Genital HSV 1 Transmission

[shh119]

Dear Doctor,

I recently had what appears to be my first herpes outbreak. Upon a having a viral culture test, it was diagnosed as HSV 1.

1. I had a fever and sore throat which was followed by blisters. My ob-gyn is certain that this was my first outbreak based on the appearance of blisters and symptoms. Is there a possibility that the virus was dormant or is it pretty likely that I had recently acquired it? What is the likelihood of future outbreaks? (I read it is low but I would like your opinion based on experience)

2. It's my understanding that HSV 1 lives is usually in the mouth. Is it safe to assume that I acquired this through oral sex? Is it possible to get it even if there were no visible sores on my boyfriend's mouth? Or could he have given it to me genital to genital?

3. How likely is it that I can pass this on to future partners genitally? Percentages would help. How contagious am I?

Also, on a previous post, you responded, "But it doesn't matter anyway; even if you acquired your infection genitally, you aren't going to transmit it to a future sex partner or your future children.  Corollary:  People who are HSV-1-positive have no ethical obligation to inform sex partners of possible genital herpes"  

Can you elaborate on this response? Am I understanding you correctly that I do not need to tell future partners? Isn't there still the possibility of genital to genital transmission?

4. Which leads me to the question, am I obligated to tell my boyfriend that he gave me herpes and that he most likely has oral HSV 1? (I have not told him yet and I assume he gave it to me since he is the only person to perform oral sex on me in the last 2 years)

5. I've had herpes zoster (I am in my mid-20s) in the past. Is there any correlation between this and HSV 1. Should I be worried about my immune system?

I am trying to grasp what implications this has on my life going forward. Any tips, stats, and advice would be appreciated.

[H. Hunter Handsfield, M.D.]

You don't say so explicitly, but I gather the blister-like lesions were in or around your genital area.  (I couldn't tell that until question no. 4, although the fact that you went to an ObG perhaps is a clue -- but I'm still not certain whether you have been diagnosed with genital or oral herpes due to HSV-1.  In answering your questions, I am assuming it is genital.

1) I agree with your ObG. Probably this is a new infection, not recurrence of a previous one.  Among people with new genital herpes due to HSV-1, about 40% have no recurrent outbreaks at all, and another 40-50% have only 1-2 recurrences in the next 1-2 years.  Only a few have ongoing recurrent outbreaks.  This situation is very different than for genital herpes due to HSV-2, in which 90% of people have recurrent outbreaks, with an average of 3-6 outbreaks per year for several years.

2) Almost all cases of genital herpes due to HSV-1 are acquired by receiving oral sex.

3) See my reply to question 1.  In addition to infrequent symptomatic outbreaks, asymptomatic shedding of the virus from the genital area is much less common than for genital HSV-2.  The risk of future transmission by genital sex is low, but probably not zero.  There are no data to be more precise than that.  These responses explain my statement that you quoted from another thread, and explain why future transmission by genital sex is low -- which in turn is why it is less necessary to warn future partners than it is for genital HSV-2 infection.

4) Of course you should discuss the situation with your boyfriend.  Do so senstively, without a sense of accusation or blame.  Undoubtedly he didn't intend to harm you.  And in any case, this should not seriously affect your relationship.

5) There is no correlation with your past herpes zoster, and no implications for your immune system.

The bottom line is that if your genital HSV-1 infection is typical, this won't be a big deal.  There are few if any implicatios "on my life going forward".  For additional "tips, stats and advice", please read the various available websites, like www.cdc.gov/std; www.ashastd.org; and www.metrokc.gov/health/apu/std (where I wrote much of the herpes information myself).  Also, expert advice is available on the MedHelp herpes community forum, where the moderators are legitimate herpes clinicians and counselors.

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

[shh119]

Thanks for your answers. And yes, it is genital hsv 1 that I have. I just a have a few follow up questions.

1. If a person has oral HSV 1, are they immuned from genital HSV 1?

2. What sort of things can initiate a HSV 1 outbreak? I'm afraid sex will cause another outbreak, is this unreasonable?

3. I think you answered this above, but for my peace of mind. If I am not having an outbreak, is it safe to assume I am not "shedding" or contagious?

4. And does having HSV1 mean I should always use a condom- aside from the usual reasons people should always use (stds, pregnancy)? I guess what I'm asking is once I get married, should I always use a condom to protect my husband?

Thanks again.

[H. Hunter Handsfield, M.D.]

1)  People are generally immune (or at least highly resistant) to new infections with the same HSV type they already have, anywhere on the body.  People with oral HSV-1 almost never get genital herpes due to HSV-1.

2) Oral HSV-1 can be triggered by other infections (hence the names cold sore, fever blister) and by trauma around the mouth and face, such as surgery; and also by UV light (sunburn).  However, most recurrent outbreaks have no obvious trigger at all.  Triggers apparently play little role in genital HSV-2 recurrences, which tend to occur randomly (despite folklore about everything from stress to sex to menstruation and other things).  Whether these or other triggers have any influence on genital HSV-1 has not been studied and is not known.

3) I did not say "it is safe to assume" you cannot transmit without an outbreak.  What we know is that with genital HSV-1, both symptomatic recurrent outbreaks and asymptomatic viral shedding are much less frequent than for genital HSV-2; and that genital-to-genital HSV-1 transmission appears to be uncommon.  There probably is always a possibility of transmission without symptoms, but it appears to be rare in most people.

4) Before you worry about strategies to protect your husband, he needs to see a health care provider to be tested for HSV-1 infection. Most likely it will be positive.  If he is the source of your infection, his test definitely will be positive; and even if not, half the population has HSV-1.  Either way, if his test is positive, you don't need to take any precautions at all to protect him (see no. 1).  But even if his test is negative, the risk probably is low (see no. 3); many couples in that situation would not alter their sex lives for fear of catching genital HSV-1.  As all the other replies suggest, if you have to get genital herpes, HSV-1 is the type you want; and as you likely will find out in the coming months or years, in the long run it probably will make no important difference in your life -- same for your husband.

[shh119]

Thanks again!

[shh119]

Is suppressive therapy necessary for those with HSV-1 Gential Herpes? And have there ever been cases where the virus goes away?

[H. Hunter Handsfield, M.D.]

These questions were already answered above, indirectly if not explicitly.  Because recurrent outbreaks and asymptomatic shedding are rare with genital HSV-1, suppressive therapy usually is not needed.  You should wait until a year or so goes by, to see whether you are having recurrent outbreaks and, if so, how often the occur.  If you turn out to be in the unlucky minority with frequent recurrences, suppressive therapy probably would help. But that's not likely to happen.

Most likely the virus doesn't "go away", but it usually stops causing problems and probably is not frequently transmitted to partners.  So for practical purposes, it probably doesn't matter whether or not the virus persists in an inactive state.

[shh119]

I could have inferred this from the previous answers. I have not had any more outbreaks since my first. I guess I am just paranoid about it coming back. Thank you for answering again, this helps my peace of mind!

[H. Hunter Handsfield, M.D.]

Unfortunately, the only way to know is to wait and see if you develop a recurrent outbreak.  Even if you do, don't panic.  As I also said above, most people with genital HSV-1 have 1-2 recurrences over a year or two, then nothing.  The likelihood of ongoing recurrences for the next few years is very low (very different than for genital HSV-2).

The MedHelp herpes community forum is excellent, run by highly experienced nurse-clinician/counselors.  You might take a look, if you haven't done so.

[shh119]

A related discussion, hsv 1 genital recurrence was started.

[logicgirl]

A related discussion, Asymptomatic transmission - Oral Versus Genital HSV-1 was started.