Genital HSV-1, again

[bigmonkeycar]

OK, so this has been somewhat of a hot topic recently and I just wanted to clarify a few things:
A) Let's say a person who was negative for both HSV1 and HSV2 had an intimate encounter involving both deep kissing and oral sex. Let's say that person later tested positive for HSV-1,having had oral symptoms but no noticeable genital symptoms. Would the assumption be that the person had most likely also contracted HSV-1 genitally?
B) On a similiar note..while HSV2 can often by asymptomatic, does HSV1 operate the same way genitally, or in general does HSV1 manifest with symptoms on the genitals?
C) How would the general appearance of HSV1 look? I know there is a "classic" case and then a million other possibilities, which is what makes it difficult...you rightfully say that the best bet is to go see an MD, but this would mean going to see an MD on a weekly basis, for some. Is it true that individual bumps are generally not herpes, and that HSV1 would manifest as a number of bumps, or a cluster?
Also, PLEASE respond to the comment below, from a forum of about 1 week ago...VERY confusing and contradictory...
"I am an MD and I have posted here before.
Some of the advice given on this web site is way too categorical and I think can be misleading. For example Doctor HHH advises many here that if one has genital HSV-1, that person can not transmit HSV-1 genitally to another individual who has documented oral HSV-1 with existing IgG antibodies "even if they tried".

This I think is wrong and should NEVER be said to anyone in these terms. I have done my share of reading and have emailed back and forth with Anna Wald, MD...the one person who knows most about this since she did the 2002 studies with Valtrex in discordant couples. She also generated the study that Dr. H quotes in which he says 40% of HSV-1 does not recur and the rest have 1-2 receurrences the first 1-2 years then none at all.

Well, Dr. Anna Wald and me and "gracefromHHP", and my Infectious Disease MD Dr. Nakada in Torrance, CA all understand that you can still pass HSV-1 genital-gential to an individual who has oral HSV-1 with documented IgGs. It DOES NOT OFFER 100% protection. I know from personal experience. It happened to me. I contracted HSV-1 genitally months after my oral infection (and I already had IgGs) by having unprotected sex with my partner who has HSV-1 genitally. In retrospect, I should have worn condoms.

So, if you have genital HSV-1 and think you can't pass it on to 50% of the population out there who already has oral HSV-1....think again. They have significant resistance to contracting HSV-1 genitally, but it does happen.  It's still HSV and it becomes a burden (big or small depending on where you are in life, attitude, etc) that you carry with you for the rest of your life. Unless you HAVE HSV of any kind genitally, you do not know exactly what it feels like emotionally and no one should attempt to minim

[H. Hunter Handsfield, M.D.]

A) Assuming the right kind of test is done--that is, a truly type-specific test--then if a negative test turns positive, it means that virus type was acquired sometime after about 3 months before the first blood test.  Aside from that, it says nothing about exactly when the infection was acquired.  (Of course there can be exceptions because of false-negative or false-positive results, lab error, etc.)

B) Genital HSV-1 can be symptomatic or asymptomatic.  However, symptomatic recurrences and asymptomatic shedding from genital infection are, on average, much less common for HSV-1 than HSV-2.

C) There are no differences whatsoever between the appearance of HSV-1 lesions and HSV-2 lesions in the genital area or elsewhere.

There is virtually nothing about herpes with which Dr. Wald and I disagree; I probably learned 60% what I know about the disease from research done by her and her colleagues.  Any differences between my comments and the ones you quote are in context, and I don't know exactly what questions Dr. Wald and others were responding to.  But if you can find a statement I made in which I said HSV-1 never is transmitted genitally or cannot be so transmitted, please point it out to me and I will post a prominent correction.

On average, genital-to-genital HSV-1 transmission probably is quite uncommon; certainly it is very much less common than genital-to-genital HSV-2 transmission.  This is because of my answer to your question (B): recurrent outbreaks are less common and asymptomatic shedding of genital HSV-1 is rare.  (It is Dr. Wald's research that showed that about 40% of people with symptomatic first-episode genital herpes due to HSV-1 have no symptomatic recurrences in the next year or so; and that the remainder have an average of 1-2 recurrences in the next 2-3 years.)  So certainly a person and his partner can be unlucky and transmit HSV-1 genitally.  But in general, it probably is uncommon.

