[Question #10] HSV2 transmission in discordant partners

41 months ago
I am a 60 year old white male seeing a 56 year old widowed white female.. Before we had sexual relations, she correctly informed me that she had contracted genital herpes in her twenties and has been on suppressive famcyclovir  therapy for more than twenty years. She still has occasional outbreaks but the frequency has been decreasing over the years. Since she has been diagnosed, she has two long term monogamous relationships- one with her late husband, and one after being widowed. Neither of her long term partners contracted herpes and were not using condoms.
I have been using condoms religiously with her. I haven't used them since I was twenty and hate them. 
I am well aware that viral shedding can occur even in the asymptomatic patient. 
Her dose of famcyclovir is 125mg qd which is not in compliance with cdc guidelines for suppression therapy by my research. 
Should she have her suppression therapy be reevaluated? Is there evidence that the non-infected partner can take antiviral prophylaxis? Do I have to use condoms forever? What is my real risk for infection. I do NOT want to get herpes from her. 
Thanks

Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
41 months ago

You are right that her dose of Famvir is not correct.  It would be far less expensive and more effective if she used 400 mg of acyclovir twice per day.  The proper dose of famciclovir for suppression is twice daily and if she's going to do twice daily medicine she might as well be using something that is cheaper, more well researched, and just as effective as the more expensive drug. There is no evidence that a uninfected partner would benefit from antiviral therapy. Whether you use condoms long-term or not is really up to you. Since she has had herpes for many years, statistically she is less likely to be shedding virus as often as someone, for example, who has been infected for two years. The statistics about transmission from females to males suggest that without antiviral therapy and without regular condom use, the risk is about 4% per year of transmission. The studies that have given us this number include, as parameters,  having sex about twice per week, the uninfected partner knowing the herpes status of their infected partner, the infected partner being aware of outbreaks or the start of outbreaks, and avoiding sex during outbreaks. Given those circumstances, the rate of transmission from an infected female to an uninfected female is about 4% per year. If you add daily antiviral therapy at the correct dose, which she is on although at the wrong dose, the transmission rate is cut almost in half. If you add condoms, that drops the rate another 30 to 50%. So if you apply those general statistics to your situation, that means that your risk of acquiring genital herpes from her, is very low, between one and 2% per year. If you have sex more frequently than twice per week, the risk goes up and if you have sex less than twice per week obviously the risk goes down slightly. In understanding that 4% number, is helpful to think that if there were 100 couples in your same discordant infection situation, about four men out of the hundred in a year would become infected. That also means that 96 men would not become infected. There is not however a guarantee of any kind that you will not become infected. We all take risks every day and we take them based on our desire to achieve the thing that requires taking risk. In sexual and romantic coupling situations, the risk will depend upon how attached you are to her and or how much you want to have sex with her. Only you two can decide that. I would also say that unless her two other partners were tested, there is no way to know if they actually got infected or not.

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41 months ago
Thank you for your succinct answer. 
What are the risks for oral sex- performing it and receiving. 
Thanks
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
41 months ago
Lots of people ask that, of course, and the bad news is that we don't have any data at all on the risk of you giving her oral sex.  but if she has HSV 2 genitally and that's all, then she can give you oral sex without risk of transmission of her HSV 2 infection.  I am assuming that you have actually been tested to know that you are not infected yourself.  If you've not been tested.  then I would strongly suggest that you do that.  Eighty percent of those infected don't know they are infected so you might be surprised by the answer.  The test you want is the IgG type specific antibody test. 

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Best,
Terri 
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