Aa
Questions from HSV-negative man in discordant relationship
Several months ago I met a wonderful woman who has HSV-2. We both got tested (IgG) and I came up negative for both types, and she positive for HSV-2 and negative for HSV-1. We are both 38; she has had HSV-2 since she was 19; she gets a very mild outbreak (“it feels like an ingrown hair”) about once a year. We’re trying to navigate the difficulties of being discordant and in a new relationship (I have to admit I have a great deal of anxiety about getting this and having to tell future partners if this doesn’t work out) – any help would be appreciated.
1) She asked her ob-gyn about antivirals – I’m not sure she said it was to prevent transmission to a new partner, but they discussed Valtrex and based on the number of outbreaks, the ob-gyn recommended not taking Valtrex because it can be hard on the liver. Is acyclovir easier on the liver? Should we even be looking at antivirals based on her outbreak history?
2) Is the prevalence of asymptomatic shedding correlated with number of outbreaks a person has? I’ve read in Terri Warren’s book that for genital HSV-2, shedding occurs on 15-25% of days. Would this number of days be lower for someone that only has one outbreak a year? And if shedding occurs as frequently as 1 in 4 or 5 days, why aren’t the transmission rates in discordant couples higher than the reported 4% over a year?
3) What’s the risk involved with a HSV-negative person performing oral sex on someone with genital HSV-2 (assuming no outbreaks at the time)? I see dental dams recommended by well-reputed sites, but it sounds like oral HSV-2 is exceedingly rare. I'm not sure how concerned I should be about transmission via this route.
Thanks
1) She asked her ob-gyn about antivirals – I’m not sure she said it was to prevent transmission to a new partner, but they discussed Valtrex and based on the number of outbreaks, the ob-gyn recommended not taking Valtrex because it can be hard on the liver. Is acyclovir easier on the liver? Should we even be looking at antivirals based on her outbreak history?
2) Is the prevalence of asymptomatic shedding correlated with number of outbreaks a person has? I’ve read in Terri Warren’s book that for genital HSV-2, shedding occurs on 15-25% of days. Would this number of days be lower for someone that only has one outbreak a year? And if shedding occurs as frequently as 1 in 4 or 5 days, why aren’t the transmission rates in discordant couples higher than the reported 4% over a year?
3) What’s the risk involved with a HSV-negative person performing oral sex on someone with genital HSV-2 (assuming no outbreaks at the time)? I see dental dams recommended by well-reputed sites, but it sounds like oral HSV-2 is exceedingly rare. I'm not sure how concerned I should be about transmission via this route.
Thanks
MEDICAL PROFESSIONAL
Good move. Best wishes.
Thank you so much for your medical advice as well as giving me some perspectives to think about. We have an appt with a specialist and will inquire about Valtrex with her. Thanks again.
MEDICAL PROFESSIONAL
Welcome to the forum. Thanks for your question.
Congratulations on your good fortune in your new relationship. Now your challenge is to not muck it up over something as trivial as herpes! And congratulations for doing your research and the level of knowledge you have obviously gained. Your questions are reasonable and thoughtful.
My first thought is that you should carefully consider how important it is to prevent you becoming infected. For many susceptible persons, the greater the promise for the long term or permanent relationship, the less important to prevent HSV transmission. Treatment can effectively limit symptoms initially and prevent painful outbreaks, and therefore the greatest fear of most people in having herpes is the problems it causes in dating, having sex, and forging new relationships. If new partners are not in your future, the biggest potential concern is moot. In that case, many couples would be less compulsive in preventing transmission and some would take no precautions at all. Even if you aren't certain about these issues, I still would encourage reasonable steps to avoid transmission, but not to an extent that it seriously interferes with cementing your relationship, romance, and rewarding sex with your new partner.
To your specific questions:
1) Your partner's ObG is mistaken, or your partner misunderstood. There is no risk of liver trouble of any kind from valacyclovir, or from the other anti-herpes drugs (acyclovir, famciclovir). Valacyclovir is one of the safest drugs there is -- in 30 years, I've never had a patient with serious or even mildly bothersome side effects.
2) There is little relationship of asymptomatic shedding with number of outbreaks. However, there is a strong relationship with duration of infection. Having had it for nearly 20 years, it is likely that your partner sheds virus a lot less often than the figures you cite. In any case, transmission frequency is a lot less than the frequency of shedding; most shedding episodes involve low levels of virus. In monogamous HSV-2 discordant couples who take no precautions except to avoid sex during obvious outbreaks, and who have unprotected vaginal sex 2-3 times a week, only 5% of couples experience transmission per year. That works out to something like one transmission for every 1,000 episodes of unprotected sex -- which you will immediately understand is a lot lower than the frequency of asymptomatic shedding. OTOH, the risk tends to be higher in new relationships, perhaps reflecting increased frequency of sex or other factors, not well understood. But in any case, with no precautions at all, transmission is the exception, not the rule; many couples go for a lifetime of marriage without it happening.