HHH, MD

[JohnnyV]

Hi,

I recently had to deal with these issues because my wife is now almost 5 months pregnant, and I had had many sexual partners before meeting her. To my surprise, she had HSV-2 and HSV-1 and I only had HSV-1. This was very confusing, and I was trying to find out if I, too, had HSV-1 on my genitals, possibly from getting a blow job from someone other than my wife.

From what I could gather (The Doc of course will tell you more), if you test positive for HSV-1 and negative for HSV-2, it's unlikely you have HSV-1 on your genitals and more importantly, even if you do have HSV-1 on your genitals it's nothing to worry about. HSV-1 is so common that almost everyone has the antibodies to it, so even if you pass it to your partner, it isn't going to be very much of an issue.

It is a dangerous issue for pregnancy, but in our case, the doctor is going to prescribe a drug during the last month of pregnancy to make sure there is no outbreak of Herpes just before delivery. Babies don't have the immune system to control Herpes and can die from skin exposure to an open sore.

J

[monkeyflower]

I think HSV1 would be even more likely to be asymptomatic genitally; there are generally fewer outbreaks, and after the first year it rarely reoccurs. It behaves very differently genitally, and sheds asymptomatically much less often than HSV2. That's partly why it's so difficult to transmit HSV1 from genitals to genitals, or from genitals to mouth, particularly if the other person already has HSV1 antibodies.

I'm not sure why this is such an issue for you and some others, because from what I can tell, it's a pretty rare occurance. But I think you have nothing to worry about. Herpes is really often a non event. Think about it this way - if you really have to look that hard for symptoms, is it *really* something that you need to worry all that much about?

[bigmonkeycar]

I agree with that, but unfortunately, feeling the obligation to tell partners of course if it happened--the majority of the public treat the word 'herpes' the same way they would 'cholera' or 'ebola'--not fair, but that's the perception...and obviously not the best conversation to have when you're courting someone you like ;)

[monkeyflower]

I don't know. I have both HSV1 and 2, and I have a fairly active and happy sex life. Maybe it's because my partners tend to be very liberal and openminded, but all of them have been okay with my status. Honestly, I think that if someone has a real problem with my STD status, it's probably not someone I would want to be with anyway, so in that sense I can see it as kind of a positive thing :-)

The best thing to do is learn as much as you possibly can about herpes. The transmission rates are nowhere near what you think, I bet - about 4%/year from female to male, and 8- 10%/year for male to female, just avoiding sex during outbreaks. Suppressive therapy cuts that at least in half, and condoms even more. Really, it's not all that risky ;-) And that's HSV2, which you don't even have. And on top of that, you don't even know if you have HSV1 genitally. You have nothing to worry about :-)

[JohnnyV]

Not that I would ever encourage dishonesty, but you don't really have to tell your partner that you have HSV-1 on your genitals. Since so much of the population has it and the outbreaks aren't fatal or anything, you only need to discuss it if there is a pregnancy involved or if she has a compromised immune system.

[bigmonkeycar]

Doctor--the info I quoted in my original question didn't infer that you said genital HSV-1 transmission is impossible. I believe you have said that a person with genital HSV-1 CANNOT transer the virus genitally to a person who already has ORAL HSV-1. This is what the "MD" I quoted from the forum is contradicting.

So the question and discrepancy is--can a person with genital HSV-1 indeed transfer HSV-1 to the genitals of a person who already has prior HSV-1 oral infection? The quoted "MD" seems to think the answer is "yes," while you seem to say a strong "no." ?

[H. Hunter Handsfield, M.D.]

If you can find such a statement from me (that genital HSV-1 cannot be transmitted), please quote it exactly and tell me precisely where it is, and I will correct the record.

