Intermittent Valtrex use and transmission

[BoomerLady]

I am HSV2(+) and probably have been for over one year.  I believe I was misdiagnosed with shingles in Nov 2005. Within 2 weeks of encounter with ex-partner, I had flu symptoms and then presented with a rash on buttocks - diagnosed as Shingles.  Then one year later had an outbreak on lower spine.  I was suspicious of the lower spine outbreak and got the HSV blood test.  My test result: HSV1(-) and HSV2(+).  I told ex-partner and he got blood test. His results: HSV1(+) AND HSV2(+).  He said he never had any classis symptoms, was shocked and to his credit very apologetic.  I have never presented anything genitally (that I was aware of)until about 1 month ago - a small lesion on vulva that was cultured and result was HSV(+).  Dr prescribed Valtrex but only enough for recurrent episodes.  I have since told my current partner who was stellar in his reaction.  He does not live near me and we may see each other every 2 months.  We had unprotected sex 3 times - that was before I knew the HSV result.  I told him to get tested in about April, which is 3 months after last exposure.  Lets assume he is HSV2(-). If I know when I will have sex, in addition to condoms can I just use the Valtrex prior to the visit to help reduce transmission to him?  If I can, do you know how much and how many days prior to the visit?  For example, I start taking 500mgs of Valtrex, 2x a day 3 days prior and also during visit.  And then can I quit until the next time I know I am going to see him?  And will that also reduce transmission to him through oral sex?

[H. Hunter Handsfield, M.D.]

There are no studies of intermittent use of antiherpetic drugs and the efficacy in preventing transmission.  However, there is no reason to believe it would not work to protect an uninfected partner.  It usually takes 2-3 days but sometimes up to 5 days for viral replication and shedding to be shut down completely, so you should start treatment at least 5 days before anticipated sex.  The dose of 500 mg twice daily is fine, but it would be equally effective and more convenient to just take 1 g (1000 mg) once a day.

The theoretical downside is development of drug resistance in your HSV-2 strain.  That risk probably is low, and in itself is not a reason not to follow through.  However, it is very important you not get into a pattern of frequent starting and stopping.  An on-off regimen over only a few days (3-5 days on, a few days off, then repeat) would carry a very high risk.  So the dilemmat will come if or when you and your partner start seeing each other more frequently, or if you want to allow for a spontaneous/surprise visit. If these are significant possibilities, I would rather you just take the drug daily.

Oral sex is apparently fairly low risk for HSV-2.  There probably will always be some small risk he could acquire HSV-2 orally by performing oral sex on you, but given the frequency of both genital HSV-2 and oral sex among sexually active people, combined with the rarity of oral herpes due to HSV-2, the transmission risk must be quite low.  In any case, valacyclovir treatment should lower that risk further.

It is nice to see a level-headed perspective on genital herpes, both yours and your partners'.  Definitely not the norm on this forum!

HHH, MD

[monkeyflower]

Isn't 500mg once a day okay for suppressive therapy/partner protection?

[BoomerLady]

Thanks for the answer.  I may be level headed now but it wasn't the best news I have ever had.  Once I got over my own dismay I armed myself with as much information as I could.  Knowlege is power and what is done is done. I am hoping this will just be an occasional nuisance that I must deal with.  I have since purchased several books that have been very helpful, and also gave current partner a book - "Understanding Herpes" and several articles from the internet so he knows what he is getting into.  Quick question, though. What type of doctor is best suited for HSV questions and diagnoses?  I went to a Gynocologist.  I read someplace - maybe here - that a dermatologist might be a better bet.

[H. Hunter Handsfield, M.D.]

Understanding Herpes is an excellent book and Charlie Ebel, the author, a respected colleague and friend.  And as you probably have learned, the publisher--the American Social Health Association--is an excellent resource on herpes.  And that's my advice about finding a provider:  contact ASHA (www.ashastd.org), which maintains lists of providers reported to be knowledgeable and understanding about genital herpes.  There is no firm guideline based on specialty:  a family med doc here, a gyn there, a dermatologist somewhere else.