asymptomatic shedding question/herpes

[eef101]

Hello,
I understand that chance of hsv2 transmission between discordant couples while only avoiding sex during noticable outbreaks ( no condoms or antivirals) is 5% per year. Do these odds change in anyway given the fact that many infected people experience asymptomatic shedding. ie, if there are no noticable symptoms then how do you avoid being sexualy active during an outbreak? Does this situation increase the odds of hsv2 transmission per act of unprotected sex with no condoms/antivirals?

[Edward W Hook, MD]

Obviously there is no single answer to your final question.  The starting point however is a frank and open conversation between both members of the couple- something that is all too often not done.  To do this we must realize that STDs are not and should not be the subject of shame or embarrassment but something that happens in the context of sexual activity.  This perspective is the basis for the ongoing movement to move away from the older, disease and fear based perspective that has guided (and hampered) U.S. STD control for the past century and to move forward towards a sexual health perspective.  This is well described and elaborated on at the ASHA web site.  Getting an STD, including herpes is simply not the end of the world and should not hamper sexual health or future sexual relationships.

This will end this thread.  EWH

[eef101]

Dr. H recommended testing for pure piece of mind, so I guess that would be the only use at this point

For pure curiosity I have one final question to end this thread. As a health care professional, I have learned a lot of information on this subject from you and Dr. H. If so many people who are infected with hsv dont know it then what would be your suggestion for protecting yourself and future partners if you dont recommend routine testing? I understand that condoms are very effective, but you could argue that couples in a serious, monogamous relationship (especially married couples) are not using condoms. How do you suggest being sure that we all stay safe and that you and a partner maintain a piece of mind?

[Edward W Hook, MD]

Once again your question is confusing.  The average risk of getting herpes IF you have sex with an infected partner, is between 1 in 500 and 1 in 1000.   This average figure is the case whether or not the person knows they are infected and even if there are no noticable symptoms to avoid.  

My sense is that you are over analyzing this.  

In your situation, I do not recommend blood tests for herpes.  As you point out, there is a high rate of falsely positive test results, even with HSV2 specific blood tests.  

EWH.  

[eef101]

So the transmission rate is 1/500-1000 when avoiding sex when there are NOTICEABLE symptoms. Does the rate of transmission increase when there are no noticeable symptoms to avoid( which you said most transmission occurs when there are no symptoms) or is this population of infected people (the ones with no symptoms) included in the above statistic

Also, what are your views on routine hepres blood tests. many doctors think that they are pointless because theoretically, they could pick up on different strains of the herpes family ( EBV, CMV, etc) would is the most accurate and hsv2 specific blood test.

[Edward W Hook, MD]

I'm not sure of your question.  Asymptomatic shedding occurs in persons with HSV-2 about 10% of the time.  EWH

[eef101]

so is the 10% you quote the rate of hsv2 transmission period? Regardless of of the ability to avoid sex during outbreaks. if so is this a rate per year?

[Edward W Hook, MD]

  Welcome back to the Forum.  I reviewed your earlier interaction with Dr. Handsfield and agree with all he said.  My comments here will build on those comments.

Most transmission of genital herpes occurs as the result of sexual contact with a partner who does not know if he or she is infected (about 80% of Americans with HSV-2 do not know they have genital herpes).  Available data suggest that most persons with genital HSV, whether they are aware of their infections or not and whether or not they have symptomatic outbreaks (some persons do not have recurrences at all and, because outbreaks can be quite variable, some symptomatic outbreaks are attributed to other causes) about 10% of the time.  As a result, most transmission of genital herpes occurs as a result of exposure to asymptomatic shedding, whether or not the infected person knows they are infected.

As Dr. Handsfield mentioned to you , there are several things which can be done to reduce the risk for transmission.  The measures that have been proven to reduce the likelihood of transmission in scientific studies include regular condom use, avoidance of sex when a recurrence has occurred (if the person knows they have HSV and recognizes their recurrences), telling one's partner that you have HSV if the diagnosis is known, and taking daily suppressive antiviral medication such as acyclovir.  Each of these interventions independently reduces the risk of transmission and if all are practiced, transmission becomes substantially rarer than the 1 in 500-1000 risk for transmission you and Dr. Handsfield have discussed.

I hope this helps. EWH