How to talk about HSV2

[backformystuff]

dr. h,

thanks for all the realistic advice you give on this forum.  last year i tested + for hsv2 and didn't even know i had it.  i realize now that i did in fact have an initial outbreak on my penis some years earlier, but didn't recognize it as such and have had no recurring symptoms since that time.  i am now on valtrex for suppressive therapy.

at any rate, i am a gay male and recently met a potential dating mate.  things started giving hot and heavy one evening, and i stopped and revealed my hsv status, because i knew it was the ethical thing to do.  but i feel as though i fumbled through my explanation of how the virus transmits, etc.  basically, i told him that transmission is complex and not cut and dry, say, for example, with HIV.  there has to be some kind of direct contact from a lesion or asymptomatic shedding with an opening or orifice on his genital region (e.g., anal sex).  for instance, i told him that he could not get it from giving me a handjob, or mild frottage (hope this is correct?) or that since my infection is in the gential region (pretty sure-- as stated above, i remember the lesion from the first outbreak), i can give him oral sex safely?  (as an aside--- surprisingly, he hasn't been tested for hsv2 and didn't know much about it).

since you're the expert would it be possible for you to provide a brief list of sexual activity considered to carry little or no risk for hsv transmission?  and, since i am on valtrex and would use condoms for intercourse, can you speculate what the transmission rate(s) would be for a case like that?  also, out of curiousity--- since at least 25% of Americans have HSV2, why are transmission rates (at least the ones I've seen on Westover Heights' page) per sex act paradoxically low?

i know there is already a lot of info floating around out there on the internet, but from what i've read here, you generally consider the lot of it to be poppycock.  

thanks much.

[gracefromHHP]

Go ahead and say it Dr H - we go at it like bunnies when we first meet someone new  so therefore the risk of transmitting the virus is higher then...he he he. After awhile the newness wears off and the tv goes on in the bedroom ;)


grace

[t1234]

I think you're on to something, but I have
a different take on it.

I think the infection rates derived from the Valtrex Study
are probably correct and the 25 per cent total infection
rate for the population is probably correct.

The infection rate increases as when the population is grouped by age and certain groups (black women) had been shown in some  studies to be as high as 50 per cent inspite of the fact they have less sexual partners than their white counterparts statistically speaking.  This runs counter to some popular
assumptions regarding transmission.

I've tryed to do some "quick and dirty" math to simulate
the progression of the desease and can't get these
numbers. Of course my statistics are pretty limited.

I've trying to find some good computer models developed by an expert but haven't been able to find any.

Where I have a different take is this.  These HSV2 infection
rates have been determined by HSV2 antibody tests.  These
tests don't prove the location of the infection, nor how
the infection was acquired--only that the virus is present
somewhere in the body.

Maybe the assumption that all HSV2 is genital is wrong and
the assumption that all HSV2 is transmitted sexually is wrong.

Note: please don't make the assumption that I'm suggesting
the most HSV2 is not sexually transmitted.  What I'm saying
is that if a small amount of HSV2 was oral for example then these infection rates could be explained because of oral
to oral transmission.

[H. Hunter Handsfield, M.D.]

MF is exactly right about the fact that the valacyclovir trial was biased in favor of a lower risk of transmission than in the broader population of people with HSV-2. (One corollary is that in the real world, valacyclovir might be more effective in preventing transmission than suggested by the study itself.)  And Grace also is right about the relative difficulty of transmitting herpes--although with many exceptions, which she is aware of.

A whole book could be written on the topic of genital HSV transmission, but here are 3 pertinent and interesting facts.  All three probably contributed to the low rate of transmission in the valacyclovir study.

1) Transmission is most common from people with recent infection, as opposed to those infected for years.  Both symptomatic recurrences and subclinical shedding are more common in the first several months after infection than later.

2) Transmission is less common in discordant couples who know that one partner is infected, even in the absence of counseling.  This reflects conscious efforts to avoid transmission, and perhaps also unconscious ones that influence decisions about the circumstances of sex.

3) Transmission is more common in new relationships than in long-established partnerships, even after accounting for frequency of sex.  If transmission doesn't occur in the first few months, the risk declines thereafter.  Part of this has to do with point 1, above:  the longer a relationship, the longer the infected person has had herpes, thus reduced outbreaks and shedding.  But it also might be related to the nature of sex.  Sexual duration, vigor (i.e., opportunity to "massage" the virus into a partner's skin or mucous membrages), and judgment about when to have sex (e.g., rationalizing a minor symptom) all are likely to be different in the earlier, maximally passionate phases of relationships.  This is only a hypothesis, with no research behind it, but you'll probably agree it makes sense.

HHH, MD

[who_is_this]

Great post, and great answers.

