Concened of herpes

[sortaworried]

I have HSV-2 for a couple months now. I have two questions. Should I also be worried about HIV co-infection with my herpes infection? I heard that people who have herpes and hiv have higher viral loads. So is it possible I could have got herpes and hiv at the same time? I wore a condom, but my herpes infection was just below where the condom was. My next question is with regards to the 1 in 20 per year for Herpes infections. That is like 5% per year, but I have read that it is much higher. From men to women I have heard it is like 16% per year, and for women to men it is much lower like 4%. There is so many websites with so much conflicting data. thank you for any responses.

[H. Hunter Handsfield, M.D.]

You raise two excellent and important questions.

First, the HIV business.  It is true that having HSV-2 increases the risk of HIV transmission:  People with both HIV and HSV-2 are more likely to transmit HIV; and people with HSV-2 are more likley to catch HIV if exposed, which is your concern.  The risk is especially high if someone is exposed to HIV at the same time they catch HSV-2.  But I stress "if exposed".  In the US and industrialized countries, HIV is rare in most populations, whereas HSV-2 is common.  If you acquired your herpes from, say, a commercial sex worker in South Africa, I would be very concerned on your behalf.  But of all people in the US or Western Europe, especially if they acquire their herpes from a heterosexual relationship with a partner not at especially high risk of HIV, it really isn't a serious worry-- and also still further reduced risk in your case, since a condom was used.

So your risk of HIV is probably zero, unless the partner you caught HSV-2 from is an injection drug user, commercial sex worker, etc.  That said, anybody with a new STD should be tested for HIV, and so should you.  If not yet done, have an HIV test now, since 2 months is plenty of time for HIV to show up by standard testing.  Or you could wait until 3 months, since some authorities (not me) recommend waiting that long to have a definitive result. You can expect negative results.

HSV-2 transmission risks:  There aren't very good data.  Most important, the risk is highly variable.  The maximum potential risk for transmission is in the first year, and especially the first 6 months, after catching the infection.  In other words, regardless of whether you have a recognized outbreak, over the next 6-12 months the chance you would infect a partner is far higher than 5% per year.  If you were to have regular unprotected sex with an uninfected partner, say a couple of times a week, there's probably a 50% chance s/he would get infected in the next few months, maybe even higher than that.  It is especially important that you take steps to prevent transmission to uninfected partners during the next year -- consistent use of condoms, being aware of mild symptoms and avoiding sex if you have them, and so on.

Another factor that affects transmission is the duration of the sexual relationship. Transmission is most common in relatively new relationships; that is, if a couple goes a few months or years and transmission hasn't happened, the risk drops to still lower levels later.  The reasons are not entirely clear.  Part of it is duration of herpes, as discussed above; the longer the relationship, the longer the infected person has had HSV-2.  It's probably also frequency of sex, but neither of these seems to be the only explanation.

Finally, another factor is whether both members of a couple know of the infected person's HSV-2.  Knowedgeable couples have lower transmission risks than those in which the infected person doesn't tell the partner.  Hence the routine advice that infected people are obligated to inform their partners.  The exact mechanisms why this reduces transmission rates are not exactly clear, although common sense predicts some of them -- such as greater care to avoid sex during outbreaks; or the uninfected partner insisting on condom use.

These facts are directly related to the research that supports the often-quoted 5% transmission risk per year.  It involved couples who were monogamous; the relationship had been going on at least 6 months; both members knew that one member of the couple had HSV-2; and they were regularly counseled with reminders to use condoms and be careful to avoid sex during outbreaks.  For these reasons, the 5% annual transmission risk -- which translates to a rate of one transmission for every couple thousand episodes of sex -- is the low-end estimate.  The overall risk in single people who are dating -- i.e. changing partners from time to time -- is obviously higher than that.  But there are no data available to put numbers to that risk.

However, even in the dating situation, the actual risk of catching herpes during any single episode of sex is low, especially if someone's partner isn't known to have herpes, and if those with herpes are taking precautions against transmission, like condom use, antiviral therapy, etc.

This is probably a much longer answer than you wanted or were expecting.  But as I said above, your questions are important and this information likely will be useful to other forum users.  If and when Dr. Hook and I ever get around to setting up an FAQ section, this reply will be in it!

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

[sortaworried]

Thank very much for your response. I went in for my HIV blood test today, and I'm actually not that stressed. I feel that my test results are going to be normal.

So in the first year after infection there is a higher potential to transmitt the infection to another person? I didn't know that, but I haven't been in a relationship or have had any other partners since I was infected which is a good thing. I've looked through many past posts and websites that say the main thing with having HSV is to avoid sex during an outbreak and to wear condoms the rest of the time. But I wore a condom when I got my infection? It is just below the area where the condom protection ends. I will still wear one too, but will it offer protection to a future girlfriend?  

[H. Hunter Handsfield, M.D.]

