genital hsv1

Dear Dr. Hansfield- Thank you for this avenue to share your knowledge and expertise with people.

1-I'm a 37 yo male. About 7 months ago I had sex using a condom with a new partner. I also gave her oral sex. A few days later I had a very severe sore thraot for a couple of weeks, in addition a single red bump on my scrotum that ulcerated and crusted and healed over 2-3 weeks. By the time urologist saw the lesion it was mostly healed so he though maybe infected hair follicle. There was mild to moderate stingin but nothing compared to the sore throat. This all went away. Now after 7 months I have three small lesion at the same location on the scrotum and stinging that shoots to the glans (glands).  My hsv serology this week shows hsv2 negative, but hsv1 positive (I was negative on both tests 10 yrs ago)

2-From this site and from your CDC report of 2003, I gather that about 40% of initial genital HSV1 people never have a recurrence, and about 50% have only one or two recurrences over 1-2 years and never have another recurrence and less than 10% have recurrence beyond 2 years. Can you please share the source of this info- whether there is long-term follow up studies or from your extensive clinical experience. because this is the most hopeful thing I have read about this disease on the internet. Am I getting my hopes up for nothing?

3- the study by anna wald goes out two years and shows 0.7 recurrences in year two. Is there a study that looks beyond 2 years?  Do people have recurrences of genital hsv1 indefinitely or does it burn itself out?

4-What is the chance of passing on genital hsv1 to a partner who has a positive hsv1 serology, using no protection for many years? Thank you again.

[H. Hunter Handsfield, M.D.]

Genital herpes uncommonly involves the scrotum.  If a knowledgeable clinician thought it was folliculitis, that's a pretty good bet (but recognizing that once a lesion is healing, it is hard to tell one cause from another).  It is conceivable that you had initial HSV-1 infection to explain your symptoms after the sexual exposure you describe, but it is equally likely you had a garden-variety respiratory virus.  Your positive HSV-1 serology could have been acquired any time in the 10 years since your negative test result.

Further, if you are the person who tried to contact me by telephone, as I suspect, you almost certainly are at occupational risk for HSV-1 by virtue of exposure to oral secretions.  Please accept my apology for refusing to speak by phone.  The STD Forum gets >200,000 hits by >100,000 separate people each month.  You can understand where it might lead if I start making exceptions to that rule.

To answer your specific questions:

1) See above.

2,3) There is only one published study, from Dr. Wald's research team, which you seem to be aware of (Engelberg et al, Sex Transm Dis 2003;30:174-7).  Data not yet published document the low rate of asymptomatic shedding in genital HSV-1 infection.  I am unaware of data that followed patients beyond 2-3 years, but it would be surprising for the frequency of outbreaks or shedding to increase in later years; the near-universal trend for all HSV infections of any anatomic site is decreasing outbreaks and shedding as time passes.

4) Once positive to either HSV type, most people have durable (probably lifelong) immunity to reinfection with the same type, regardless of anatomic site.  There are anecdotal reports of exceptions, but they clearly are uncommon.  Anyway, genital-to-genital (or genital-to-oral) HSV-1 transmission probably is uncommon even to seronegative partners, for the reasons noted above.

Bottom line:  The odds are you don't have genital HSV-1; or if you do, that transmission risk is low.

Good luck--  HHH, MD

[kevin123]

thank you for your comments.
I will see a couple of urologists today to acertain the diagnosis. Again, I was wondering the reason or source for the info on this site that said "genital hsv1 has 40% with no recurrence and another 50% or so with only 1-2 recurrences in the first 1-2 years and never again, and less than 10% go beyond 2 years" I desperately want to believe that this is the case and be in the 50% of people with only 1-2 recurrences ever. Do you ever see patients with genital hsv1 who have recurrences 5-10 years out or almost never.

[kevin123]

The comment above is addressed to Dr Hansfield. thanks

[H. Hunter Handsfield, M.D.]

The source for the 40%/50% figures etc is the same one I cited above.  To my recollection I have never cared for a patient with recurrent genital HSV-1 who had persistent outbreaks that continued more than 1-2 years.

HHH, MD

[kevin123]

I promise that this is my last comment on this topic. I will read wald's paper that you mentioned. How long were the patients followed up in this study in order to conclude that "less than 10% have recurrence beyond 2 years" ?   Thanks.

[H. Hunter Handsfield, M.D.]

