Genital HSV-1 transmission risks and prevention advice

[hsv1nc]

History: 20 years ago, my boyfriend gave me genital HSV-1 through oral sex while he had an active cold sore inside his mouth. There were no indications externally that he had HSV-1, but he did tell me that he had more than one occurrence of these.

Since then, I have had recurrences very infrequently (once a year or less). I do almost always get an outbreak with a new partner -- probably from the friction caused by intercourse. Once my body has acclimated to the activity though, I am back to my once-a-year-or-less outbreak schedule.

I have had two healthy children and several relationships (during which we engaged in sex both with and without condoms -- mostly without), including a 6-year marriage. None of my partners have contracted the virus from me and I have always told them I have it.

As I am about to about to have "the talk" again and have gleened that genital HSV-1 and genital HSV-2 have different risk factors, I really want to give my partner solid information of the likelihood of HSV-1 transmission to him -- both oral and genital -- with and without condom protection.

After 20 years, would I shed the HSV-1 virus asymptomatically or do I really only need to worry about using a condom or abstaining when I have an active outbreak (as I have successfully done in the past)?

Do you think my taking Valtrex or acyclovir would reduce his risk further even though my outbreaks are so infrequent? I don't really want to take unnecessary meds, but if it helps to reduce the risk to him, and the initial

[H. Hunter Handsfield, M.D.]

I'll try to help.  Unfortunately, however, there simply are no available data to support any kind of reliable answer.  Nobody has studied asymtpomatic shedding or the frequency of symptomatic genital herpes outbreaks in people who have been infected more than a few years, for either HSV-2 or HSV-1.  My best guess is that subclinical shedding of HSV-1 20 years after infection is extremely low to zero in most people.  Also, there are atypical aspects of your story.  Among other things, sex does not trigger genital herpes recurrences.

As Sparkeler (below) suggests, if your occasional outbreaks have not been confirmed as herpes in recent years, you definitely should see a herpes-knowlegeable provider immediately (within 1-2 days) the next time it happens, for confirmation of the diagnosis.  Also, if the diagnosis of HSV-1 infection all those years ago was based only on the oral exposure, and not on lab testing, you should have a blood test to determine your status with respect to both HSV-1 and -2.

So in response to your specific questions, I would not recommend you take suppressive therapy until your diagnosis is confirmed, and you establish that your occasional outbreaks indeed are herpes and which virus type is responsible.  Your partner also could be tested for both HSV-1 and -2.  With both your results and his in hand, you'll be able to make more useful decisions (and I will be able to advise you with more reliability) about the chance of transmission and potential precautions to prevent it.

However, if your HSV-1 infection has been confirmed, and you know you don't have genital HSV-2, I would suggest your partner have a blood test for HSV-1.  If positive, he is immune from catching it again and you need take no precautions against transmission.  If negative, then the main strategy is for you to avoid intercourse when you're having symptoms that might be an outbreak.  Asymptomatic shedding of genital HSV-1 appears to be rare.

Good luck--  HHH, MD

[sparkeler]

Are you positive you have hsv1 on your genitals?  Are you positive you have herpes at all?  20 years seems like an awfully long time to still be having breakouts.  I thought the o/b's stop after at least 10 years.  I'm very interested to read the answer to this.

[hsv1nc]

Hmm. Actually, I never had a test to confirm HSV-1 or 2 or HSV at all, for that matter. I assumed that since he had sores in his mouth, my recurrences were so few and far between and no one had ever gotten it, that it was HSV-1.

But I supposed he could have gotten HSV-2 in his mouth and then gave it back to my genitally. Right? He said he never had any sores on his penis. But tehn again, I suppose he could have been asymptomatic there. Ugh. So many possibilities. I guess the only way to know for sure is to have the test.

Let me be clear, I have gone years without recurrence, but it is always in the same place and has all of the characteristics of an HSV outbreak -- the tingling, itching followed by a blister which opens then heals for a few days. I am 99.9% sure it's HSV of some sort.

My initial outbreak was very painful and lengthy -- more than 2 weeks until I was healed, but all outbreaks since have been very minor and always associated with extreme stress, illness or a new sexual partner. What else could recur in the same place with those symptoms over a 20-year period?

I definitely have gotten an outbreak when there has been some trauma to the skin of my vulva as a result of energetic sex. I think my body may also react to changes in vaginal chemistry when a new partner ejaculates in me.

[hsv1nc]

Follow-up to above. The Gynocologist originally confirmed herpes via a visual exam, no testing was done. Not even sure if it was available in those days.