’m pregnant, and I have genital herpes. What should I do?
A.
Women with longstanding recurrent genital herpes are at low risk for
transmitting the virus to their babies. To be safe however, a cesarean section
often is done if a woman with recurrent herpes has an outbreak when she goes
into labor. (A cesarean section delivers the baby by surgery, so the infant
does not pass through the vagina.) Any
pregnant woman with genital herpes, or whose partner has either genital or oral
herpes, should inform the doctor or other clinician providing care for the
pregnancy. Many obstetricians now
prescribe acyclovir to pregnant women with herpes during the last month before
delivery. This helps prevent outbreaks,
and therefore can prevent an otherwise unnecessary cesarean section.
Q18. I’m pregnant and
haven’t had herpes, but my husband or partner has herpes. Should we do anything?
A.
Yes! By far the greatest risk for
neonatal herpes occurs when a woman first catches herpes when pregnant,
especially in the last trimester. If
your partner has genital herpes, you should avoid intercourse after the 6th
month; if that isn’t practical, be sure your partner uses condoms consistently
or takes suppressive antiviral therapy (preferably both). Even better, get a blood test: if your test is negative for HSV-2, take the
precautions I just outlined. But if the
result is positive, you don’t need to worry about getting a new infection from
your partner; your risk of transmitting herpes to your baby is low (although
your obstetrician will want to be on the lookout for herpes outbreaks as your
due date approaches). Similarly, if
your partner has oral herpes (due to HSV-1), and your own blood test is
negative for past HSV-1 infection, you must not receive oral sex during the last
3 months of your pregnancy.
Q19. I feel ashamed and dirty I have herpes, is
it common?
A. Don’t feel ashamed. An estimated 25% of adult Americans (1 out
of 4) have genital herpes. Each year, 500,000 to a million new infections are
believed to occur. Studies show that most people with genital herpes do not
realize they are infected; they either have never had symptoms or have not
recognized their symptoms as herpes.