3) Oral sex indeed appears to carry even lower risk than vaginal, for the reasons you state. Frankly, I don't recommend barriers for oral sex -- although if you decide that transmission needs to be avoided at all costs, it's something you would have to consider.
All things considered, the chance you'll be infected if you take no precautions at all probably is low -- I would guess no higher than the 5% chance per year I cited above. If you like my main advice -- to take reasonable steps to further reduce the risk, i.e. to allow some small risk in the name of sexual satisfaction and a healthy and rewarding relationship -- then I would suggest 1) no sex if and when your partner has an outbreak (a no-brainer), and 2) that your partner take valacyclovir for suppression. The next level of protection beyond that would require 3) consistent condom use for vaginal or anal sex. If I were in your shoes, I would have oral sex (both ways) without protection.
I hope these comments have been helpful. Let me know if anything isn't clear. Best wishes-- HHH, MD
Congratulations on your good fortune in your new relationship. Now your challenge is to not muck it up over something as trivial as herpes! And congratulations for doing your research and the level of knowledge you have obviously gained. Your questions are reasonable and thoughtful.
My first thought is that you should carefully consider how important it is to prevent you becoming infected. For many susceptible persons, the greater the promise for the long term or permanent relationship, the less important to prevent HSV transmission. Treatment can effectively limit symptoms initially and prevent painful outbreaks, and therefore the greatest fear of most people in having herpes is the problems it causes in dating, having sex, and forging new relationships. If new partners are not in your future, the biggest potential concern is moot. In that case, many couples would be less compulsive in preventing transmission and some would take no precautions at all. Even if you aren't certain about these issues, I still would encourage reasonable steps to avoid transmission, but not to an extent that it seriously interferes with cementing your relationship, romance, and rewarding sex with your new partner.
To your specific questions:
1) Your partner's ObG is mistaken, or your partner misunderstood. There is no risk of liver trouble of any kind from valacyclovir, or from the other anti-herpes drugs (acyclovir, famciclovir). Valacyclovir is one of the safest drugs there is -- in 30 years, I've never had a patient with serious or even mildly bothersome side effects.
2) There is little relationship of asymptomatic shedding with number of outbreaks. However, there is a strong relationship with duration of infection. Having had it for nearly 20 years, it is likely that your partner sheds virus a lot less often than the figures you cite. In any case, transmission frequency is a lot less than the frequency of shedding; most shedding episodes involve low levels of virus. In monogamous HSV-2 discordant couples who take no precautions except to avoid sex during obvious outbreaks, and who have unprotected vaginal sex 2-3 times a week, only 5% of couples experience transmission per year. That works out to something like one transmission for every 1,000 episodes of unprotected sex -- which you will immediately understand is a lot lower than the frequency of asymptomatic shedding. OTOH, the risk tends to be higher in new relationships, perhaps reflecting increased frequency of sex or other factors, not well understood. But in any case, with no precautions at all, transmission is the exception, not the rule; many couples go for a lifetime of marriage without it happening.
3) Oral sex indeed appears to carry even lower risk than vaginal, for the reasons you state. Frankly, I don't recommend barriers for oral sex -- although if you decide that transmission needs to be avoided at all costs, it's something you would have to consider.
All things considered, the chance you'll be infected if you take no precautions at all probably is low -- I would guess no higher than the 5% chance per year I cited above. If you like my main advice -- to take reasonable steps to further reduce the risk, i.e. to allow some small risk in the name of sexual satisfaction and a healthy and rewarding relationship -- then I would suggest 1) no sex if and when your partner has an outbreak (a no-brainer), and 2) that your partner take valacyclovir for suppression. The next level of protection beyond that would require 3) consistent condom use for vaginal or anal sex. If I were in your shoes, I would have oral sex (both ways) without protection.
I hope these comments have been helpful. Let me know if anything isn't clear. Best wishes-- HHH, MD
You are reading content posted in the STDs Forum
Herpes spreads by oral, vaginal and anal sex.
Herpes sores blister, then burst, scab and heal.
STIs are the most common cause of genital sores.
Millions of people are diagnosed with STDs in the U.S. each year.
STDs can't be transmitted by casual contact, like hugging or touching.
Syphilis is an STD that is transmitted by oral, genital and anal sex.