HHH, MD

[bigmonkeycar]

Again, I did not say that you claimed genital HSV1 could NOT be transmitted--but rather that it could NOT be transmitted to a person who already has HSV1 in another location, such as orally. You've made it clear that genital HSV1 can be passed on genital-to-genital, though it seems uncommon--but I *thought* you stressed that someone with oral HSV1 cannot get genital HSV1. I.e. if you have oral HSV1, someone who also has oral HSV1 actively can perform fellatio on you without fear that their HSV1 will spread to your genitals.

[aloha37]

Can someone who is HSV 1 positive orally, later on down the road, get HSV 1 genitally from having genital contact with a partner who is also HSV 1 positive?

[JohnnyV]

I'm dizzy. Here's a recap to the best of my knowledge (which is not great since I'm just some stooge who works in an office):

You can get both types of Herpes in both your mouth and genitals.

If you test positive for one or the other kind of Herpes, you can't know which part of your body the Herpes is in, unless you swab it when you have an open sore.

Both types are transmissible in both areas, through oral and vaginal sex.

If you have antibodies to one, it means you've been exposed to it somewhere in your body, so therefore you could have outbreaks in the future.

If you've been exposed in one part of your body and another part of your body becomes exposed, then the fact that you have antibodies does not necessarily prevent the new part of your body from being exposed.

None of this is that big of a deal because so many people have herpes and it isn't life threatening unless you're talking about a mother in labor.

J

[9848]

Dr. H,

I believe there is some confusion here that you could clear up.

1.  The points made by Johnny V in comment 10 were:

"If you've been exposed in one part of your body and another part of your body becomes exposed, then the fact that you have antibodies does not necessarily prevent the new part of your body from being exposed."

2.  In previous Forum answers to the question, "If I test positive via HerpesSelect for HSV-1 antibodies due to a prior oral HSV-1 infection during childhood or sometime in the past, would that provide immunity from catching Genital HSV-1 in the future?"

The answer to the above question on previous Forum threads have been, Yes, it would provide immunity as you cannot catch HSV-1 again(anywhere on the body)once you have been infected with it on another part of your body and have had antibodies to the same type of virus.  

3.  In the "Herpes Frequently Asked Questions" on this site, Question number 18, "I'm pregnant and haven't had herpes, but my husband or partner has herpes.  Should we do anything?"
Part of the answer to this question advises folks to get a blood test because if the blood test is positive for the same Herpes type that the partner has, you are immune from catching it again anywhere else on the body.

Which statement are true, those under number 2 & 3 above or number 1, the one quoted above written by JohnnyV under comment 10?  

Thanks Dr., this answer is important given the activity of this thread......

[H. Hunter Handsfield, M.D.]

I was going to respond to JohnnyV's summary.  It is accurate except for the statement "If you've been exposed in one part of your body and another part of your body becomes exposed, then the fact that you have antibodies does not necessarily prevent the new part of your body from being exposed."

The immune response generally prevents new infection with the same virus type (a person with HSV-1 cannot acquire a new HSV-1 infection of any body part; same for HSV-2).  It also almost always prevents auto-inoculation, i.e. infection of a new body area with the person's own virus.  Auto-inoculation can occur during initial HSV infections, e.g. transfer of HSV-1 to the eye or a finger (herpetic whitlow) during initial oral herpes.  But auto-inoculation is rare, if it occurs at all, in people with chronic, longstanding HSV infections.

There are no absolutes in biology and medicine, and there are exceptions to almost all generalizations.  If Grace and/or other clinicians have observed such cases, I have to respect that; but I have not and it is clear that such cases are uncommon.

HHH, MD

[bigmonkeycar]

Thank you doctor. THAT is the crux of the issue that I was asking about, and that the other forum user was contradicting. Thanks again.

[regretsthis1]

Dear Doctor,

I have the same issue as the thread starter. In your FAQ, you state that if one has had a history of HSV-1 orally then he or she is proteceted from receiving it genitally. Also you state that HSV2 is not transmitted via oral sex.

