HSV1 Transmission to HSV2

[shesconfused]

Hi Doctors,

I posted this in the general forum, and sincerely appreciate the replies there; but as upset as my partner and I are, I decided to seek physician's advice as well. See my post below, and I thank you for any information you have to offer here.
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If I've tested positive for HSV2 but negative for HSV1, and my partner has tested positive for HSV1 but negative for HSV2, what are our risks of transmission to one another (during kissing, oral sex, intercourse)? We are both still in a great deal of shock since receiving our test results because neither of us have ever exhibited symptoms and were certain that we would both test negative for either antibody. Does having a positive result for one strain offer any protection from acquiring infection from the other strain (we each were likely infected more than 10 years ago)?

We would always use a condom for birth control, but he is very worried about transmitting HSV1 to me through kissing or oral sex, even if he/we were to initiate suppressive therapy. This may or may not make a difference, but both of us are in exceptional physical health, with very strong immune systems (which may explain why neither of us ever recall exhibiting outbreak symptoms), and do not suffer any health related issues whatsoever. Our physicians apparently have not provided either of much reassurance with this...Thanks again, any words are greatly appreciated.

[H. Hunter Handsfield, M.D.]

I glanced at your thread in the herpes community forum. You had some accurate advice there.  "Shock" is not warranted at such test results, certainly not for HSV-1; half the US population has it.  And 20-25% of all people have HSV-2.  In both cases, most people have no recollection of symptoms that would suggest either oral or genital herpes.  So don't feel like the Lone Ranger; you're defniitely not alone.

You can pretty much disregard your partner's HSV-1 infection.  It probably is oral, but if he isn't having symptomatic cold sores, the chance you will catch it is is low.  And if you do catch a second genital infection with HSV-1 due to oral sex, it probably won't be a big deal.  Genital HSV-1 infections typically don't recur often.  If your partner ever has a cold sore, avoid kissing and cunnilingus at that time.  (Unlike genital HSV-2, asymptomatic viral shedding is a lot less common for oral HSV-1.)  Otherwise, forget it.

So the main issue is the risk of transmitting your HSV-2 to your partner.  You can be sure your HSV-2 infection is genital, and further you can be sure there are times when the virus is present even if you have no symptoms.  (That is called asymptomatic viral shedding.)  However, if you pay attention, likely you will notice symptoms that previously you didn't recognize.  Over 60% of people in your situation come to recognize mild outbreaks.  It could be only a localized itch, but if you look, you would see blisters or open sores.  Recurrent herpes is always localized to one side of the genital area or the other (or in the midline, but not both sides); and almost always reappear within an inch or so of the previous episodes.

What can you do to prevent transmission to your partner?  Three strategies:  1) Pay attention to recognize mild outbreaks and avoid sex at those times.  2) Use condoms consistently.  3) Consider taking suppressive antiviral therapy, such as valacylcovir (Valtrex).  Any one of these strategies is fairly effective by itself.  If you use all three, most likely your partner never will catch it.

On the other hand, lots of couples in your situation just don't worry about it much.  If your partner gets HSV-2, he might not even know it; if he gets an infection with symptoms, effective treatment is available; and as long as the two of you are in a commmitted relationship, presumably there isn't fear of transmitting to a new partner.  (Of course this can get dicey, if either of you isn't confident about the permanency of your relationship.)  A middle ground, if condoms aren't your favorite thing, is to rely on symptom recognition plus suppressive therapy.  Using just those two strategies often is highly effective in preventing transmission.

It's good you and your partner are healthy, but that fact has no bearing on the "strength" of your immune system's response to HSV.

The whole business of preventing HSV transmission can get pretty complex, and many people need more direct advice than is practical in a forum like this. I recommend you find a herpes-knowledgeable health care provider.  Or consider contacting the American Social Health Association's Herpes Resource Center for highly expert personal telephone advice.  HRC also keeps lists of herpes-knowlegeable doctors and might be able to help you find someone in your area.  Visit www.ashastd.org and follow the links.  (Full disclosure:  I am on ASHA's Board of Directors.)

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

[shesconfused]

Thank you Dr. Handsfield...your information is very helpful and I sincerely appreciate it...I will pay attention to any symptoms as you describe, but to this date, I am certain that I have never noticed anything at all to the genital area...nothing...I have dated extensively and have always been extremely conscious in this arena (i.e. using condoms and inspecting for outbreak symptoms), which is why I am still so surprised to have tested positive for HSV2 while testing negative for HSV1. If anything, I would have anticipated testing positive for 1 (based upon the large percentage who seem to unknowingly have it) and negative for 2. I know it's not likely that my test results were inaccurate, but because I'm so sure I've never exhibited any symptoms, I am almost inclined to retest. Would it be possible for my results to be skewed and actually be positive for 1 and negative for 2?  Thank you also for the direction to ASHA/HRC, I likely will pursue that. Thanks again.

[H. Hunter Handsfield, M.D.]

It is not likely there is a mixup between HSV-1 and HSV-2 results.  However, if your HSV-2 result is weakly positive -- with an ELISA ratio below 2 and certainly if it is below 1.5 -- you might talk to your provider about repeat testing.  False positive results for HSV-2 are uncommon, especially in people without HSV-1.  Still, no test is perfect and it's often reasonable to recheck when a test result doesn't seem to make sense.  But if the ELISA ratio is high, and definitely if it is over 3.5, there's no point; you have it.