I don't recall the study in that much detail.  I don't think very many people were followed >2 yr, but you'll have to read the paper.

I'm holding to your promise.  No more responses from me.  Best wishes.

HHH, MD

[passedHSV1]

I am an MD as well and I have posted here many times. Your questions are the same questions I had. How long do these episodes continue to occur in genital HSV-1? Where did the less than 10% come from for people who have long term recurrences. The Wald study was only carried out to about 2 years. All you have said is valid and the answers given here seem to be too general and unsubstantiated.

There is more than anecdotal evidence that genital HSV-1 can be passed on to a previously seropositive person with oral HSV-1. I have discussed the matter with Dr. Wald directly by email and she has answered that it CAN be passed on and that the protection of existing oral HSV-1 is NOT 100%. Please see "Genital HSV-1, again" post a few weeks ago on this very sight and look for my input in that series of comments in which I pasted my email communication with Dr. Wald.


In addition to this I have talked to a number of people who have had the virus for more than 3 years. One person had it for seven years and she had her last episode of genital HSV-1 two years prior. Others say the same thing: it slows down but never completely goes away. For Dr. HHH to say that "after 2 years only 10% have ongoing recurrences" without substantiating it with real life events is ridiculous. All you have to do is write a couple of emails to the HSV-1 people isted on the dating site MPWH.net and ask them what their experience has been.

I have contracted HSV-1 genitally after contracting it orally. So...is that anecdotal?

[monkeyflower]

Well, yes, it is anecdotal. I don't have substantive proof that you have HSV1 genitally AND orally, nor that you contracted it the way you describe. You also haven't said whether your genital lesions were ever cultured for HSV1, or whether you simply diagnosed yourself with HSV1. You also haven't really acknowledged that it is possible that if you DO have HSV1 genitally, you could have autoinoculated yourself during your primary outbreak. I'm just not buying your story.

[passedHSV1]

I saw your comments earlier and I think you are probably missing a couple of facts. If I had "autoinocculated" myself as you say, I would not have had several episodes of oral HSV recurrences for 2 months before having my first genital breakout with HSV-1. I also did not have any genital lesions until taking of the condoms and proceeding with unprotected sex because of the belief that once you have oral HSV you can not get the virus anywhere else in the body maintained so fervently on this site. Remember that I already had IgG's with my first known oral outbreak at the same time that my partner was diagnosed by cultured with HSV-1 (primary).

I only ask that the likelyhood of contracting genital HSV-1 after having it orally not be described in absolute terms like it is by Dr. HHH. If the protection of IgG's to HSV-1 is very high but not 100% (as you read is also the opinion of Dr. Wald) please state is as such. Just DO NOT SAY "you are immune" from catching it anywhere else in the body. The chances are small, yes, but they do exist.

The process of aquiring "immunity" to Herpes is time sensitive and does not only require antibodies (evidenced by the fact that several vaccines have shown great IgG response but very poor protection form aquisition in vivo). It requires a strong cell mediated immune response, such as is driven by T4 Helper cells. This takes time and is evidenced by the fact that people have a lot of outbreaks the first year and then less so the following years. If you have just aquired HSV-1 you may have IgG's but your ability to control the virus is still poor. That's where I believe I was in the early phase of aquiring this infection when I began writing on this site.

One more concept that may not be familiar to non-doctors is that HSV-1 has in itself different strains. My ID doctor has mentioned that you can carry one strain and  still infect someone who has HSV-1 but of a different starin

[monkeyflower]

You still haven't said, do you know for sure that you have HSV1 genitally?

Anyway, so okay, you can contract HSV1 genitally even after you have it orally - or so Anna Wald *thinks*. Terri Warren, who's no slouch in herpes research herself, thinks it's "very, very unlikely". But assuming it does happen, it's clearly rare enough that there aren't exactly a lot of documented cases of it - or these two would be able to give you a nice, conclusive yes or no answer... none of this "I think" fudging :-)

I do think you seem overly concerned about this. Have you considered therapy to help you deal with your diagnosis and concerns? Again, I stress that seeking counseling is a sign of mental health :-)

[solera]

Last week I thought I had a yeast infection. I went to the doctor and took a urine test, he treated me for yeast infection and bladder infection.  I had some discharge and burning when I urinated. The next day litter blisters had formed in the vaginal area, lots of red irritation and several blisters. Sunday I went back to the doctor and she is doing a herpes culture.  I was married for 37 years and have had a boyfriend for a year now.  Never have I had this problem.  Could I really have contracted herpes or is it possible to have these other infections so bad they caused these blisters.

