[Question #1117] General questions about STI transmission & risk, primarily via oral sex

85 months ago
This question "piggy-backs" on my previous question - #953. Once again - thank you for your expertise & service.

I am now 7 weeks post "potential HSV exposure".  I performed frequent self exams for a month & never saw any sores/lesions/blisters typical of HSV & still don't.  My partner & I remain close & see each other often. I have decided to wait until his divorce has been finalized for a few months & then suggest that we both have a full STI screen done, but that won't be for another 4 or so months.  Until then, I want to abstain from intercourse, but also be realistic about anything else we may do, & be smart about it if/when it happens. So, my questions are these: 

1.) First, a specific follow-up question from the last one.... I've read that completely asymptomatic HSV infection is quite common, as in "no primary outbreak & no symptoms whatsoever despite being infected," so would you advise IgG testing despite the absence of any symptoms since the possible exposure several weeks ago? 

2.) I've read that oral sex is generally "safe sex."  Is there a significant risk for HSV 1 or 2, chlamydia or gonorrhea from me giving him oral sex if he is actually infected with anything? I've read that contracting oral HSV2 is less common, but still possible?? HIV isn't really a concern, but can that be transmitted through oral sex at all? 

3.) I read somewhere that some STI's can affect other body parts, like the nipple/areola in women. Is that true? Seems odd, but I'm certainly not the expert. 

Thank you in advance for your reply.
Edward W. Hook M.D.
85 months ago

Welcome to our Forum.  I will be answering your questions today as they are a bit beyond the issues of a possible exposure to herpes that you mentioned in your earlier exchange with Terri...Before I address your specific questions, let me agree with Terri that your risk for having acquired herpes from the earlier exposure that you described is quite low.  Although your partner's wife may have HSV-2, we all have cared for many couples in which one person has genital herpes and the others do not despite years of unprotected sexual activity.  If lesions are not present, we typically estimate the risk of transmission of infection from an asymptomatic infected person to an uninfected partner as being less than 1 infection per 1000 exposures and perhaps lower still- factors such as the duration of infection impact this estimate since the longer a person has HSV, the lower their viral shedding and recurrence rates are.  In your case, you do not even know that your partner is infected- I would not be worried about the exposure you described if I were you.

Also, before I address your specific questions, let me add that most persons overestimate the likelihood of exposure as well.  Not only do most people not have STIs but even when exposure to an infected partner, most exposures do not lead to infection. 

As for your follow-up questions:

1.  there is a difference between completely asymptomatic infection and unrecognized infection and both occur.  there is debate as to which is most common.  Recent studies indicate that at lest of persons who acquire HSV-2 do so without being aware that they were infected.  At lest as many and probably more mistake herpes outbreaks for other self-limited problems such as chaffing or yeast infections.  I see little for you to gain by having a repeat IgG test at this time.  You would risk a false positive test result and if you succeed in your plan to abstain until your relationship has progressed further, then both getting tested at the same time is a great way to move forward with your relationship.  Your risk from infection related to non-penetrative sex is vanishingly low.

2.  Of all forms of penetrative sex, oral sex is about the lowest risk activity.  There is a very, very low risk (so low it is hard to quantify) of getting HIV from performing oral sex on an untreated, infected partner.  One can also acquire gonorrhea and more rarely still chlamydia of the throat from performing oral sex on an infected partner but most men with these infections would show signs of infection.  While persons with oral herpes (HSV-1) certainly can transmit infection to a partner's genitals with oral sex, it is very rare for persons to acquire oral herpes from performing oral sex on an infected partner. further, as you suggest, for reasons that are not completely understood the HSV-2 virus does not seem to "like" the mouth and very, very rarely causes oral herpes.

3.  STIs which are transmitted by non-mucosal skin to skin contact (we're talking here mostly about syphilis and herpes) can occur at any site of skin to skin contact but this too is very, very rare.  The reasons for this is that the skin of non-genital parts of the body are thicker and more resistant to infection than the thinner, more susceptible skin in the genital regions.  STIs of the nipple/areola of women are rare- I do not believe I've ever seen on in more than 35 years of STI-focused practice. 

I hope these comments are helpful to you.  EWH

84 months ago
Thank you for your reply, Dr. Hook.  These answers definitely provide me with some good information & are quite reassuring.  I have just a couple of short follow up questions:

1.) In regards to oral sex, with the prevalence of oral HSV1 in the adult population, is contracting it genitally via oral sex a larger concern than most people realize, or not much at all?  I've read varying answers from "Yes, it is common & can be transmitted mouth-to-genitals anytime, even without obvious mouth sores" to "No - shedding is infrequent with oral HSV1 & cannot be transmitted in the absence of lesions." 

2.) In regards to all STD's & practicing safe sex, I've read that the female condom may provide better protection because it covers a larger surface area.  Is there any truth to this?  I am familiar with female condoms, however have never used one & have no idea how well they stay in place, how effective they are at STD prevention, etc.

3.) Finally, is it safe to assume that all forms of mutual touching, (even in the presence of bodily secretions), are relatively risk-free when it comes to STD's?  I would think that if there was a significant risk with that alone then many more people would acquire STD's.  I imagine that some form of penetration is usually required, but once again - that is why I come to the expert forums.  :)

Again - thank you in advance for your knowledge & information.  You all provide a wonderful resource via these forums.
Edward W. Hook M.D.
84 months ago

1.  Persons who already have oral herpes due to HSV-1 are not susceptible to further infection at any site.  Since so many people have oral HSV, whether they know it or not, this eliminates there risk for infection.  As for uninfected persons who receive oral sex from a person who has oral herpes, the risk for infection is low- certainly less than 1% per act of oral sex as long as the person performing oral sex does not have lesions. 

2.  I know of know comparative studies of the female vs the male condom for STD protection.  I would assume that either method would be a highly effective method for reducing STI risk.

3.  Correct- touching/masturbation is a no risk activity in terms of STI risk, including for HIV, even when genital secretions from the partners get on each other.  Mutual masturbation is widely accepted as safe sex. 

Glad you found my comments helpful.  Take care and stay safe, as you are preparing to do.  EWH

84 months ago
Thank you again for your reply. I have one final question about prophylactic treatment.....

When we get tested in a few months, if my partner does test positive for HSV, is there such a thing as prophylactic treatment with Valtrex or another antiviral for the uninfected partner? Would that at all be beneficial in helping to prevent transmission? Although it would be unfortunate, I'm not sure that him having HSV would be an absolute deal breaker for me & reason to discontinue/not pursue a relationship with this particular person, but I would of course prefer NOT to contract it myself if it can be avoided.  

I understand this is the final post, so again - thank you so much to all of you for the work you do & the help you provide to the public in these matters. I have found this site very helpful & informative. Take care! 
Edward W. Hook M.D.
84 months ago

We do get questions from time to time about HSV prevention.  There are steps but prophylaxis with anti-herpes medications for the uninfected partner is not one that has been studied (so we do not know if it would work or not) or recommended.  The things which are proven to reduce risk for acquisition, and each of which reduce risk for HSV transmission by between 30% and 50% are:

1.  Avoidance of contact if lesions are present

2.  Correct and consistent condom use

3.  For the infected person to take anti-herpes medications such as valacyclovir daily to reduce asymptomatic shedding of the virus as well as recurrences, each of which is associated with transmission of infection

Thanks for your thanks. We do this in the hope that the information we have will be helpful. I'm pleased that you found my comments helpful.  Take care.  EWH