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Minimizing risk of HSV-1 transmission
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The STD Forum 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.

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Minimizing risk of HSV-1 transmission

Dear Dr. Handsfield and Dr. Hook,

Thank you so much for your great work on this forum, it is by far the best Herpes resource I've found.  My situation is not unique, but it is causing me a great deal of stress.  

I am a 32 y.o. male in a serious relationship with a 23 y.o. oHSV1+ female.

In March I had the HerpesSelect test. I was - for HSV1 and 2.

In April I began dating my current girlfriend.  In Sep. she casually mentioned that she has had coldsores before.  (She may have been exposed as a child, but had what sounds like a primary outbreak in Nov 2007 and outbreaks in Nov. 2008 and Dec. 2009).  This Sep. we both retested.  She was + for HSV1, I was - for both.

1.  What are the ethics of disclosure?  I think, because of asymp shedding, disclosure is required before the first kiss.  Am I wrong?  I have had trouble fully trusting her because of her failure to disclose.

2.  What is the risk of transmission if the only precaution we take is avoiding risky contact during outbreaks, otherwise assuming frequent kissing and oral sex?  (She says she has always felt the prodrome symptoms). Are there studies of oHSV1 discordant couples? Am I going to get it?!?!

3. How can we minimize the risk of transmission? Wear Chapstick? Rinse with Listerine and wash up after intimacy?  Am I more at risk if I'm sick or run-down, or she is?  Do canker sores increase the risk?

4.  Can she take Valtrex to reduce the risk to me?  Her gyno dismissed that idea. Can she do anything else?  Can I take Valtrex to prevent infection?  Take a vaccine as part of a clinical study?

5. How contagious is she during asymptomatic shedding?  Is there anyway to predict it?

6.  Does seroprevalence vary by race, region, SES, etc?  Where can I find the best stats on this?  I bet the rate of infection is much lower among 20-30 y.o. upper middle class white collar professionals.

7.  Is it foolish to knowingly expose myself to HSV1 unless I think we'll get married?

Your help is appreciated. THANK YOU!
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Welcome to the Forum.  I see you have asked a number of similar questions of Terri.  In comparing our answers, as I'm sure you will do, please realize that while there may be modest differences in terms and wording, Terri and I, like Hunter and I all share information and typically agree with each other.   So with this, let's work through your questions:

1.  I do not agree with you on disclosure.  Most people have not been tested and most (about 80%) of people with herpes infections are unaware of their infections.  Transmission is relatively rare.  While I do agree that when one is aware of their infections it is a good idea to mention it, I personally would not hold everyone accountable for failure to mention that someone gets an occasional cold sore.  Couples go for decades without transmission of HSV-1 from one another.

2.  There are no studies that I am aware of looking at HSV-1 transmission among discordant couples.  The major precaution is to avoid contact (kissing, oral sex) if a cold sore is present or coming (i.e. if she is having a prodrome).  While asymptomatic shedding occurs risk of infection at that time is lower than when lesions are present.

3.  See above. there are no data on chap stick or Listerine and I doubt that they would do much in the way of protection.  Fatigue does not increase risk of infection but some people do get cold sores when they are fatigued.  Canker sores should not increase risk of getting HSV unless they are incorrectly identified cold sores.

4.  There are no current vaccine studies. The last prototype vaccine failed to work.  Similarly there are no studies of valacyclovir for prevention.  Typically it takes more acyclovir to treat HSV-1 than HSV-2.  Similarly there are no studies of persons taking drug to prevent acquisition.

5.  There is no way to predict asymptomatic shedding, that's the reason it is called asymptomatic shedding.  In discussions with others, we estimate the probability of being exposed and acquiring infection due to asymptomatic shedding as being in the neighborhood of a 1 in 10,000 chance.  These estimates are "back of the envelope" and are not the results of studies but reflect casual conversation with other investigators.

6.  The best data of seroprevalence come from national studies and trying to subdivide these data greatly reduces their accuracy.  Rates are higher among African Americans than whites but you can be confident that even among whites rates are over 50%.  All studies that have evaluated SES class or educational status have failed to show meaningful differences in prevalence of infection.

7.  Personally, I feel it is foolish to worry about it.   Getting HSV is just not the end of the world.  Remember, it is quite safe to assume that over half of the people you have ever kissed had HSV-1.  Other than avoiding contact when cold sores are present I would not worry - life is too short.  EWH
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Dr.  Hook,

Thanks so much for your prompt and thorough answer.  You have definitely helped to set my mind at ease.  I have a few follow-up questions from your responses:

4.  My understanding is that a suppressive dose of Valtrex significantly reduces asymptomatic shedding and rates of transmission for HSV-2.  Even in the absence of studies, but given the similarities of the virus, doesn't it make sense that suppressive Valtrex would reduce asymptomatic shedding and rates of transmission for HSV-1?  Is there any reason NOT to take this precaution?  Would it cause any harm if my girlfriend took Valtex in the absence of outbreaks?

5.  I understand that 1 in 10,000 is just a rough estimate, and I appreciate your sharing it with me, but for clarification purposes:  Is that 1 in 10,000 exposures? So if I kiss my girlfriend 100 times in one evening, is that 100 exposures?  And does the type of exposure matter, i.e., is the risk of a french kiss similar to the risk of oral sex?  If the chance of acquisition is so low, why is HSV-1 so widespread?

7.  I very much appreciate your advice that life is too short to worry about it, but so far I have been unable to shake off a lingering feeling of fear while kissing my girlfriend.  I know HSV-1 is not the end of the world, but it seems likely to impede my sex/relationship life in the future if my current relationship doesn't work out.  I'm just searching for ways to responsibly minimize the risk in a way that doesn't affect our love life.

Finally, I'm a little confused as to how the virus actually infects the body.  Does it need a break in the skin, like a chapped lip?  Is the site of an outbreak where the virus enters the body?  How does it work with a mucous membrane? If I get infected saliva in my mouth, could I break out anywhere the trigeminal nerve reaches?  And how fast does the infection take place?  If I kissed an infected person, but then washed up with soap, could that kill the virus before it can infect me?

Thanks again for all of your help.  I greatly appreciate it.  It's so hard to find good information.
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4. As I said, there are no data to prove that this will work.  It has not been studied and when there have been studies of HSV-1 treatment with valacyclovir, it takes higher doses of medication to have an effect.  Valacyclovir is well tolerated with few side effects and is now generic but still quite expensive. If you are going to push your GF to do this, you should at least pay for the drug.

5.  Contact is contact. The estimate is based on 1000 contacts, be they kisses or whatever.  The infection is widespread because there is a lot of it and there is a lot of contact between people.  

7.  I don't know what to say except that you seem to be hung up on stigma that is inappropriately imposed by society.  Do you feel the same way around people with colds?  Would you feel the same way about it if the virus did not have the name herpes?  I don't think so (BTW, did you know that chicken pox is a herpes virus too, so, given your age, you almost certainly already have one form of herpes.)  I'm not saying the you want to get HSV-1, or a cold, or the flu but stuff happens.  As I said, life is far too short to allow something like this to compromise your interactions with others

Take care.  EWH
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