Chances that I gave Herpes to my boyfriend

[signmeconfused]

I am a 38 yr old single female. I have had herpes for 18 yrs, been married once and have had numerous sexual partners. I have never given herpes to anyone. I abstain from sex when I have an genital outbreak, use intermittent therapy for the symptoms (acyclovir), and condoms for sex the rest of the time.

I have outbreaks in two different areas, the back of my thigh and my genitals. They never occur at the same time. I have not typically abstained from sex during an outbreak on my thigh. I just don't touch it and make sure my partner doesn't either.

My questions: I was genitally symptom free (and my genital herpes has always announced itself loud and clear, blatant prodrome, prounounced "pimple" and then ulcer (usually one on labia or anus) but did have a cluster of blisters on the back of my thigh (thigh area of herpes is generally 10+blisters in a circle the size of a nickle or quarter)  that my bf and I were careful not to touch.The blisters were not open or oozing but had just erupted that day. But his leg did brush against it during sex as did his arm (during oral sex)  for a few moments before I mentioned for him to move it.

Okay that was a statement, here are the questions attached to it: 1.If I am genitally symptom free but have a lesion on the back of my thigh, can my boyfriend get herpes orally from performing oral sex (obviously on my genitals not my thigh!) I asked my Dr. this and her answer was "you can shed virus asymptomatically"! Grrr...that wasn't my question!!
2. If the blisters weren't open  (and the contact wasn't prolonged)  is it less likely that he will contract it?
3. Is healthy leg skin and arm skin less suseptible to the virus?
4. Chances that I gave it to him orally or on his arm or thigh?
5. If I've had herpes for 18 years and haven't used surpressive therapy just abstained and then intermittent therapy, and use condoms religiously, is it possible to give it to someone orally without symptoms present or with only thigh symptoms present?

Obviously, I am feeling guilt for possibly passing this to my boyfriend despite our caution.

And finally Thank You in advance. This is an invaluable service. I spent an hour on google and didn't find the answers I was looking for and my Dr. is generally too busy to hold still long enough to pin down on a Q & A. session.

PS do you know the typical dosing for Acyclovir for intermittent therapy? What I am on is the dose I've seen for surpressive therapy 400mg 2x a day.

[H. Hunter Handsfield, M.D.]

Avoiding sex in the presence of lesions is one of the hallmarks of preventing HSV-2 transmission, as you obviously know.  But most experts would say that should include your thigh lesions as well as genital lesions.  It isn't possible to know whether you also have asymptomatic genital (e.g., cervical, vaginal) shedding at the same time you are having an outbreak on your thigh, but most experts would assume that is likely to be the case.  In other words, I cannot tell whether you and your partners have just been lucky.

1) Your doctor's answer about asymptomatic shedding doesn't sound so crazy to me.  I'm basically saying the same thing; there probably is an increased risk of asymptomatic shedding of HSV in the genital tract when you're having a herpes recurrence on your thigh.

2) Common sense says the risk of transmission might be less by contact with intact blisters compared with open lesions, but to my knowledge this has never been studied.  No data are available to estimate how much lower the risk might be.

3) Thicker skinned areas (in medical terms, more cornified skin) probably are less susceptible to HSV than thinner, moist skin and mucous membranes.  Brief, brushing contact probably does not usually result in transmission; in most cases, transmission is higher when the virus is "massaged" into the exposed surface.  This is why initial genital herpes lesions (and genital warts, for that matter) tend to occur most commonly at sites of sexual friction (penis, labia, and vaginal opening rather than pubic area, for example).  But it's a matter of degree, not absolutes.  You should avoid any contact by partners with your herpetic lesions.  If you conintue to have sex when having outbreaks on your thigh, I suggest covering the lesions with a dressing or at least a large bandaid and insisting on condom use by your partners.

4) I cannot predict the likelihood your partner was infected by the exposure you describe.  You'll just have to wait and see if he develops symptoms.

5) If by "orally" you mean performing oral sex on your partners (your mouth, their genitals), the answer is no.  If you mean infecting them orally when they perform oral on you, the answer clearly is yes, if you are shedding virus at the time.  However, oral HSV-2 infection is not common, perhaps because oral tissues are less susceptible to the virus than genital tissues.  But certainly some risk is there.

I'm confused by your treatment question, which refers to both episodic and suppressive therapy.  For suppression, acyclovir 400 mg twice daily generally is effective.  But I avoid giving specific dosage recommendations online; it comes too close to practicing medicine from afar.

I hope this helps.  Best wishes--  HHH, MD

[signmeconfused]

Thank you Dr. HHH for your response.  I am somewhat relieved by it, somewhat chastened as I thought I was being smart (not that that was your intention), definitely more educated.

Sorry to have been unclear about my question about the dosage of Acyclovir. I've read surpressive therapy is commonly 400 mg 2 x a day for a long time.

My Dr. prescribed that same dosage for intermittent therapy 5-7 days. I've read that intermittent therapy could be 200mg 4x a day for 5-7 days. I was just curious if I should be taking more milligrams per day for better relief during a recurrence.

I understand your reluctance to talk much about Rx as you aren't my Dr. I would follow up with her to adjust the dosage though, obviously couldn't get a prescription just based on your suggestion.

[H. Hunter Handsfield, M.D.]

Several research studies in the past few years show that episodic treatment for recurrent herpes need not be continued more than 3 days, and the most recent studies show that 1-2 days treatment is just as effective.  The usual acyclovir dose is 400 mg twice daily for chronic suppression and 400 mg 3 times daily for 2-3 days for episodic therapy.

HHH, MD

[signmeconfused]

Dr. Handsfield, Thank you again for the very good information and for the service you provide! And thank you for the information on the recent studies and episodic treatment, surpressive treatment and dosing. I am seeing my Dr. tomorrow, quite coincidentally but will ask for her thoughts on a new prescription for the Acyclovir. I am going to ask her also about surpressive therapy as an option for me. As careful as I thought I was being, I will be devastated (and so will he) if I gave this to my boyfriend. I would continue to be as cautious even on a daily regimen of Acyclovir.

Sign me, Not as Confused!!

[monkeyflower]

Is that timing the same for periodic suppression? I thought you had to take Valtrex for at least three or four days before sex with HSV negative partners in order for it to be effective.

[H. Hunter Handsfield, M.D.]

The short-course (2-3 day) regimens are based solely on clinical resolution grounds, not prevention.  You are right:  even with treatment and symptom improvement, it takes a few days to be confident that viral shedding has been stopped.  The best guideline for someone with a symptomatic outbreak, as you probably know, really isn't duration at all:  it is to wait until the lesion has totally healed before having sex again.  That typically takes at least 7-10 days after onset, even with antiherpetic therapy.

HHH, MD

[monkeyflower]

Thanks so much for the response! Is 3-4 days adequate if you're asymptomatic, and just relying on suppression to reduce risks of transmission?

[H. Hunter Handsfield, M.D.]

I recommend against anybody using suppressive therapy intermittently for 3-4 days (or for any period of time) in preparation for an anticipated sexual exposure.  Suppressive therapy should be taken continually (for several weeks or months at a time) or not at all.  Intermittent therapy risks of inducing resistance of a person's HSV strain to the drugs.

Cheers--  HHH, MD

[monkeyflower]

Jeez, that's good to know. Since I never have recognizable outbreaks, my husband already has herpes, and I only have sex with HSV negative partners maybe a couple of times a month at most, taking Valtrex every day seemed like overkill. So I created my own little dosage regimen, which unfortunately was obviously not such a wise move. I'll start taking it every day, i.e. as prescribed ;-) Thanks so much for the response!