Genital HSV-1 Transmission

[kkle12]

I'm hoping you can help me!
I was diagnosed with genital HSV-1 via a swab culture about 6 months ago from oral sex with a partner who had a cold sore forming. It has been a rough time emotionally to say the least. I had a terrible first outbreak which lasted over 2 weeks. Since then, however, I have had no problems or outbreaks at all. I take 500mg of Valtrex every day.

I've since started seeing someone new and am now faced with a lot of questions. He is negative for HSV 1 and 2 (and everything else, he was tested twice and extensively.)  We always use condoms and I am on the valtrex, I've had no outbreaks. I have done a ton of reading online etc about the transmission rates of genital hsv-1 and I'm very, very confused-
1. How likely am I to transmit this to him? Some experts say genital-genital hsv1 transmission is highly unlikely, much less than genital hsv-2, and there's no need to worry about it at all, just to avoid sex during an outbreak. Some say "there's always a chance." What is the exact percentage of this chance? How likely is this, really?

2. In your years of practice, have you heard of someone transmitting genital hsv-1 to their uninfected partner genitally WHILE using condoms/no outbreak/and on valtrex?

3. Same question as above but ORALLY? Have you heard of an uninfected partner getting hsv-1 in their mouth by performing unprotected oral sex on someone with genital hsv-1 (no outbreaks and on valtrex)? Is genital hsv-1 more transmittable to someone's uninfected mouth than their genitals?

4. Obviously I'm sure the risk of transmission goes up if we were to STOP using condoms, but again, how much?

5. I've heard valtrex is more effective in preventing hsv-2 outbreaks than hsv-1. Is this true? I find it brings me great peace of mind but am wondering about it's efficacy.

Thanks you so much in advance for your time. I'd be lost without these forums.

[H. Hunter Handsfield, M.D.]

Conceivably that could happen, but it's statistically unlikely.  Almost all oral HSV-1 infections are acquired by oral-oral transmission, usually by kissing.

Thanks for the thanks.  I'm glad to have helped.

[kkle12]

Thank you so much for your answers. I appreciate them so very much.
There's only one question that you missed, I reworded it here:
-Is my uninfected partner at risk of acquiring my genital hsv-1 in his mouth if HE gives ME unprotected oral sex?

Thanks in advance for your time Doc!

[H. Hunter Handsfield, M.D.]

Welcome to the forum.  Thanks for your question.

It is common for patients with genital herpes due to HSV-1, and persons potentially exposed to the virus, to have questions and confusion.  Genital herpes is the most complex of all STDs, other than HIV/AIDS, in issues like transmission, symptoms, treatment, and so on.  Many physicians are not up to speed.  However, your question suggests you have seen some of our responses on this forum (thank your for looking for questions similar to your own).  Here are links to three threads that started with questions pretty much like yours.  You may have seen one or more of them.

http://www.medhelp.org/posts/STDs/Recently-diagnosed-with-Genital-Herpes-HSV1/show/969931
http://www.medhelp.org/posts/STDs/Herpes-Confuses-Me/show/1414935
http://www.medhelp.org/posts/STDs/Asymptomatic-Shedding-hsv-1/show/1274603

A couple of general comments:  Genital herpes due to HSV-1 has many important differences compared with HSV-2.  Most important, you are less likely to have recurrent outbreaks, and if you do, they likely will be infrequent; you are less likely to have asymptomatic shedding of the virus; and for both reasons you are less likely to transmit the infection to any partners.  In general, I do not prescribe suppressive antiviral therapy to my patients with genital HSV-1.  There is no proof it prevents transmission (unlike HSV-2); and in theory, to be effective would have to be taken in larger doses.  It is possible that your treatment is preventing outbreaks you otherwise would have, and that it is helping protect your partner.  But most likely it is making little or no difference.

To your specific questions:

1) You are unlikely to transmit a genital HSV-1 infection to a partner.  Certainly it can happen, but the risks are far lower than for genital HSV-2.  The reasons are described in one or more of the threads linked above.

2) I am not aware of any genital to genital HSV-1 transmissions in my 40 years in the STD business.  That doesn't mean it can't happen.  In fact, I'm sure it does.  But it appears to be rare.

3) If you had no oral symptoms during your primary genital HSV-1 infection several months ago, it is unlikely you are infected orally.  Assuming you are not, you cannot transmit HSV-1 by kissing or by your oral contact with a partner's genital area.

4) Actually, I'm not sure I agree with your statement about condoms.  Even without condoms (and also without valacylovir treatment), I would expect the chance of transmitting your genital HSV-1 to your partner to be low.

5) As implied above, there has been no research on the effectiveness of valacyclovir (Valtrex) on suppressing genital HSV-1.  However, we know for sure that HSV-1 is inherently less susceptible to the drug than HSV-2 is.  Therefore, to be effective, is is likely that higher doses would be required.

The bottom line is that genital herpes due to HSV-1 usually need not be a big deal.  It is reasonable for you to take precautions to protect your partner, but don't go overboard.  I suggest you print out this discussion, and perhaps the other threads linked above, and use them as a framework for discussion with your partner.  You may jointly decide it's not a big deal at all, and need not interfere significantly with romance, commitment, and mutually rewarding sex.

Best wishes--  HHH, MD