Suppression and Transmission

[Kateja07]

Dr - I am a female and was diagnosed with genital herpes in February although I don't know how long I may have had it.  The person I think I caught it from says he doesn't have it but that doesn't mean much coming from him. I had one small sore and have not had another since February.  

My first question is more ethical than medical but was hoping you could give me your opinion anyway.  I am in a new relationship and want to protect my new partner in every way possible.  We have dicussed this and he still wants to be with me as long as it is safe for him to do so.  I of course would never have sex during an outbreak and would use condoms every single time.  My question is regarding shedding and even though condoms are used I know there is still a risk of transmission.  I discussed this with my doctor and I asked about supressive therapy and the dr didn't feel it was necessary since I haven't had any other outbreaks other than that initial first sore.  I personally don't want to go on supressive therapy because I don't think I need it, it's another expense, it may cause side effects, and I just would prefer not to.  But, I'm torn because I know it would help with lowering the risk of transmission.  Can you give me your opinion on this, I'm really struggling. Will condom usage be enough?

Second, also regarding shedding, I've heard about predomes.  As I stated above I have not had another outbreak but I'm concerned about shedding.  Do predomes happen before shedding?  Once in a while I will have a weird sensation in my vaginal area, I don't know if it's anything or just me being hyper sensitive because of the situation.  Anyway, my question is, if I do feel this sensation and assuming it is a predome, how long should I wait before engaging in sexual activity (assuming there is no outbreak)for the virus to clear and no longer be transmitted?

Again, I realize this may be more of an ethical concern but I am trying to do everything in my power to keep myself and my partner healthy so any advice you could supply would be greatly appreciated.

[H. Hunter Handsfield, M.D.]

Congratulations on your responsible reaction to your genital herpes and your caring approach to protecting your partner.  I'll try to help.

You don't provide the single most important piece of information.  Which type of herpes simplex virus (HSV) is causing your genital herpes?  Almost half of new genital infections these days are due to HSV-1, which in most people causes infrequent outbreaks and low rates of asymptomatic shedding, and therefore carries a relatively low risk for transmission by genital intercourse.  The risk is much higher if you have HSV-2.  That you have had no symptomatic outbreaks since the intial one over 6 months ago is a clue you might have HSV-1.

The second piece of necessary information is your new partner's HSV status.  Assuming he has been sexually active with past partners, the odds are fair he already has HSV-2 (25% of the population does), and they are especially good that he has HSV-1 (orally)--because half the population does.  He is pretty much immune from catching the same virus type again.

So if you're unsure of your own virus type, check with the provider who diagnosed you.  If testing for virus type wasn't done, a blood test can tell.  And your partner definitely needs to have the blood test.  That will tell whether he has been infected and if he is susceptible or immune to the type infecting you.  With luck (for example, if your herpes is due to HSV-1 and he has a positive test for HSV-1), you need take no special precautions at all to prevent transmission.

So your main questions come down to the worst case scenario.  If you have HSV-2 and he doesn't, then your 3 choices to prevent transmission are 1) avoidance of sex during symptoms (including prodrome), 2) using condoms, and 3) antiviral therapy.  Each of these by itself is only fairly effective over the long run, but using them in combination is highly protective.  Since you are reticent about suppressive therapy, and presumably you don't want to be stuck indefinitely with using condoms, knowing your virus types will be major help in deciding your straegy as a couple.

By definition, asymptomatic viral shedding is totally asymptomatic.  While shedding is very common during a prodrome, absence of prodromal symptoms doesn't give much reassurance; the virus could still be present.  In any case, your symptoms sound pretty vague; most likely they aren't herpes prodromes.  But if you do have symptoms you are concerned about, you should wait at least a week after they go away before you have unprotected sex.

Bottom line:  Learn your virus type, with a blood test if necessary; and have your partner tested.  Those results will guide your prevention strategies.

Good luck-- HHH, MD

[Kateja07]

Sorry, I should have included that information.  I have HSV type 2, I also have had type 1 since I was a child.  My partner is negative for both which is why I am so concerned.  If we don't have sex during an outbreak and use condoms what are the chances of transmission?

[Kateja07]

One other thing, I haven't had a type 1 outbreak in over ten years so I'm not so concerned with that type, I'm more worried about type 2 transmission via intercourse.  I lead a very healthy and drug free lifestyle which is part of the reason why I don't want to take any suppressive medication plus without having outbreaks I really don't see a medical need for it.

[H. Hunter Handsfield, M.D.]

It really isn't possible to predict the transmission risk for any particular discordant couple.  The risk should be quite low if you maintain careful attention to symptoms plus use condoms consistently.  But it isn't possible to put a number to it.  Although the average risk is only 3-4% per year in couples who have sex 2-3 times per week (without condom), that research was done in long-term couples in which most infected persons had had genital herpes for a few years.  On the other hand, statistically, transmission risk is highest in the first year after acquiring herpes, and early during new sexual relationships--both of which apply in your case.  

The definition of "medical need" is subjective.  That is, only you (presumably in consultation with your partner) can decide whether the benefit in reducing transmission risk is worth the inconvenience and cost of suppressive thearpy.  At least valacyclovir is harmless; you needn't worry about side effects or any long term adverse effects of treatment.

HHH, MD

[Kateja07]

Thank you for your advice.  The risk of 3-4% is reassuring but considering this is the first year (I think) of having this and a new relationship we will have to discuss things.

[ryred12]

westover clinic stated this averages for suppresive and condom during a relationship for one year.



With one a day valtrex and condom  Women 2.5-3%

With one a day valtrex and condom  Men 1%


They say the key is not to have sex if lessions are present

[Kateja07]

Thanks Ryred12.  I'm wondering what those percentages go up to though without Valtrex and just with condom use.

[JDog7]

my understanding is condom use in itself lowers transmission by by about 60%.

another way to look at suppression therapy is that (in my impression from reading), it lowers shedding rates about 10-fold (obviously this varies person to person).  If so, this means the total number of days you are shedding virus (and have any potential for transmission) is a lot lower.

[ryred12]

valtrex reduces shedding by about 75%


westover clinic on Webmd states one year without condom men 3% women 10 percent.


The take home point I think is use valtrex if you are going into a relationship with a neg partner. Within the next few years you will have more options such as microbicides and possibe a vaccine for HS2.

[Kateja07]

What is the difference between Valtrex and Acyclovir?  From what I've read they both seem to do the same thing and Acyclovir is A LOT cheaper.

[H. Hunter Handsfield, M.D.]

Indeed, they are almost exactly the same thing.  Valacyclovir (Valtrex) is simply a high-tech form of acyclovir.  After ingestion, it is converted to acyclovir.  However, it is much better absorbed, i.e. each dose results in higher and more prolonged blood levels than acyclovir itself, so it can be taken once a day; acyclovir has to be taken twice daily.  If you're the sort that doesn't have trouble remembering to take daily meds and twice a day works for you, feel free to use acyclovir.

HHH, MD