Condoms with future partners should still protect them.  However, condoms are not perfect, probably around 80% reduction in transmission risk for HSV-2.  If you start having recurrent outbreaks with lesions above condom range, the protection might be evel less than this, but there are no data on which to estimate any more precisely.

By the way, all this -- including my reply above -- assumes the diagnosis of HSV-2 is correct; in other words, a lab test showing the type 2 virus.  Presumably that was done, based on your original question.  However, some people think that any genital herpes is HSV-2.  In fact, half of new genital infections are due to HSV-1 -- but most of what I said above and here doesn't apply to that virus.

[sortaworried]

Because I wore a condom, and it was a one time encounter, and because the HSV-2 infection was below where the condom covered, HIV is probably not very likely? I'm not sure of her status, it was sorta a one night stand. I know she isn't a commerical sex worker, and pretty sure she hasn't done injection drugs. But even if she did have HIV, even though it most likely isn't the case, a one time exposure is still fairly low isn't it? Like 1 in 300? I feel that most likely is the case she isn't infected, and if she is there is still pretty good odds I wasn't infected.

I feel that I was very unfortunate for my situation, as I've only had sex a small handful of times. I've pretty much always used condoms as well. On that note, I hear the female condom offers much more protection then the male condom due to the fact there is a ring that covers the outside, which would offer more protection for a female. I just thought I'd throw that out there for other forum readers to consider.

I still would like to be a sexual person, and even exploring things aside from sexual intercourse I'm very open too. I realize there is more to sex then just intercourse. What other sorts of activities are safe?

[H. Hunter Handsfield, M.D.]

You, and all persons with newly diagnosed genital herpes, need much more information and advice, both about protecting partners and other aspects, than is practical through a forum like this.  Sorry I can't help further.  Find a herpes-knowledgeable provider.  Read some quality websites (examples below).  Visit the MedHelp herpes community forum, where the moderator is an excellent herpes clinician and counselor.  And consider calling the American Social Health Association's Herpes Resource Center for expert telephone advice (www.ashastd.org, then follow the links to the HRC).  (Full disclosure:  Dr. Hook and I are on ASHA's Board of Directors.  ASHA is nonprofit and we receive no compensation.)

Aside from ASHA, excellent herpes information sources are my former health department, where I wrote much of the information myself (www.metrokc.gov/health/apu/std), CDC (www.cdc.gov/std), and Portland, Oregon's Westover Heights Clinic (www.westoverheights.com).

[sortaworried]

I went to get my HIV test done, and my doctor never called me back. I called them after a week and half and they said they don't call if there isn't anything wrong. I ended up going to the doctor yesturday for an unrelated reason, and I asked about it, and of course it was normal. My final question is with regards to valtrex. Being just newly infected, if I were to go on Valtrex would that interfear with my bodies natural ability to fight against the HSV infection? I hear the first year is the worst for HSV infections, so is this because the bodies is developing antibodies to fight HSV infections? If I took Valtrex would this have any negative effect on that?

[H. Hunter Handsfield, M.D.]

Valacyclovir (Valtrex) does not interfere with the immune response to herpes.  But there are other reasons you might not want to take it yet.  If you are treated from the get-go, you may never know the natural course of your infection.  You might be fated to have 2 symptomatic outbreaks a year or 10 per year, or anything in between; and your outbreaks may be typical or atypical.  If you wait a few months to start suppressive treatment, you will miss the opportunity to learn these things.  With that knowledge, you also will know what to expect in the future if or when you decide you don't need or want to continue taking the drug.

The downsides of waiting are that you will probably have a few outbreaks, which might be uncomfortable, and your infection will be more transmissible to partners.  However, you can treat individual outbreaks with valacyclovir (or acyclovir or famciclovir); and you can use condoms and be careful to avoid sex when you have symptoms.

On balance, I recommed waiting for 6 months or so -- or at least until you experience one or two recurrent outbreaks -- before starting continuous suppressive treatment.  During that interim, treat individual outbreaks as they appear; and always use condoms, unless you know your partner has had HSV-2.  And of course inform all future partners you have HSV-2, regardless of your plans for condoms, suppressive therapy, etc.

FYI, your doctor's approach to abnormal lab tests is very common.  It might not always be best, and it is a kindness to actively inform people about specific test results they might be nervous about, such as HIV testing in some situations.  But you shouldn't be very critical about a provider who follows the usual practice of most of his or her peers.

[gracefromHHP]

"I still would like to be a sexual person, and even exploring things aside from sexual intercourse I'm very open too. I realize there is more to sex then just intercourse. What other sorts of activities are safe? "


Anything you did pre- herpes - you can still do post- herpes.  Just be open and honest about it with your partner(s) and talk about how they feel and decide together what precautions you want to take. Daily suppressive therapy will go a heck of a long way in protecting your partner. Throw in condoms too and the risk is even smaller yet. You really should be more surprised in a relationship when herpes is transmitted than when it isn't ( when the infected partner is aware that they are infected and avoids sex during symptoms ).  

grace