[aloha37]

I just wanted to thank you for providing the additional information about hsv 1 transmission in this post.  I obviously can't speak for other users of this forum, but your points are understood and appreciated by myself. It seems you are saying the rules of transmission might be different in a newly aquired infection.  This is because the body has not had time to build up an immunity to the virus yet.  Furthermore, even a long term hsv 1 positive person who had built up immunity could still get a different strain of hsv 1 on the genitals (rare, but could happen).  I'm sorry it happened to you.  Keep posting.  

And to monkeyflower I would say you seem excessively resistant to the possibility that passed hsv1 could be correct.  For a healthy exercise of your own, perhaps you could see a counselor to discuss it.  Good luck.

[aloha37]

A culture of the lesion will tell you for sure if it is herpes.  If it is herpes a culture will not tell you when you first got the underlying infection.  But I think if you have a herpes select test (which is a blood test) it may help to tell you if this is a new infection or not.  The blood test checks for an immune response and this would change over time if this was a new infection. You can have one now and then repeat it later (a few weeks down the road) and if there are changes the doctor can use that information to decide if this is a first outbreak or not.  This may help you figure out where you got the infection.  I would ask your doctor about it when you go for the culture.  No reason you can't have a culture and a blood test.

[monkeyflower]

Lol. I admit that I've become rather overbearing on this particular issue, and I apologize if I've offended anyone. However, even though I think this is really just a matter of semantics, I stand my ground on this one. I understand what passedhsv1 is saying, but I suspect that in real life, there is probably virtually no difference between a categorial NO, and an equivocal "maybe - we think so". I'm suspicious of passedhsv1's conclusion, but even if I weren't, maybe he's one in a million (or whatver). Why incite more unnecessary anxiety and fear in a population, i.e. posters on this board, that is already overwhelmingly and needlessly anxious and afraid?

[aloha37]

There are two types of users on this forum (and probably more):  There are those overwhelmed with anxiety and they just want reassurance that life is not "over".  We all start off here.  However, once the anxiety passes, there are some that need biological answers so they feel they have some control over the situation. For example, they want and need to know how to NOT go from oral hsv to genital hsv.  You are advocating for the anxiety ridden (and should stand firm) and passed hsv1 is trying (and has a need) to help those ready for more information (so you should back off).  You are both right.  It's not semantics, it's a paradox.

[passedHSV1]

I don't check this site regularly. Obviosuly I am not very happy with the advice given here as I belive it is too broad. Yes...I have been diagnosed with genital HSV-1 and I am not just panicking or fabricating. Yes I am talking to a therapist just like I am sure everyone who is newly dealing with this is.  I certainly don't need monkeyflower's "expert" advice on how to make peace with this diagnosis. Simply because you frequent this forum constantly does not make you an expert. You are just regurgitating information you have read here or in other sources.

My problem with monkeyflower is the way in which you blindly "follow the leader". If Dr. HHH said it you will defend it to the end. I explained to you that I only ask that he stop using absolute terms like "you are immune from catching it again". If you are in the acute phase of this illness you do not have complete cellular immunity. I think it's necessary for people who have just contracted HSV-1 orally to know that they have to be careful for the first few months lets say. Maybe even for 1 year.  I don't think the presence of IgG is an indication that you have full immunity. Since most people do not even know when their primary episode was, I think it's wise to advise people to be careful. Dr. HHH brushes over and tells everyone that if you have oral HSV-1 you are "immune from catching it again anywhere in the body".  without explaining any other nuances. If he doesn't have the time then he should just explain that there is a low rsik, but it's best to be careful. Then give some references. It only takes a few seconds to write the advice. Why not be completely accurate?

From my question in the archives "Aquiring HSV-1 genitally after having it orally":

Dr. H,

I previously posed the questions:

1. Can anyone aquire HSV-1 genitally after having it orally?

2. If an individual who has genital HSV-1 has unprotected sex with another individual who has oral HSV-1, will the second individual be at risk for contracting genital HSV-1?

