Transmission rates in monogamous gay sex?

Hi Dr.,

I am a gay male who is also a serial monogamist (but currently single).  I recently found out I am + for HSV2.  I didn't even know I had it, or when I contracted it, since I have been frequently tested for HIV (-) but not HSV.

Anyway, I would like to know if there are any stats on the transmission risks amongst gay sexual activity from an infected partner to an uninfected partner, assuming no visible outbreaks and no condoms.  In this case, we engaged in some oral and anal, both unprotected (less than 10 acts, total).  Of course, I had no visible signs of an outbreak during the entire relationship (which lasted approximately 2 months.  Are the stats for transmission thought be along the lines as those for hetero sex?

Also, if you wouldn't mind re-assuring me here: HSV2+ people still lead normal lives with an average lifespan, correct?  I know that sounds silly, but I'm still adjusting to the news of my HSV status and wouldn't mind finding some silver lining.

Thanks!

[H. Hunter Handsfield, M.D.]

Unfortunately, to my knowledge there are no research studies (nor even reported non-research clinical experience) that address the risk of HSV-2 transmission among gay couples in which one person is infectd and the other is not.  Overall, the proportion of gay men who have positive HSV-2 blood tests is higher than in the general population, but that likely is related to total number of lifetime partners, which generally is much higher than for straight people, and not necessarily on the transmission risk per se.  It is likely that more gay men than heterosexual men have asymptomatic HSV-2 infection, particularly if infection is in the rectum; but even this is speculative.  And that raises the other uncertainty:  transmission risk undboutedly is related in part to the anatomic area infected (genital vs anorectal) and specific sexual practices.

All in all, I would guess the risk of transmission, if your partner isn't already infected, is higher than in heterosexual couples.  In straight couples, it averages 3-5% per year.  But whether your possibly higher risk is 5-10%, 10-20%, or even higher simply isn't possible to predict.  Your first step is to advise your partner to be tested for HSV-2 with a type-specific blood test, such as HSV-2.  Since over 50% of gay men are infected, the odds are good he already has it--in which case you have no herpes-related worries; neither of you can reinfect the other.

Yes, HSV-2-infected people have normal health and longevity.  With one caveat, and another theoretical one:  1) People with HSV-2 are more susceptible to catching HIV if exposed; so in that sense, HSV-2-positive persons at high risk for HIV probably have lesser longevity on average than people without HSV-2, but herpes itself isn't the reason.  2) In HIV infected people, there is some very soft evidence that the course of HIV disease may be more aggressive.  If so, it is a minor effect, and as I said above, that risk is highly theoretical.

I hope this helps.  Best wishes.  Stay safe!   HHH, MD

[JohnnyV]

Hi,

Is there a way for this guy in San Francisco to find out exactly where in his body the HSV-2 is? That might make it easier. It it's in his rectum, he knows to avoid being the bottom. If it's in his mouth, he knows to avoid fellatio. If it's on his genitals, he knows to avoid being the bottoms, etc....

Concerned: It's great that you're a serial monogamist, but if you can, try to stall longer before doing things without condoms. As someone who's been with guys in the past and just made it through a bad STD scare, I feel worried when reading that you had 10 acts of unprotected anal sex with someone when the relationship only lasted 2 months. I know in the heat of things you can get swept away by a guy, esp. if he says he loves you, but often 2 months isn't long enough for you to find out everything about his ability to be faithful, his honesty, his risk history, etc. While I know many MSMs who got HIV by having anonymous and promiscuous sex, I also know four guys who got HIV in whirlwind love relationships that looked eternal during the first month and then broke down by the fourth month. In that state of heightened trust and lowered inhibitions, they were so convinced of their boyfriend's goodness that they went all the way, sans condom.... And in those cases it wasn't a question of deception; the infectious boyfriend had only recently gotten the virus (we've talked about recent infections here a lot) so he didn't know he was positive himself, when he infected the HIV- partner.

J

[opinion222]

I am not sure if you will comment;

I find it interesting that your risk of infection increases if you are infected with HSV-2. Is that due to ulcers resulting from herpes or does it pertain to when the virus is actually in your system and trying to replicate?

[opinion222]

Sorry doc no need to answer i found it. It seems it is not so theoretical as a study has been done on the increased risk from HSV-2. For anybody interested! SA.http://www.mrc.ac.za/policybriefs/simplexherpesbook.pdf

[opinion222]

http://www.mrc.ac.za/policybriefs/simplexherpesbook.pdf

[H. Hunter Handsfield, M.D.]

In response to JohnnyV's question:  No, there is no test to determine the anatomic site of an HSV infection--except to be on the alert for symptoms (even very subtle ones).  If there is an outbreak, the lesions can be cultured for the virus.

HHH, MD

[concernedinsf]

Hey JohnnyV, give me a break, will you?  I'm still dealing with the news of my new friend-for-life (HSV2), and I don't need judgment pronounced from someone who doesn't even know me.

[concernedinsf]

Dr. H:

As a follow up, I went to my personal physician and requested Valtrex.  Is it true that the HSV may develop its own "immunity" to the treatment after a while?  Also, is itching in the crotch area (by itself-- not accompanied by any other rashes or lesions, neither of which I have had) a sign of an active outbreak?

Thanks again.

-CSF

[H. Hunter Handsfield, M.D.]

