why do i have to tell?

This is a follow up to an answer I had received about 2 weeks ago (was traveling).  Briefly, I have genital herpes type 1 with a primary episode 6 months ago and one recurrence over the past 6 months.  The question was if I would have to tell future partners about this.  Of course, if I had genital hsv type 2 I would tell. But I am talking only about type 1 and only having sex with no active outbreaks and with condom use.  Your answer was that most people would tell.

My reasons why I think it might not be morally necessary to tell are 1)  as you have stated, genital hsv 1 has such a rare transmission rate to the genitals or oral area of the partner.  you have stated you have never even seen a case (I assume you have been practicing for years), so it must be quite rare.  2) people with oral hsv 1 are much more likely to transmit  herpes than genital hsv 1 people. But, most people don't even know if they have oral hsv 1 and even if they do I doubt if they disclose this before they kiss someone. We don't ask future partners that we may kiss to get hsv 1 antibody testing, eventhough 50 - 60% of people will be positive.  So over half the people out there are kissing and hsv 1 positive, and this kissing is a far more likely route of transmission than people with genital hsv 1.  So if these oral hsv 1 people don't discuss their status,or even know it, or get tested, why should the genital hsv 1 person have to?

I know you can't say anything is not possible i.e., genital hsv 1  being a transmission source to a partner.  The problem is as you have stated most people are irrational and fearful of the word herpes, and unable to differentiate between genital type 1 and 2.  So given all of the above, why is it necessary to disclose ones hsv 1 status?  Thanks for your thoughts.  Just trying to do the right thing.
tdx

[H. Hunter Handsfield, M.D.]

I didn't say it is "necessary to disclose ones hsv 1 status".  My reply last time was "Most people agree that anybody with recurrent genital herpes is ethically obligated to inform their current and future sex partners about their infections.  The risk of transmission indeed is low for any particular episode of sex, but it isn't zero; and the fact that you have had at least one symptomatic recurrence suggests the risk of transmission may be greater than for some people with genital herpes due to HSV-1.  There are no hard and fast rules, however."

You give several valid considerations to think about in coming to a decision.  I don't disagree with them.  But as before, I do not presume to give you a conclusion or to give you advice.  My very last comment last time was "...assure the diagnosis is correct, then behave as your consience dictates."  That remains my opinion.

HHH, MD

[gracefromHHP]

I also commented on your last post - not sure if you saw that or not?

My question to you now is - why is it that you are even trying to rationalize why this isn't something to talk to a partner about?  Just curious.

grace

[tddx]

I did read your prior post.  I don't think i'm trying to rationalize, just using all the data/facts that are available.  I would tell a 'girlfriend' about my status, but i would be able to explain in detail all i mentioned in my post (i.e., very low transmission rate of genital hsv 1, how most people have oral hsv 1 and much more likely to get herpes from oral hsv 1 person ect.).  I would have time to explain.  I guess i am wondering why necessary to tell a casual sexual encounter. Obviously, much more difficult to explain in detail all of the above.  I know you state you have done so for casual encounters, but i do think would be different if a woman says it over a man.  Sexist, maybe, but most causal men encounters are not going to care.  Do you have type 1 or 2.  I do think it makes a difference for the need to tell.

[tddx]

Thanks again, and i get your answer.  I guess i just wanted a more yes and no answer.  I promise this will be my last 2 questions regarding genital hsv 1.

I am correct that with no active lesions (intact skin), I have no increase risk of acquiring hiv than someone who is hsv 1 negative.  Would always use condoms, no sex with any active lesions.

Would you recommend valtrex prophylaxis for the first year after the primary episode.  I know studies done for type 2 not 1, but makes sense would lower any asymptomatic shedding.  1 gram dose since hsv 1 less sensitive, correct?  Thanks again, sorry to be a pain.  tddx

[H. Hunter Handsfield, M.D.]

The association of HSV-2 with increased HIV risk is clear.  Many studies also looked at HSV-1 antibody and none found a relationship with HIV acquisition.  However, I believe most of those studies did not evaluate (or know) whether the HSV-1 postive study subjects had oral or genital infection.  Even so, I doubt it makes much difference, if only because asymptomatic viral shedding (as well as symptomatic outbreaks) are much less common for genital HSV-1 than -2.  But without data it is impossible to know for sure.

In general, I do not recommend suppressive antiherpetic therapy for genital HSV-1, except for those atypical cases with frequent recurrences, e.g. 3-4 times a year or more.  But there are no hard and fast rules here either.  If you decide to do that, I agree you should take at least 1 gram Valtrex daily, not the usual 500 mg dose (or even consider 1 g twice daily), for the reason you say.  There are no data, but it's logical that higher doses make sense.