[gracefromHHP]

Herpes really isn't that easy to transmit as folks think it is. The problem is - most folks who have it have no idea they have it so they aren't avoiding sex during prodromal signs or "vague" symptoms down yonder. Having sex with an active ob has a much higher chance of transmitting it to a partner.  Just avoiding sex during an ob goes a long way in avoiding transmission of the virus but suppressive therapy and condoms can reduce the chances significantly.  One prior study showed that just knowing that you have hsv2 genitally was enough to reduce the transmission to a partner.

Yes indeed the transmission rates in the valtrex study were a little lower than some others - 4% in males compared to the usual 5% you usually see quoted and 8% in females compared to the usual 10% you see quoted. I should hope that if you are participating in a study you are extra vigilant and do what they ask you to do!!! There is a table in the online edition of the study in the NEJM that even breaks it down into transmission with condom use.  They were also given extra education about how to recognize signs of an impending ob/ active ob. They were encouraged to always use condoms.  They were on suppressive therapy. They were told not to have sex with an ob. They got a lot more than the 5 minutes that many folks get when they are diagnosed with herpes in the doctor's office.

When talking about herpes with a partner be open and honest.  Ask what they know about herpes - chances are good not much will be their reply.  Give them some basic facts about it. Let them know how you are actively trying to reduce their risk for it.  If it's a situation where they will have time in between your std talk ( because herpes is not the only std out there ) and when you are going to possibly be intimate then provide them with a copy of the herpes handbook ( or the link to it ) at www.westoverheights.com or the info on herpes at www.ashastd.org so that they can learn more.  The herpes homepage ( www.racoon.com/herpes ) is another place they can go to learn more - there's a chat room there and a message board that they can post to and ask questions.  It's a good resource when you want to talk to someone about the questions you have. It's also a good place to go for support when you do know you have genital herpes.  They are good folks over there for the most part if I do say so myself :)

grace

[backformystuff]

hey dr. h,

thanks for the reply.  FYI, i know for a fact that i am hiv- and free of other stds.  the partner i described in my original note is hiv- as well.  so, i will take your advice and encourage him to get a full std work-up.  it seems entirely probable that he may indeed have hsv2 as well, in light of your statistics.
so anyway, thanks again!

[monkeyflower]

I find the HSV statistics a little odd, too. I think the Valtrex study showed the risk from female to male is only around 3-5%/year, and male to female 4-8%/year... and that's over an *entire year* of sex (~3x/week?), only avoiding sex during outbreaks. If you add a certain percentage of people who regularly use condoms and/or suppressive therapy, 25% of people seems awfully high.

So here's my theory. I think the Valtrex participants were probably extra vigilant about watching for outbreaks. After all, they already knew they were hsv discordant and were participating in a study. So, chances are they were very aware and careful to begin with, hence the low transmission rates.

However, most people never know they have herpes, because they don't have recognizable outbreaks and never get tested for HSV. They might be dismissing their outbreaks as a result of too much friction, or a yeast infection or whatever, and having sex when they're most infectious. That might account for the high percentage of infected people in the general population.

I either just made that up, or I read it someplace a long time ago (maybe even here), lol. Does it make sense?

[H. Hunter Handsfield, M.D.]

The first and most important thing for you to do is advise your partner to be tested for HSV-2.  Among gay men, including those without symptoms or any past STD history, 50-70% are HSV-2 positive.  If your partner already is infected, you have no worries and cannot transmit HSV-2 to one another.  In that case, there are no limits whatsoever on your sexual practices together.  (At least not with respect to herpes.  I assume you both know and have shared your HIV status with one another and, if different, are taking appropriate precautions to avoid "the big one".)

You have it right.  People with genital or anal HSV-2 shed the virus only from those sites.  That is, your penis has to come into contact with a susceptible surface in order for transmission to take place.  You can kiss him (using the term broadly, ie on any part of his body) without fear of transmission.  The big unknown is whether you might also have anorectal shedding.  Some people with primary genital infection can also shed virus anally.  This has been most studied in women, however, and I cannot say how likely it is in men.

Assuming he is susceptible (and until you know for sure), the three main strategies to prevent HSV-2 transmission are a) avoid sex during recognized outbreaks (which you undoubtedly are already doing); b) consistent use of condoms; and c) taking antiviral therapy to reduce asymptomatic shedding and transmission. None of these is perfect, but by judicious use of various combinations of the 3 strategies, most HSV-2-discordant couples can go for years with regular sex without transmission.

Since your infection and probably your asymptomatic shedding most likely involves only your penis, any sex that doesn't expose your penis to his mouth or rectum will pretty much prevent transmission.  Mutual masturbation and frottage probably are pretty much risk free.

Bottom line:  Get your partner tested, then take it from there.  I hope this helps.

Good luck--  HHH, MD