If your opening comment about serial monogamy means you currently have a regular partner, it seems premature for you to go onto suppressive therapy with valacyclovir (Valtrex) (or anything else).  The main purposes of suppressive therapy are 1) to prevent recurrent symptoms, but you don't have any (no, itching in the groin is unlikely to be due to herpes); and 2) to prevent transmission to a partner.  Since 50% to 70% of gay men already are infected--and those numbers may be even higher in San Francisco, where your username suggests you live--the odds are your partner already is positive for HSV-2 and is immune to catching it again.  But maybe you are between partners (?).  Either way, having your partner tested and knowing whether or not he is susceptible or already infected would be your best guide to the need for treatment.

In theory, HSV strains can become resistant to the standard antiviral drugs over time, but it is very rare.  It is seen most often in HIV-infected people who have taken especially large amounts of antiherpetic drugs for long periods of time, and even then it's uncommon.  If the indication for treatment is clear, concern about resistance isn't a consideration.

HHH, MD

[concernedinsf]

Dr H--

Thanks for your continuing advice.

Yes, I'm in San Francisco, and I am between partners.  Actually, acquiring HSV2 has been a catalyst for change in my behavior.  I wasn't particularly promiscuous before (I've only been sexually active for 2 years, and I'm 25), and can count my number of sexual partners on two hands.  But as they say, all it takes is 1 time with the wrong person.  With the news of my infection, casual intimacy will be a no-no now, and romantic intimacy with a partner will be done only after a thorough discussion of sexual histories and testing.
Anyway, I elected to go on Valtrex as a precautionary measure for any potential outbreaks in the future (which is probably unlikely) and to reduce the chances of transmission with any future partners.  But as you said, it's something to discuss with any potential future partners anyway.  Maybe doing Valtrex is sort of my "security blanket" at this stage of my acceptance of herpes, if you know what I mean.  It sort of makes me feel better about the situation.
Thanks for all your advice, Doctor.  You've been extremely helpful in passing along information.

[JohnnyV]

Concerned,

Sorry for the TMI. I wasn't judging, just interested in sparking some discussion. I was just happy to see another gay/bi male posting on the forum, since there are so few. I hope everything works out for you.

J

[concernedinsf]

Johnny,

Sorry.  I've always tried to be responsible.  When not in a "relationship" status, I've always used protection during anal intercourse.  I can also count my number of sexual partners on two hands, which a lot less than average for gay/bi men.
But this has been a catalyst for a change in behavior for me.  A warning shot across the bow, so to speak.  I thank God I didn't contract something much more serious.  And, in the grand scheme of things, HSV-2 is at best an annoyance, not the end of the world.  Life's too short to sit around and cry about it now.  But for now on, I'm going to be much more discerning and safe(r) when it comes to sexual encounters.

-CSF

[JohnnyV]

CSF,

You're doing fine and rest assured that everyone on this forum will be rooting for you. 25% of adult males have genital herpes, so even if you were straight, your situation would be fairly common. I recently dealt with a pretty bad Herpes scare, because I got someone pregnant and I couldn't sleep at night, thinking I may have passed on genital herpes and an outbreak during delivery would kill the baby. I quickly found out how easy and manageable Herpes is.

I'm afraid of saying something that will sound judgmental, but I would just add one thing out of sincere caring, since I'm bi, I live in New York City and I've seen so many friends get HIV (probably half the men in my gym have it.) It's about the gay dating scene. Recently there has been a change I've noticed in how relationships evolve. A lot of young gay men seem focused on reaching a threshold in relationships where the condoms can be thrown away. It seems like it's become a rite of passage that indicates to both boyfriends that they love each other. Condomless sex seems to distinguish the relationship and make it more legitimate.

Just think of barebacking as a bond equivalent to marrying someone. Straight couples talk about their wedding for a long time, they remain engaged for as long as two years before the ceremony; my philosophy is that gay men will be a lot better off following a similar pattern. Maybe it will make the moment of going natural all that more significant. My current female partner, for instance, has been with me for six years. We only stopped using condoms after about 18 months. I have no idea why she has stayed with me through all my insanity, but I guess I'm lucky.

You are definitely in a good position though. When I hear you've had sex with less than 10 people, I'm jealous and ashamed. I tried to estimate my sexual history once and came up with roughly 250 males and 35 females, many of them HIV+ and all of them high risk. I still have many of my past male partners hovering around trying to get  me to top them bareback, and now I have a baby to worry about. By comparison, your situation is pretty easy!

I hope everything works out for you and I know that HSV-2 will be a blip with no effect on your life. Most importantly I hope you find a good love in SF.

From NYC,
J

[concernedinsf]

Hi Johnny

Thanks for replying.  And caring.  I now understand where you're coming from.  I do have some more questions for you-- perhaps you'd be willing to go off the forum and talk further?  My email is user040776 @ gmail.com

-CSF

[JohnnyV]

Concerned,

I will try to email you later tonight, after I come back from the gym.

J

[concernedinsf]

Dr H--

If you're still reading this, I was wondering about the chances of spreading the HSV-2 infection to other parts of the body (e.g., eyes).  Frankly, sometimes I will scratch myself, as men often do, and sometime later unthinkingly rub my eyes.  Is this type of infection common?

Thanks again.