You answered:

"Auto-inoculation of HSV to new body sites only occurs with measurable frequency during the initial infection. Similarly, anybody who is infected with HSV-1 or HSV-1 at any body site is immune from acquiring the same virus type again, at any body site. Your partner will not be at risk for transmitting her genital HSV-1 infection any anatomic site of a future partner who is HSV-1-seropositive."

Response:

Dr. HHH:  "To my knowledge, there has never been a virologically documented case of new acquisition of genital HSV-1 in someone with a prior HSV-1 infection at any site. If there are, it occurs rarely enough to justify counseling persons with your concerns to not worry about it".

I wonder if Dr. HHH would be so cavalier if he himself had contracted HSV-1. He doesn't think it's much of a big deal. I quite disagree.

[monkeyflower]

I think that we will have to agree to disagree. It's true that I'm certainly not an expert, but Dr. Handsfield, Anna Wald, and Terri Warren are. Saying that they "think" it might happen, and saying "it's very, very unlikely", are probably the same in the end as Dr. Handsfield's categorical "no". Maybe there are a couple of patients this happens to now and then - but think about it, if they don't actually KNOW that this happens, it surely can't be common. So, if you have other, conclusive information about this phenomenon, please post a link. I would love to read it.

Also, I have both HSV1 and 2, and I can tell you that it's not the end of the world. Not even close. I think it's your reaction to having a STD that's really causing problems for you emotionally right now, and spurring your anger and frustration over this issue. I swear, if you caught herpes from someone sneezing on you, it'd be treated like the total non-event it really is. I'm sorry you're experiencing this as such a traumatic event in your life. It really doesn't have to be. Things will get better :-)

[oh2beme]

Well I'm new here...36 y/o, married for 13 years.  Husband has oral HSV1 though we've never thought much of it - he just steers clear of everyone when he's having an episode...

WELL...July 4th I had an EXPLOSION going on in my genital region and thought I was going to die from the pain...off to the E.R.  - I JUST got diagnosed yesterday (FINALLY!) with genital HSV1.  It took them a long time because apparently it's not "presenting" in a typical manner with me, as I have "cuts" in my genital region due to dry skin (??) which is painful enough at times...plus the hemmorhoid from son #2 and now this...which seems to like the entire area from front to back and all up inside!  This is ridiculous!

Isn't it bizarre that I would just contract it now?  Guess we weren't paying attention...

BUT I do have a point...my Dr. has told us that we DO need to use condoms because I CAN pass it back to dh genitally...so that's just another 2 cents for your discussion...

[chinny]

Amazing! Your "story" sounds very similiar to mine. I too had a " genital explosion" over this past fourth of July weekend! Turns out I was diagnosed with Genital Herpes 1..... contracted via oral sex from my partner of over 2 years...... he has a history of cold sores but has not had an outbreak for years. Why I would contract this now after two years of active sex is beyond me! And I tested positive for Herpes 1 right away, so it looks as if I was already carrying the virus. Tests 12 weeks later proved negative for Herpes II. At age 52, this was about the last thing I ever expected. I was married for 27 years, and have had only 3 partners in my life. Very bizarre. The outbreak I experienced was about the most painful thing I've ever been through....... I thought I would pass out each time I had to empty my bladder. So far, no further outbreaks.... although I have had yeast infections and rectal itching both of which I had never had problems with before. Enough to make one give up sex!?
Good Luck to you!
" chinny"

[solera]

Last week I wrote about my blisters, the doctor did a culture and came back positive HSV. I have been out of state and now the doctor is on vacation and I'm lost.  I have been seeing this man for a year, does it take this long for this to appear?  I have never been with anyone other than my husband for 36 years. My partner said he had some burning urination and I asked him if he had ever had that before and he said no.  He had it for just a few days and it's better, never went to the doctor, I am still in some pain just no blisters.  I have been taking Valtrex now also prednisone.  Could he have had this for a while and really not know he is passing it?  How long am I contagious?  My husband and I are trying to work things out and I need to be careful I don't know how to tell him yet.  How can I get around the condom thing?  I read diaphrams can be used?  How often will I break out? I am really so dumb to this.  I intend on doing the blood test to see what else is going on and if this is new or not.  My outbreak was so bad I am nervous about HIV now, should I be.

[smartygal]

A related discussion, HSV-1 Reccurance was started.

[42153]

A related discussion, 58 yr old married 39 yrs initial hsv-1 diagnosis was started.

[chuck0011]

A related discussion, VHS-1 was started.