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Questions about herpes 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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Questions about herpes transmission

I recently started dating someone who has Herpes Type 2 and are reaching the point in our relationship where we're considering sex.  I don't know that I want to spend the rest of my life with this person but I don't want herpes and I don't want to break things off with her. I've read the FAQs here and a lot of other information online and have just a couple of clarifying questions.  She's had herpes for 12 years and has breakouts only every 2-3 years.  Her doctor has said that when she is not symptomatic it is nearly impossible to trasmit and she has never infected previous parnters.  I realize it is still possible for me to get infected but if we use condoms and she's on suppressive drugs how likely is it?  I work well with concrete numbers.  Is it 5% likely?  1%?  Less than or more than?  Am I more likely to get herpes from her than say get struck by lightening?  Also, can I be infected with Herpes from performing cunnilingus?
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First, congratulations to you and your partner for thinking it through and not acting on an emotional basis; and to your partner for being open with you about it.

The first thing for you to do is decide how important it is to avoid herpes and balance that with the importance and potential longevity of the relationship.  Lots of monogamous couples simply decide to not worry much about it.  The biggest stress/problem with genital HSV-2 is the potential to transmit it to other partners, and the effect that might have on your future relationships--the obligation to inform future partners, etc.  But for some couples that issue is no longer an issue.  On the other hand, I don't know (and maybe you don't yet know) how important this is likely to be in your future.  But I often stay that herpes simply should never stand in the way of a promising relationship; it just isn't that important a disease.

Leaving asside the issue of transmission to future partners, for most people genital herpes is a pretty trivial issue.  Most people who acquire genital HSV-2 infection have such mild symptoms they don't even know it; and if there are significant symptoms, excellent treatment is available both for the initial infection and to prevent recurrent outbreaks.  But for the remainder of this response, I'm going to assume you're going to try to prevent infection in your new relationship.

The first thing you need to do is have a type-specific HSV-2 antibody test, such as HerpeSelect.  Since a quarter of the population is infected and most don't know it, there is a fair chance you already are infected, assuming an average sexual lifestyle up to this point in your life.  If your test is positive, you are home-free; you would be immune to catching HSV-2 again (of any body site) and would not need to take any precautions at all to prevent transmission.

Your partner's doctor may be partly right; with such infrequent outbreaks, it may be that asymptomatic sheddding of the virus also is infrequent.  Unfortunately, there is no way to know with certainty.  The doc's "nearly impossible" statement probably is wrong, however.  The odds of transmission during any single episode of sex (when your partner isn't having symptoms) is very low, but not zero; and of course that risk rises with the number of sexual exposures.  In monogamous couples in which one person has genital HSV-2 and the other does not, and who have sex with average frequency (2-3 times per week), transmission occurs in about 3-5% of the couples each year.  But the risk in any particular couple can be much higher or much lower, depending on how good they are at noticing symptoms, how consistently they use condoms, how recent the currently infected person acquired the virus (that factor is in your favor), etc.  If the infected person takes valacyclovir (Valtrex), that risk is cut in half.  (Actually, valacyclovir may be more effective than that in preventing transmission, but that's what the main research study showed.)

In summary, your risk of getting HSV-2 is much higher than the lighting strike range.  But if your partner is taking antiherpes therapy, you avoid sex when she has symptoms, and you use condoms consistently, my guess is the likelihood you will acquried HSV-2 less than 1% per year.  Even without the condoms, it might be in that range or less.

Oral herpes due to HSV-2 is rare; and when it occurs, recurrent oral lesions appear to be even rarer.  I wouldn't worry much about performing cunnilingus as long as she has no symptoms.

Good luck--  HHH, MD
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