Genital HSV prevention/partner questions

[toughdg]

1.  Can a noninfected monogamous partner of a person with genital HSV-1 benefit from taking an antiviral (such as Valtrex) chronically as prophylaxis against becoming infected?  Would seem to make sense if the presence of the the antiviral in the system of the noninfected person could kill or prevent an early infection before it gets established in the nerves.

2.  Can chronic use of a topical antiviral (or other agent) in an area of previous outbreaks potentially help suppress new outbreaks (in addition to systemic antiviral suppressive therapy) and/or reduce asymptomatic shedding?  Would there be any potential adverse effects of this?

3.  Can topical steroid used on a primary or early recurrent herpes lesion (applied mistakenly thinking it was a psorasis lesion) delay the appearance of a positive IgG antibody?  The steroid in question was one of the weaker ones, although stronger than hydrocortisone.

4.  Can the presence of HSV-1 in one site of the body (e.g. genital) with IgG antibody prevent the occurrence of the same virus at another site (e.g. oral)?

5.  Can autoinoculation occur once an antibody response has occured?

6.  What is known about the differences in virus and/or immune status of symptomatic versus asymptomatic HSV+ individuals?  Why do so many people seem to have the virus but never have outbreaks?

Sorry for the barrage of questions.  I am having a hard time finding good answers doing my own literature review and talking to local doctors.  Thanks.

[Edward W Hook, MD]

Welcome to the Forum. You provide no information about the context from which your questions comes so my answers will be more general than they would be if you had provided more information.

1.  There are no studies of this sort of strategies for prevention, most often because it would be a huge waste of resources, would be an ideal way to stimulate development of resistance to antiviral medications and it would not necessarily work.

2.  The potential adverse effects of this would be the impact on a person's wallet and causing local skin reactions.  It is unlikely that such efforts would reduce the chance of transmission of infection.  Typically topical medications for systemic disease are less effective than systemic medication.

3.  Unlikely. The effect of topical steroids is local.  Antibody production is systemic.

4.  Once a person has HSV (1 or 2) at one body site, it is most unusual for the infection to be spread to other body sites.  When it happens, it almost always happens during the first episode of infection.

5.  See above.  Very, very rare.

6.  There is no difference shown in studies to date.  Most persons who have HSV but were unaware of it mis-identified their initial and sometimes even recurrence outbreaks, attributing the symptoms to other, less stigmatized causes such as chaffing, yeast infections, etc.

The proven mainstays of genital HSV prevention remain condom use, avoiding sex during symptomatic recurrences, informing partners of the presence of infection and chronic antiviral suppressive therapy by the infected person.  

EWH

[toughdg]

I appreciate your further indulgence, and will respect your limits.  This is an excellent forum!

[Edward W Hook, MD]

The tests for HSV antibodies and for HIV are very different. While it is well known that HSV antibody test positivity can be delayed and even negative in a small proportion of perons, this is not the case for HIV.  Your HIV test results are to be beleived.

It is now time for this thread to end.  There will be not further ansers.  EWH

[toughdg]

I just had a negative HIV rapid ELISA test, now at almost 16 wks from the last possible exposure (since I have the psoriasis, I became concerned about passage from vaginal secretions through nonintact skin, and I did have the nonspecific rash on my thighs within a week of the possible exposure and now seem to have an exacerbation of my psoriasis which I've read can be symptoms of acute HIV infection).  My question is: I know this is normally sufficient time to seroconvert, but given my negative HSV-1 IgG test at 14 wks but positive culture, should I be concerned that I may simply have not seroconverted to HIV yet?  Do people who seroconvert late to one virus generally seroconvert late to other viruses?  Or are the kinetics of HIV seroconversion or nature of the tests just so different than for HSV-1 that this generalization does not hold or is not supported by the data?  Is there anything about psoriasis, being an immune disorder, that might cause generally delayed seroconversions?  I really would like to believe the negative result, of course, but I want to be objective.  Thanks for your ongoing support and advice.

[Edward W Hook, MD]

To look for a physician in your areas who is expert in management of HSV, I would suggest a visit to the American Social Health website or hotline. They can often help with issues such as these.  EWH

[toughdg]

I'd like to ask you if you know of a doctor with similar interests in this disease, who could be a good ongoing resource for care relating to this in my area.  My doctor here doesn't know of anyone specific.  I'd prefer not to post my geographic location though - can you send me a message to which I can respond using the messaging feature on this website?  Or some other way to contact you?  Thanks.

[toughdg]

I'm also puzzled.  I'm not sure if the rubbing of vaginas on my pelvis where I had psorasis is relevant.  I do I have a painful vesicular rash on two of my fingers, though, where I had some severe psoriasis previously, which I think might be whitlow I acquired somehow, maybe from rubbing an area of infected skin either on myself or the girls.  I don't know about the psoriasis lesions on my pelvis being a source because they all continue to look and feel like regular psoriasis.  I think the penile lesions probably came about via autoinfection from masturbating with the hand with whitlow (with infection facilitated by penile psoriasis), or possibly by being passed back and forth between myself and a regular partner with whom I had unprotected sex (without know I had herpes obviously), before I built up an antibody response.  I do not think I had this infection before because my antibodies have been negative so far, unless I'm one of those rare people who takes a really long time to develop antibodies.  The last possible prior contacts where I may have gotten it from 2 other sex partners was about 9 months ago, and that sex was with a condom for vaginal but not for oral.  Whatever the case, I know that my story is quite unusual.

[taylorlea]

I've been reading your posts with great interest.

