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STDs (Expert Forum)
HSV-2 Diagnosis and questions
Answered by
Edward W Hook, MD - HIV Prevention, stds
Welcome to the STD Forum, which is intended only for questions and support pertaining to sexually transmitted diseases other than HIV/AIDS, including chlamydia, gonorrhea, syphilis, human papillomavirus, genital warts, trichomonas, other vaginal infections, nongonoccal urethritis (NGU), cervicitis, molluscum contagiosum, chancroid, and pelvic inflammatory disease (PID). All questions will be answered by H. Hunter Handsfield, M.D. or Edward W Hook, MD.
HSV-2 Diagnosis and questions
by wiggley72, Jun 07, 2009 08:11AM
Doctor,
Last week I went into see my OBGYN for my yearly checkup and asked her to do a full STD panel since I am getting more serious with my current boyfriend and we have discussed using other forms of birth control besides the condom. On Friday afternoon I received a phone call from my OBGYN with some very alarming news. She said I tested positive for HSV-2, but negative for HSV-1. I was in such shock I didn't get any more information about the test other than it was type specific and that it was performed by Quest (perhaps that will tell you what test it was).
After racking my brain for the last 2 days I think I have come up with a plausible answer as to why I have never had a genital outbreak. That is because I have HSV-2 orally. Back in 1992, I had what I thought was a cold sore, and others who had had them in the past agreed. I went to see a small town Doctor (in Canada) and he said it was impetago, and gave me bactroban. It eventually went away, but almost exactly a year later it reappeared in exactly the same place. Since then I have had an additional 1 or 2 more appearances. This sore, is just below my lower lip and almost in the corner of my lip. It starts with tingling, then blisters, then it weeps, and then the scab seems to shed itself for a few days. Finally it goes away.
So here are my questions:
1) Does this sound like oral HSV-2? Is there any way to confirm that it is?
2) If so, is there any way to tell how often I am contagious, other than the obvious when I feel an outbreak coming on?
3) What precautions should I take with my partner to ensure that I don't give it to him.
4) Is there any point in taking a viral suppression drug?
5) Can you have HSV-2 in both areas (oral and genital)? If so, could I concievably pass it to him through oral sex, and then could he pass it back to me so that I end up with it in both areas?
signed - Confused and concerned
Last week I went into see my OBGYN for my yearly checkup and asked her to do a full STD panel since I am getting more serious with my current boyfriend and we have discussed using other forms of birth control besides the condom. On Friday afternoon I received a phone call from my OBGYN with some very alarming news. She said I tested positive for HSV-2, but negative for HSV-1. I was in such shock I didn't get any more information about the test other than it was type specific and that it was performed by Quest (perhaps that will tell you what test it was).
After racking my brain for the last 2 days I think I have come up with a plausible answer as to why I have never had a genital outbreak. That is because I have HSV-2 orally. Back in 1992, I had what I thought was a cold sore, and others who had had them in the past agreed. I went to see a small town Doctor (in Canada) and he said it was impetago, and gave me bactroban. It eventually went away, but almost exactly a year later it reappeared in exactly the same place. Since then I have had an additional 1 or 2 more appearances. This sore, is just below my lower lip and almost in the corner of my lip. It starts with tingling, then blisters, then it weeps, and then the scab seems to shed itself for a few days. Finally it goes away.
So here are my questions:
1) Does this sound like oral HSV-2? Is there any way to confirm that it is?
2) If so, is there any way to tell how often I am contagious, other than the obvious when I feel an outbreak coming on?
3) What precautions should I take with my partner to ensure that I don't give it to him.
4) Is there any point in taking a viral suppression drug?
5) Can you have HSV-2 in both areas (oral and genital)? If so, could I concievably pass it to him through oral sex, and then could he pass it back to me so that I end up with it in both areas?
signed - Confused and concerned
Doctor's Answer
by Edward W Hook, MD, Jun 07, 2009 09:25AM
, Jun 07, 2009 09:25AM
in 5 Americans. Most persons with HSV-1 have oral infection and most persons with HSV-2 have genital infection but each type of virus can also infect the other site. For both infections, the majority of people who have the infections are not aware that they are infected, either because they either acquired it without knowing in the past or because they misidentified their herpes as something else. I will do my best to answer your questions but in general, many of these questions and information about herpes can be obtained by accessing excellent informational web sites such as the one run by the American Social Health Association (disclosure, Dr. Handsfield and I are both on the Board of Directors of ASHA).Your questions are good ones and I hope that I can help to address them, as well as perhaps offer a suggestion or two as to what might be going on.
Blood test diagnosis is sometimes difficult and occasionally there are false positive results in which HSV-1 is mis-identified as HSV-2 and vis versa. Please check with your doctor and make sure the the test result is strongly positive. Presuming that it is, please remember that over 20% of adults in the U.S. have HSV-2 but that of those only about 1 in 10 is aware that they are infected. Infections are often missed or mis-identified. In your case you could, like most people with HSV-2 have genital herpes that you are unaware of or you could have oral infection. Now that you have a positive test, I would urge you to be aware and have a low threshold for seeking PCR/culture evaluation of lesions which might occur in your genital regions.
