genital herpes symptoms, tests, prevention

[nick72]

I am a gay male, 50s, with multiple previous partners. (I am HIV-negative and have never had unprotected anal sex.) In August, I developed a small, painless, slightly elongated cluster of vesicles on an erythematous background near my coccyx; the cluster went up to but did not cross the body midline. My doctor prescribed valacyclovir, including ongoing suppressive therapy. The vesicles crusted over and resolved. There have been no other symptoms of any kind, and no recurrence so far (seven weeks).

Two days after onset, viral cultures were negative for HSV1/2 and zoster. HerpeSelect IgG antibody tests were negative for HSV1/2 (both ratios zero). Unsurprisingly, zoster antibody test was positive. Six weeks later, HSV antibody tests were still negative, but with a slightly nonzero value for the HSV2
ratio. (The later tests were nine weeks after the most recent unprotected oral or protected anal sex, though I engaged in mutual masturbation and anal fondling a few days prior to onset of symptoms, six weeks before the later tests.)

I plan to take the HSV antibody tests again in another month. Meanwhile, my doctor says I probably have genital herpes, but possibly not (the vesicles could have been from zoster instead, even though they were painless). Do you concur?

I've abstained from all sex since the onset of symptoms. Assuming I do have herpes, what sexual activity, if any, can I engage in without risk of transmission when no outbreak is present? (Mutual masturbation, for example? Giving oral sex?) What sexual activity can I engage in with very low risk of transmission? Am I right to assume that the virus can be shed from my penis or anus, and not just from the site of the past outbreak?

[H. Hunter Handsfield, M.D.]

I'm not clear on the time of your latest HSV blood test compared to onset of symptoms.  If more than 6-8 weeks, that's strong evidence against HSV-1 or  -2.  But to be safe, a final test at least 3 months after onset would make sense.  The change from a ratio of zero to "slightly nonzero" means nothing; any result below 0.9 is absolutely negative--i.e., lower ratios do not indicate "a little bit" of HSV antibody.

That said, I don't understand your doc's apparent strong suspicion of HSV.  Your negative HSV blood test results, positive test for varicella zoster virus antibody test, lack of HSV by culture only 2 days after onset, yet apparent response to valacyclovir all add up to herpes zoster in my book.  Although shingles can be widespread and/or painful, mild cases like you describe are not uncommon.  (My own episode of zoster a few years had only 3 small lesions in my hairline, minimal pain, and no post-herpetic pain.  Welcome to the club!

Bottom line:  Have another test at least 3 months from onset, if not yet done.  If that result also is negative, there is no reason for you to continue to be concerned about HSV and I do not recommend any precautions against sexual transmission--except for appropriate safe sex precautions for general reasons, depending on the nature of your partnership.

Good luck--  HHH, MD

[nick72]

Thanks for the reply! Sorry I was unclear about the timeline. Just to be sure, here it is:
* Most recent unprotected oral and protected anal sex: three weeks prior to onset of symptoms.
* Most recent other sexual contact (mutual masturbation): two or three days prior to onset.
* Virual cultures and initial antibody tests: two days after onset.
* Later antibody tests: six weeks after onset.

[H. Hunter Handsfield, M.D.]

OK. Have another HSV-1 and -2 antibody test 12 weeks after onset of symptoms. I expect it to be negative.

HHH, MD

[nick72]

Thanks, will do! If I want to have sex in the meantime, though, is there any risk of transmission from mutual masturbation? Or from my giving oral sex? (Let's assume no detectable recurrence and that I continue to take the suppressive daily dose of valacylovir.)

[monkeyflower]

While you wait for Dr. Handsfield's response, I think it's safe to say that mutual masturbation is definitely okay. I also think giving oral would certainly be fine, since your HSV1 tests were negative and your concern is about having genital herpes anyway :-)