I must admit I'm a little confused.  Do you think you got infected with HSV1 from the women rubbing her vagina and oil on your pelvis?  If so, how did the infection spread so immediately to your penis?  Do you think you always had this infection?

[Edward W Hook, MD]

How surprising.  Less is known about genital HSV-1 than genital HSV-2 which is so much more common.  That said, it is important to point out to you what we DO know about genital HSV-1.  Genital HSV-1 recurs less frequently than genital HSV-2, has less asymptomatic shedding of the virus, and is less often transmitted to sexual partners.  There are no good data on the effect of chronic suppressive therapy on genital HSV-1 transmission, mostly because the disease is rarer and transmission is less common, making it harder to study.

I agree with your doctor.  Other than the suggestion, by extension from the data on HSV-2 regarding suppressive therapy, there is no proof that other drugs such as lysine or NSAIDs have benefit.  On the other hand, the toxicity of these meds is also low so I would not argue against trying them is they seem to be helpful to you.  There remains much that we do not know about genital HSV-1, whether caused by HSV-2 or HSV-1.  

That more sensitive assays detect virus more frequently is not a surprise.  At the same time, that does not change the data on transmission which have been developed by direct study.  Thus, it is hard to say precisely what the personal impact of the data on shedding you mention are.

Hope these comments are some help.  You are asking good questions.  Wish we had more answers.  Take care.  EWH

[toughdg]

Well, despite the low probability, the viral culture of the lesion at my urethral meatus came back positive for HSV-1.  My doctor is puzzled that I haven't developed antibodies yet, but I know it can take longer than 3 1/2 months in some people.  

So I guess most of the questions I have now are about management.  I will remain on suppressive Valtrex at 500 mg/d and try to manage stress.  My doctor said there is really no evidence for anything else, including lysine.  I have heard NSAIDs can help also though, and seemed to help me symptomatically.  Of course there are a zillion other things advertised out there but most of them are patently absurd.  Can you offer any advice here?

Also, I have read a recent study using viral PCR of frequent swabs of asymptomatic areas that shows that viral shedding is more frequent than previous reports, but there seems to be some controversy over whether the bits of viral DNA detected represent potentially infectious particles or just DNA remnants without infectious potential.  Any thoughts here?

[Edward W Hook, MD]

You are correct.  Your test is negative.  It does not suggest that you are developing antibodies.  EWH

[toughdg]

Many thanks for the advice and reassurance.  My doctor made a comment that since the HSV-1 ab was 0.8 it may be "on the way to being positive" and that (as well as my symptoms) was his reason for retesting.  I have read elsewhere on this forum however that with this particular test (Herpeselect), the actual number is meaningless as long as it is below the cut-off.  I know with some medical tests this is true and with others not (e.g. a rising but still normal white blood cell count may be significant in certain circumstances).  Can you comment?

[Edward W Hook, MD]

Thanks for the clarification.  At this time, particularly with a partner who you know is negative for antibodies to both HSV-1 and HSV-2, my guess is that the chance that you have HSV is very, very low.  Given the complexity of your dermatological situation, the best course of action relating to these various rashes is to work with a dermatologist who you can discuss things with frankly and whom you trust.  It is time to stop worrying about HSV however and, in my opinion, there is no need for further HSV testing.  EWH

[toughdg]

Thank you.  I will provide some details for your review and comment.  

My questions at this point were general because my understanding is that I am basically still at the tail end of the window period for IgG ab production after some questionable exposures 14 weeks ago (skin and female genital contact on psoriasis lesions on my pelvis with oil during a massage, as well as kissing (my mouth to her mouth) in Asia) followed within a week by an episode of what looked and felt like diffuse contact dermatitis on large areas of both my thighs, but then a subsequent episode of red tender penile lesions (meatus and head) 2 months later, which resolved within a week, and then another similar episode of penile lesions with dysuria now 1 month after that.  Complicating matters also is that I have psoriasis on my penis, which has been painful at times in the past when it has been irritated but never to this extent. Following the first "outbreak", I had a flare of what looked like classic psoriasis on the head of my penis.  I was therefore treating the penile lesions as psoriasis with a topical steroid, and the lesions may have been mildly vesicular at times, but never burst, crusted, or scabbed.  The second "outbreak" had a similar appearance.  The lesions were painful though and there was the dysuria, so I got tested for HSV at the 14 week (from last possible exposure) mark.  Results:  I had an IgG HSV-1 of 0.8 (<0.9 is neg) and HSV-2 of 0.12 (same reference range).  (Also neg for GC and Chlamydia) I had a culture also around the 14 week mark for which the results are not back, but the lesions were dried out at that point.  Complicating matters further is that I have been having sex with a single partner during this period up until 3 weeks ago, which lots of oral/genital contact, as well as finger/genital contact, and I now have a strange ?vesicular rash on the two fingers I inserted into her vagina most frequently, and a lesion which could be a cold sore around my lip which has recurred once.  I have had psoriasis on these fingers in the past.  She was also just blood tested and is negative for IgG HSV-1 and 2.  She has never had recognizable symptoms, although had an anal fissure recently diagnosed (first symptoms occurred during the period since I returned from Asia and after we had sex again), and there were times I placed the finger that now has a rash in her anus during sex.

I am to be retested in 1 month for the IgG ab's (the 18 week mark from exposure), and will see a dermatologist for evaluation of the rashes.  I am reassured by the current negative antibody results for both of us, but know that sometimes seroconversion can be delayed, and worried by the time course and my symptoms.  Any  other comments/insight would be welcome.

Thanks for your help.