Oral HSV-2 does occur but it is rare. When it occurs it can appear as cold sores which sound to be like what you are experiencing. On the other hand, these could be some other process as well. My advice would be that the next time you have an outbreak, it would be a good idea to get a PCR or culture taken from the lesion. While all lesions due to recurrent herpes are not culture positive, many are, particularly of the cultures are taken soon after they appear and a positive culture would provide definitive evidence that this was HSV. On the other hand, as implied above, a negative test does not mean it is not HSV. Typically we suggest that clients get cultures on several occasions before they assume their sores are not HSV. In addition, we request that they not take antiviral therapy or medication of any type prior to getting the PCR/culture to increase the chances that it will be positive if the problem is HSV.
As for your specific questions:
1. IT is possible. See above.
2. It should be assumed that if a sore is there it is contagious. In addition, all HSV infections have asymptomatic shedding of the virus from infected sites. The amount of virus present with asymptomatic shedding is less than with lesions and therefore on a percentage basis a smaller proportion of exposures to asymptomatic shedding lead to transmission. But because asymptomatic shedding is common and typically occurs without warning, it is the source of most transmission. See the web site mentioned above for more information on asymptomatic shedding.
3. That in part depends on the site of infection. Because the vast majority of HSV-2 infections are genital we recommend the following 4-part strategy. Disclosure to partners is important for understanding risk and concerns. Second, avoidance of contact when lesions are present. Third, condoms are highly effective for prevention of genital herpes transmission. Forth, suppressive (every day) therapy with antiviral medication such as valacyclovir will reduce HSV transmission by about 50%. Finally, it may be worthwhile to have your partner get a blood test as well. If he has HSV-2 as well (remember, the chances are at least 1 in 5 that he does) then he cannot gt it again and there is little to worry about.
4. Chronic suppressive therapy reduces risk of genital herpes transmission by 50%. There have not been studies of oral HSV (due to HSV-1 or 2) suppressive therapy on transmission however, in general higher doses of medication have been needed to treat oral HSV-1 than genital HSV-2.
5. No. Once a person has HSV-2 their body develops an immune response which almost always prevents second infection in other sites.
Hope this helps. EWH
Blood test diagnosis is sometimes difficult and occasionally there are false positive results in which HSV-1 is mis-identified as HSV-2 and vis versa. Please check with your doctor and make sure the the test result is strongly positive. Presuming that it is, please remember that over 20% of adults in the U.S. have HSV-2 but that of those only about 1 in 10 is aware that they are infected. Infections are often missed or mis-identified. In your case you could, like most people with HSV-2 have genital herpes that you are unaware of or you could have oral infection. Now that you have a positive test, I would urge you to be aware and have a low threshold for seeking PCR/culture evaluation of lesions which might occur in your genital regions.
Oral HSV-2 does occur but it is rare. When it occurs it can appear as cold sores which sound to be like what you are experiencing. On the other hand, these could be some other process as well. My advice would be that the next time you have an outbreak, it would be a good idea to get a PCR or culture taken from the lesion. While all lesions due to recurrent herpes are not culture positive, many are, particularly of the cultures are taken soon after they appear and a positive culture would provide definitive evidence that this was HSV. On the other hand, as implied above, a negative test does not mean it is not HSV. Typically we suggest that clients get cultures on several occasions before they assume their sores are not HSV. In addition, we request that they not take antiviral therapy or medication of any type prior to getting the PCR/culture to increase the chances that it will be positive if the problem is HSV.
As for your specific questions:
1. IT is possible. See above.
2. It should be assumed that if a sore is there it is contagious. In addition, all HSV infections have asymptomatic shedding of the virus from infected sites. The amount of virus present with asymptomatic shedding is less than with lesions and therefore on a percentage basis a smaller proportion of exposures to asymptomatic shedding lead to transmission. But because asymptomatic shedding is common and typically occurs without warning, it is the source of most transmission. See the web site mentioned above for more information on asymptomatic shedding.
3. That in part depends on the site of infection. Because the vast majority of HSV-2 infections are genital we recommend the following 4-part strategy. Disclosure to partners is important for understanding risk and concerns. Second, avoidance of contact when lesions are present. Third, condoms are highly effective for prevention of genital herpes transmission. Forth, suppressive (every day) therapy with antiviral medication such as valacyclovir will reduce HSV transmission by about 50%. Finally, it may be worthwhile to have your partner get a blood test as well. If he has HSV-2 as well (remember, the chances are at least 1 in 5 that he does) then he cannot gt it again and there is little to worry about.
4. Chronic suppressive therapy reduces risk of genital herpes transmission by 50%. There have not been studies of oral HSV (due to HSV-1 or 2) suppressive therapy on transmission however, in general higher doses of medication have been needed to treat oral HSV-1 than genital HSV-2.
5. No. Once a person has HSV-2 their body develops an immune response which almost always prevents second infection in other sites.
Hope this helps. EWH
1) That I could be positive for HSV-1 instead of HSV-2 since the only sores I have ever had are oral? I will follow up with my OBGYN regarding the current set of tests, and am hoping to have a PCR test done genitally and if possible orally in addition to a retest of the blood tests.
2) The next time I have an oral outbreak (which seems to be every 4-5 years now), I should go have a PCR test done. This is all find and dandy, but what do I do until then?
3) In the mean time practice safe sex, and take some form of viral suppressive medication.