I have had a history of HSV1 orally (on upper lip up to the nose sometimes), but about 6 weeks ago I received a blowjob from an anonymous man, and 7 days later I saw herpes sores on my penis. The doctor who treated me said it was most likely HSV1 because it is more often transmitted orally than HSV2.

Anyways, your statement was misleading for me. After reading your statement I was lead to believe that having HSV1 orally meant that I would not get HSV1 genitally, but my diagnosis contradicts that (and my doctor told me as well that you could get HSV1 genitally even if you had it orally).

I have had a recurring breakout since my initial one, around my scrotum, and the breakouts have all been very mild, but I am still very traumatized by the event. I am still worried that I might have received HIV, and I am going to get my HerpesSelect test and HIV ELISA test tomorrow. Your comments have been very reassuring about the almost impossible HIV transmission but I was kind of misled by your HSV1 transmission statements.

[moet]

Sounds like you may have HSV 2? Get a herpeSelect now and if 2 is negative (below 1.1) then do it again at 6 weeks. If positive (and you abstain), you will be able to isolate the exposure. That's what I did...

[JohnnyV]

How much does your doc know about STDs? Sometimes general practitioners fly fast and loose with the STD facts because they don't know the latest research. Last summer, after having some oral sex wtih strangers, my doctor told me I needed to wait one year before taking an HIV test, which is obviously not true. My gut as a layman would say you probably got HSV-2 on your genitals and your doc is functioning on some misperceptions. Can you take a culture from the open sore, because that would answer the question very quickly?

[passedHSV1]

I am writing to clarify my previous posting since I was quoted above in the main text of the initial question.

I am an MD and I have written here a few months back when I accidentally passed HSV-1 oral -to- genital to my partner. I had HSV-1 IgGs at the time this happened.

I am posting my correspondence with Dr. Anna Wald so that everyone can see what question I asked and what her expert response was. I have taken out my name from the email header. Her answers are incorporated within the text of my email:

Date: Fri, 23 Sep 2005 14:10:50 -0700 (PDT)
From: "Anna Wald" <***@****>  View Contact Details   Add Mobile Alert
To: "passedHVS1"
Subject: Re: a couple of questions from a fellow MD

see answers below -

On Fri, 23 Sep 2005, "passedhsv-1"  wrote:

> Dear Dr. Wald,
>
> I am an Anesthesiologist in California and I hope I am
> not being too bold for emailing you directly with a
> couple of questions regarding HSV-1. I have had some
> trouble discerning which information to trust and I
> know that you are an authority on the subject matter
> given your research.  I know your time is very
> valuable and I appreciate any answer you can provide.
>
> I have HSV-1 orally and serologically (IgG titer 5.1,
> HSV-2 negative). My first (that I can remember)
> outbreak was 2 months ago.
> Soon after my  girlfriend  contracted genital HSV-1
> (by culture)  from me unfortunately (1st episode).
>
> 1. Having oral HSV-1, am I "protected" from
> contracting genital HSV-1 from my girlfriend if we
> have sex without a condom? Should we both be on
> supressive valtrex 500 mg daily?


you are mostly protected. we don't think it's a 100% but we see it
rarely in persons who have oral hsv-1. this is not a situation where
suppressive therapy would usually be recommended.
>
> This source says  I would not be protected:
>
> http://herpesonline.org/hsv1vs2.html
>
> Dr. H. Hunter thinks I would be protected:
> http://www.medhelp.org/forums/STD/messages/1438.html
>
> 2. Does having HSV-1 IgG's indicate "Immunity" from
> contracting HSV-1 at a different body site? I have had
> three recurrences of oral HSV-1 recently  and I have
> been feeling tingling around the eye area the third
> time. I am worried about spreading the infection to
> myself.

no, we do not see people spread the infection around their body except
during primary infection, so no worries!

take care, anna
>
> Thank you in advance for your time in answering these
> questions.


