HSV1 Genital Exposure

[Katherine364]

Dr. Handsfield,



Thank you for taking the time to read and answer my question.  I sincerely appreciate it.



A few nights ago my boyfriend performed oral sex on me in the middle of the night.  When we woke up in the morning (about 5 hours later), I noticed a cold sore forming on his lip.  After looking in the mirror he told me that it did indeed look like cold sores he has had in the past, though it did not itch, hurt, or tingle.  He had no idea he was about to get a cold sore and no idea that oral to genital transmission was even possible.  



We are both very concerned about this exposure, because about 8 months ago I had HerpeSelect bloodtests that indicated I am seronegative for both HSV1 and HSV2.  I have no history of cold sores or genital symptoms.  Here are my questions:



1.  What are the chances that I am now infected with genital HSV1?  We also kissed a lot that evening and in the middle of the night.  If I became infected orally, would that keep me from becoming infected genitally?



2.  Assuming for the moment that I did NOT get infected genitally, what precautions should we take with oral sex in the future?  He says he has had only "two or three" coldsores in his life.  This one was extremely mild and is already gone.  Do we really have to use dental dams?  That seems like it would take away so much sensation, and besides, where do you even BUy those?  I don't know ANYONE who has ever used one (probably because they are uncomfortable and impractical.  Ugh.)



Thanks for your time.

[H. Hunter Handsfield, M.D.]

You are at significant risk of genital HSV-1 infection.  How long is "a few nights ago"?  The longer you go without developing symptoms, the more likely transmission didn't occur--by 10 days, if no symptoms you're probably home free.  Asymptomatic infection remains possible, though--so to be sure, wait for 4-6 weeks then repeat the HerpeSelect HSV-1 test.



Asymptomatic shedding of HSV-1 in people with oral herpes seems to be less common than for HSV-2 in people with genital herpes.  The odds of transmission during any particular exposure when he isn't having an outbreak is low.  But it isn't zero.  (Sorry, there are no available data to give you any numerical odds of transmission.)



So assuming you weren't infected this time, what you do in the future depends on how important it is to you to avoid infection.  Remember that genital HSV-1 usually doesn't cause recurrent herpes, and if you do get an infection with symptoms, effective treatment is available.  So a lot of couples would be happy to accept low to moderate risk rather than doing the sorts of things you suggest, like dental dams.  (More practical than dental dams, by the way, is plastic wrap out of your kitchen; it also allows greater sensation than latex.)



My personal choice shouldn't necessarily be yours.  But knowing what I know about the disease, if I were you I wouldn't change my sexual practices at all, except to avoid oral exposure if/when he has future outbreaks of oral herpes.  And don't go crazy about it:  i.e., don't make him be paranoid about every little funny thing he feels in or around his mouth.  But others will have very different views about avoiding genital HSV-1, and you have to make your own decision.



Best wishes--  HHH, MD

[Katherine364]

Bummer.  I was hoping the risk would not be so high.  This happened late Friday night (actually early Saturday morning--about 3 a.m.)    



OK, so let's assume ten days pass and I have no genital symptoms.  I wait 6 weeks for another blood test, have the blood test, and the results come back positive for HSV1.  That won't tell me whether I am infected orally or genitally, will it?  I mean, I continued to kiss him even after we knew about the cold sore, because getting oral HSV1 would not be a big deal to me.  I even reasoned that it would be a good thing, since it would mean I didn't have to worry about genital HSV1.  Does that make sense?  So unless I have symptoms, there will really be no way for me to know if I have oral or genital HSV1, right?



Thanks for the advice, and I certainly won't make my boyfriend feel guilty about this in any way, or paranoid about future risk.  He's a keeper.

[H. Hunter Handsfield, M.D.]

That's right--if your repeat HSV-1 test is positive and you have no symptoms, you won't know whether you acquired the infection is or genital--unless you develop future symptomatic recurrences (which can happen even if the initial infection is asymptomatic.)



In either case, you are right--whether oral, genital or unknown, if you are infected and remain asymptomatic, you won't have to worry anymore about genital HSV-1.  You would even have less worry about HSV-2, in the event you have other relationships someday:  people with HSV-1 generally have less severe (and more asymptomatic) genital herpes if they get HSV-2.



But some clarification about symptomatic and asymptomatic herpes:  Most (certainly many if not most) initial infections probably cause symptoms, but they are subtle and people don't know what they mean and later don't remember them; or they have symptoms not "typical" for herpes, such as irritative symptoms thought to be yeast, bacterial urinary tract infection, viral sore throat, canker sores, etc.  As a result, when blood tests are done, many with positive results--either HSV-1 or 2--don't recall symptoms.  But when someone knows s/he was exposed and is on the alert (maybe hyper-alert), most people probably will know it if they are infected.  So if you notice nothing within 10-14 days, the odds are you dodged the bullet and your blood test will be negative.



Regards--  HHH, MD

[steve123]

if you have oral HSV-1 can you transfer it to yourself to the genital region?  Also, if both partners have HSV-1 is there anything to worry about?

[H. Hunter Handsfield, M.D.]

During the initial infection with either HSV-1 or HSV-2, the infection can be transmitted to any other body part (autoinoculation).  It usually shows up as herpes of the eye or a finger during the first outbreak of genital or oral herpes.  But once the infection has been established for a few weeks, autoinoculation occurs so rarely that nobody need be concerned about it; the immune