Long-term relationship, recent genital HSV-1 culture diagnosis - discordant couple

-I have been in a monogamous relationship with my fiancee for 8 years. She is 27, I am 26.

-We have been having sex (unprotected first year – birth control/unprotected from there on out – so about seven years no condoms)

-About 1 year into our relationship, she told me that she thought she might have contracted herpes as a child. She was molested at 11 (orally) and had a painful outbreak. At the time, doctor only visually diagnosed as herpes. I had always thought herpes was something that recurred often – I asked her if she had subsequent outbreaks from that time, and she told me no.

I figured she didn’t have herpes and thought nothing more of it. We went on with our lives.

About two months ago she noticed two “white bumps” on her vagina – not painful or irritating – just there. I told her it was probably nothing, but to go see a doctor to check it out. By culture she was positive for HSV-1.
My blood came back negative for HSV-1 and 2.

1) I’ve read reports that in discordant couples, HSV-2 usually will pass onto the partner around half the time in long-term relationships, even with all precautions taken. Are there anecdotes around genital HSV-1?

2) Am I under the right impression that we should use condoms in the interim to a) alleviate my anxiety, and b) see if she gets any further outbreaks? Or is this unnecessary?

3) I feel like I can’t give her oral sex until I eventually get GHSV-1 from her. The last thing I want to do is get both. If I have to get one, based off of information out there, I’d rather get GHSV-1 since it has fewer outbreaks. Is this a crazy hypothesis?

4) Is it true that it is easier to get GHSV-1 from somebody that has oral HSV-1 from oral sex rather than from somebody with GHSV-1 through genital sex?

5) My biggest fear is getting my first outbreak will be while on a vacation or somewhere where I can’t seek medical treatment and/or obtain Valtrex. Is treatment usually needed for an outbreak or can I just keep sores dry?

[H. Hunter Handsfield, M.D.]

Welcome to the STD forum.  I'll try to help.

Although it is true that most symptomatic genital herpes recurs fairly frequently, that applies primarily to HSV-2.  Genital HSV-1 infections usually recur infrequently.  In the first 2-3 years after onset of genital HSV-1, about 40% of persons have no recurrences at all and most of the rest have just 1 or 2 recurrences.  But the potential for recurrent outbreaks probably continues indefinitely, and that's probably what's going on here.

As far as transmission to you, either orally or genitally, I really don't think you should worry about it.  Unlike genital HSV-2, there is little asymptomatic shedding for genital HSV-1, so that transmission when she isn't having an outbreak is unlikely.  You have been having regular sex with your partner for over a year, without getting infected, so obviously the chances are fairly low.  If you should become infected, either orally or genitally, most likely you would not have frequent outbreaks.  Finally, since you will be on the alert for early symptoms, you could get prompt and effective treatment.

To the specific question:

1) Genital to genital HSV-1 transmission appears to be pretty rare, presumably because both outbreaks and asymptomatic viral shedding are infrequent.  In 30+ years in the STD business, I have never knowingly seen a case of genital HSV-1 that was acquired by genital sex.  So I suspect the chance you'll catch your partner's infection are well under 50%, maybe nearly zero.

2) For all the reasons above, I doubt condoms are necessary.  As for anxiety relief, that seems an overreaction.  But it's something for you to discuss with your partner.

3) Yes, that is indeed a "crazy hypothesis".  Most people with oral herpes have no symptoms at all, and those with recurrent cold sores usually have them only once or twice a year.  And just as for genital herpes, they can be effectively prevented or treated with antiviral therapy.

4) Probably yes, but there are few data on this.

5) So talk to a physician and take a prescription for valacyclovir (or other antiherpes drug) with you when you travel.  Whether treatment is "really needed" depends on severity.  But treatment normally is recommended, especially for initial infections.

In summary, you are overreacting to this situation, especially if this is an important relationship that would otherwise become permanent.  Herpes, especially HSV-1, should never be permitted to interfere with love, romance, and rewarding sex.  If I were in your situation, knowing what I know, I would not alter my sexual practices or the relationship in any way, except to avoid either genital or anal sex if and when your partner has another genital outbreak.   That may never happen.

Please discuss this reply with your partner and make any and all decisions with her active participation.

Best wishes---- HHH, MD

[dillegent28]

Dr. Handsfield,

Thanks for your insight. Just for two minor points of clarification for other readers and archival purposes -- she actually was molested around 5 or 6 years old.

Secondly, we have been having unprotected sex for well over 6 years. For the first year of the relationship, we used condoms.

Unfortunately, it appears my general practitioner is a bit misinformed -- he said there is a 99 percent chance I'd eventually get it and it's like "Russian Roulette" (very comforting and great bedside manner - won't be seeing him again).

After reading your posts, along with Anna Wald, Terri Warren and Dr. Hook's, I am a bit more comforted.

It's too bad many doctors are unaware of the differences of HSV-1 and 2 and just start guessing.

The diagnosis isn't going to change anything -- when she said she might have herpes before I was ready to take on HSV-2 if necessary. Now, a few years later, and a bit older, I am suffering from depression and anxiety, but am doing my best to deal with life's pressures.

All of my other questions are just anxiety-based, so I will spare you from having to tell me to chill out. :-)

Appreciate your help and insight, and if you do care to tap me for future references or case studies around this, I'd be happy to keep you in the loop.

[H. Hunter Handsfield, M.D.]

Glad to be of help, and happy to hear you are more acclimated to the herpes situation than I first understood.  Thanks for the thanks about the forum.