a few more transmission question

[quazar]

Doc, I posted earlier, but I have some more transmission questions.  
1.  If someone is tested 3 or 4 weeks after an "incident," and the results with a respectable blood test are positive for hsv 2, how likely is it that the incident is the cause?  I guess I'm just wondering how many people develop antibodies 3 or 4 weeks after getting the virus.  And, fyi, I'm talking about people who have led regular sex lives--a few relationships, etc.  

2.  I posted earlier wondering if I could have received the virus (hsv2) from a woman who rubbed her arm against my penis, then rubbed her stockinged leg there as well.  Your clear response (thanks, of course!) was no, it is inifinitely more likely that I got the virus by another, more normal sexual encounter.  But in that case, I'm wondering why so many websites seem to say people who do rub, engage in foreplay, can get it then, even without sex.  I don't mean to be an annoying follow-upper, but your confident "no" seems offset by the other pages, info I've read.  I believe you, but I'd like clarity on why.

3.  Would you recommend Valtrex to someone who does not have obvious/overt symptoms or is asymptomatic, for prevention purposes?  

Thanks in advance.  I hope I haven't crossed into the "you already asked this line," because I didn't intend to.

[H. Hunter Handsfield, M.D.]

Don't worry--you didn't cross any lines about appropriate questions.  I'll try to help.  The following responses probably are not the ones you hope to hear, but I don't beat around the bush.

1) Three to 4 weeks is possible for a positive HSV-2 test.  About half of people infected with HSV-2 would develop a positive test by that time, so if you had actually had an exposure that could have given you HSV-2, that could explain your positive test result.  The frequency of genital HSV-2 infection is about 25% in "people who have led regular sex lives", including those with only "a few" relationships.  Since the exposure you describe could not have given you HSV, it is certain you were infected beforehand.

2) No, you could not have acquired HSV-2 from the exposures you describe.  Certainly genital rubbing without condoms or clothing in the way, oral sex, and other heavy-duty foreplay can transmit HSV.  But I doubt any website says you can catch HSV by rubbing against an arm or through clothing.  If so, they are lying or badly misinformed.  You can be 100% certain your HSV-2 infection preceded the exposure you describe.

3) There are 2 main indications for suppressive therapy against herpes with valacyclovir (Valtrex) or other anti-herpes drugs:  To control symptoms, which doesn't apply to you; and to help prevent transmission to sex partners, which may apply.  A decision to get on therapy should be guided by a herpes-knowledgeable health care provider involved directly in your care.  Seek such medical advice before you decide to go on suppressive therapy.  Also, you should know that being on suppressive treatment does not prevent all transmission to partners.  Whether or not you are on treatment, you are ethically obligated to tell future sex partners of your HSV-2 infection, before you have sex with them.

Best wishes--  HHH, MD

[quazar]

Oops, forgot to mention, for question 2--is it just because her genitals, where hsv2 tends to reside, were not part of the interaction?

[binky2005]

See study below.  

Time course of seroconversion by HerpeSelect ELISA after acquisition of genital herpes simplex virus type 1 (HSV-1) or HSV-2
Ashley-Morrow R, Krantz E, Wald A. Sex Transm Dis 2003;30:310-314.

BACKGROUND: HerpeSelect HSV-1 and HSV-2 ELISAs are glycoprotein G-based, type-specific antibody detection tests that are approved by the US Food and Drug Administration for diagnosis of genital herpes. GOAL: The goal was to determine seroconversion times by means of HerpeSelect ELISAs. STUDY DESIGN: Four-hundred and thirteen sera from 113 patients with recently acquired genital herpes were tested by HerpeSelect ELISAs and Western blot (WB). Thirty-one patients had primary genital HSV-1 (group 1), 56 had primary HSV-2 (group 2), and 26 had prior HSV-1 antibodies and newly acquired HSV-2 (group 3). RESULTS: Median interval from onset of symptoms to seroconversion was 25 days, as determined by HerpeSelect HSV-1, versus 33 days by WB for group 1; 21 days by HerpeSelect HSV-2 versus 40 days by WB (group 2; P = 0.0005); and 23 days by HerpeSelect HSV-2 ELISA versus 47 days by WB (group 3; P = 0.02). In long-term follow-up, transient reversion to HerpeSelect negativity occurred in three of 31 HSV-1-infected subjects (10%) and in two of 82 HSV-2-infected subjects (2%). CONCLUSION: Seroconversion to HSV-2 was determined faster by HerpeSelect than by WB.

Now I don't know what all that means, but it would appear that at 28 days (4 weeks) with the appropriate HerpeSelect HSV-2 test, there's a very good chance the test would have caught your seroconversion if, in fact, you are ever going to seroconvert.  

[binky2005]

I should add to my last post the big assumption in my comment is that the onset of symptoms (whether typical or atypical) occurred in the first several days.  That actually raises an interesting issue. How long would a reliable HSV-2 specific test take to pick up seroconversion in a person who was non-symptomatic?  We've all heard of these rare cases where the person doesn't develop an outbreak for 2 or 3 months (or sometimes even years) after the "incident".  Would that person's body not create the antibodies until that much later outbreak, such that the virus could be in his/her system for months or years and still valid tests would indicate negative?

My suspicion is that the reason such people don't have typical or atypical outbreaks for such a long period is that their bodies were actually able to create the antibodies very successfully and rapidly once the virus entered the body. If true, it's likely such folks would seroconvert no sooner or later than those with typical or atypical symptoms. But I'm a lawyer, not a doctor, so don't listen to me :)

[quazar]

Doc,

actually, those were the answers I was hoping to hear, and that is one of the best aspects of your/this service, simple truth and confirmation.  Thanks.  

On that note, are you sure about the stocking thing?  I really, really don't want to have gotten hsv from the exposure I described.  Are stockings thick enough to prevent transmission?  Or is it just that legs rarely have recurrences (except way up high, inside thigh)??

Either way, thanks for your care and info.