In conclusion:

I just ask Dr. HHH to consider never telling people who have HSV-1 orally that  they can not get it genitally by having genital-genital  contact with a genital HSV-1 person. Please do not use the terms "you can't get it even if you tried" when giving this advice. Even the top expert in the field, Dr. Anna Wald whom you attribute 60% of your knowledge to contradicts you (see above). There are plenty of instances in this forum when this advice has been given by you and I will search them out if you want. Other frequent readers know about them also.


>

[monkeyflower]

Did you actually read her response to you? Particularly this quote: "you are mostly protected. we don't think it's a 100% but we see it rarely in persons who have oral hsv-1. this is not a situation where suppressive therapy would usually be recommended."

I think that pretty much says that while they think it may not be 100% (and they key word is "think" - that suggests there may not be actual documentation to back this up), it's pretty darn close.

I wonder if your anxieties about your HSV status aren't blinding you to other possibilities. Sometimes when we're really upset about something, it colors our perception of reality.

The truth is, you may or may not have HSV1 genitally. I'm not a doctor, but I think it's safe to say you very likely don't. But if you do, you may have autoinoculated yourself during your primary outbreak a couple of months ago. There is no reason, aside from your own anxieties and fears, to believe that your gf may have infected you genitally.

I would suggest perhaps seeking counseling, to help you work through your issues with this.

[aloha37]

I think you did say your primary oral hsv 1 infection was only two months ago (where did that infection come from, by the way???) and Doctor Wald did say you don't auto innoculate EXCEPT in the primary outbreak.  If you are now HSV 1 positive genitally, which monkeyflower seems to think you are, it seems as possible to me that you got it from yourself as it is that you got it from genital contact with your gf.  Either way, I bet it has more to do with the fact that it was a primary outbreak.  Probably this added to making you the exception to the rule. I doubt you'll ever know for sure why this happened.  But this still does not change the general advice given on this forum: It is RARE and that's what most people care about.  For most of us the basic information is complicated enough without getting down to the nitty gritty. However, I'm not sure I agree with monkeyflower that you appear to need counseling.  This is a tough topic and as a doctor you have intellectual insight that makes this more difficult to process emotionally and it will take time to work through it.

[LoneRanger]

It sounds like the problem here is nuance. It's a public website, so it's fair to ask the doctor H to be a little careful about how the words are chosen, because you never know how many eyeballs are on this site.

I don't agree with Monkey Flower because it does look like Dr H and anna Wald say different things. Not simple enough to just tell PassedHSV1 that he's got a mental problem. It looks like Anna Wall said it is not 100%. The Dr H said "you can't get it if you tried." H makes it sound like 100% while Dr. Wald says it isn't 100%. Even though there's a little bit of difference between 98% and 100%, if you're one of the 2% who caught something after someone says you can't get it, guess what, the advice was 0% right.

Maybe it sounds like PassedHSv1 is splitting hairs, but that's what you gotta do when it's a public website and lots of people are reading it. You don't want someone in Bumkin, USA, to read it and think he's never gonna catch something, if there's a small chance he can. Besides this is a case of 3 doctors all saying different things. DOn't know who I trust.

[monkeyflower]

Whoa. I never said anyone had a mental problem (nor do I think he has genital HSV1). Suggesting someone seek counseling does not imply a "mental problem"; I personally think it's a sign of mental health. Who couldn't benefit from a little introspection? My feeling was, passedhsv1 seemed to be excessively concerned about having HSV and about its spread, since he's posted on this subject (in the same tone) quite a few times. Just because he's a doctor doesn't mean he doesn't have feelings - he's still a person, you know. I just think talking with someone could be helpful :-)

As for the rest, the thing is, there just aren't any guarantees in life. Saying we *think* it might happen (but it's rare) and saying it doesn't happen may not be that different in actual life. Trying to split hairs benefits no one; rather, my guess would be it only amplifies anxiety. Sometimes you gotta just let it go. Life's short - why waste it on such essentially trivial details?

[LoneRanger]

If I knew where and who you were, I'd send you a bouquet to kiss and make up.

Peace!

[monkeyflower]

Hey, no worries :-) I didn't take it badly; just wanted to clarify my opinion. I know this is a really sensitive subject, especially on this board, lol.