[Question #1559] ? for Dr. Handsfield

75 months ago

Good Evening Dr. Handsfield, thank you for this valuable service.  I was recently diagnosed with G-HSV1 and would like to start a new relationship with someone who is HSV1 negative.  I read this article and have some questions: https://thehairpin.com/how-i-found-out-i-didnt-have-the-herpes-i-d-been-living-with-for-four-years-5a30c2ac9efc#.pyuy532qm

-"As long as I use protection, Dr. Handsfield told me, 'I think you can make a perfectly valid ethical argument that there’s no need for disclosure because the risk of transmission, even if you’re infected, is very, very low.'"- is that just if you're sleeping with multiple partners, what if you're in a committed relationship and don't want to use condoms?  As i understand condoms don't fully protect, my lesion was on the perineum.  

-in the article, if her antibodies are no longer detectable, does that mean she is at risk to become infected orally even though she had been infected genitally in the past?

-regarding my condition i contracted it from a boyfriend with oral HSV1 in 2014 but i didn't have my first symptoms until 2016.  Would that be considered my primary outbreak years later? my concern with that is,  could have autoinnoculated myself (mouth, eyes), or were the antibodies already present even before the first noticeable outbreak?

Thank you, i look forward to hearing your response.

Terri Warren, RN, Nurse Practitioner
75 months ago
Kim, I answer the questions about herpes on this forum.
I'm a little confused about one thing you wrote - if you contracted this in 2014, but didn't have symptoms until recently, how do you know you contracted this is 2014?  If that's correct, then yes, you had antibodies present before this first outbreak that you noticed, correct.  You would normally make antibody within 3 weeks-3 months.  This outbreak that you having now would not be considered a primary but rather a recurrence.  Autoinoculation after the infection has been established, about 3 months, is extremely rare and I wouldn't spend time worrying about that.

If you are in a committed relationship, I personally think it is best to disclose and if your partner it truly negative and feels strongly about staying negative for HSV 1, then condoms and daily antiviral therapy would be the best ways to reduce the risk of infecting him.  You mention that he is HSV 1 negative - does that mean that he has actually tested negative by IgG or just doesn't believe that he is infected?  And remember that the antibody test for HSV 1, according to a paper we are about to release, misses about 30% of HSV 1 infections.  That's far higher than the percentages listed in the writings that you list above. 

And that leads me to the next part of your post which describes someone whose antibody is no longer detectable.  There are a few explanations for that:  1) the test is missing her HSV 1 infection due to the poor quality of the test or or 2) she experienced what we call seroreversion or 3) she didn't have herpes.  It happens, albeit rarely, with the IgG test but not with western blot.  If I had to bet, I'm guessing it was the first.  HSV 1 often never recurs and this could have been the case with her.  It's not possible to know what happened here as she didn't pursue the western blot apparently. 

If your partner has not been tested, it might be useful for that to happen, just to know with about 70% certainty, what he does and doesn't really have.

Terri
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75 months ago
Good Morning Terry,

Thank you for your quick response Ma'am.  I was in a relationship with that individual with oral HSV1 from 2014 to early 2015, and have not had a partner since.  That is how i know there was a delay from the time i saw my first noticeable symptoms.  

Regarding antivirals, i thought because G-HSV1 has such a low rate of shedding, that medication is not really indicated. I really appreciate your response and own your book, "The Good News a About the Bad News: Herpes: Everything You Need To Know," as well as read information on your forum, Westover Heights Clinic, and paid for a different question on that forum as well.  All of which you had great responses to.  However, when i found another expert, Dr. Handsfield, i was looking forward to hearing  his opinion particularly as i had a question specifically about something he said.  This website does not specify that only you would be answering questions on herpes, which is misleading.  Could you ask for Dr. Handsfield's response as well?  or is there another method he offers new clients to speak with him, phone consultation/email/another forum in which he responds to herpes questions?  Thank you for your time!
75 months ago
my apologies for misspelling your name, i meant Terri! .  oh and i also meant to ask what is seroconversion?  And regarding my potential partner, I have already disclosed to him of my condition.  They did the IgG testing.  Regarding the western blot test, is that readily available at most clinics? is it a blood test as well?  Thank you Ma'am
Terri Warren, RN, Nurse Practitioner
75 months ago
The medication isn't "indicated" really, I was just telling you the things that you could do to reduce the chances of transmission the very most.  We know that antivirals are effective against both HSV 1 and 2, perhaps slightly more effective against HSV 2, but still works for HSV 1.  The western blot is not readily available, you would need to contact the University of Washington and ask for a kit to be sent to you, then someone would need to draw blood and spin it down and ship it back.  People that want this test do it successfully all the time - the trick is usually finding a provider who will draw the blood and spin it.
Seroconversion is going from a negative test result to a positive one, sorry for using "the lingo" with an explanation.
I'll ask Dr. Handsfield to look at your post and let me know if he wants to add something.  Are you asking about his statement quoted on disclosure? 

Terri
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H. Hunter Handsfield, MD
75 months ago
I'm happy to add a couple of comments at Terri's invitation.

Once antibody positive for HSV1) you can assume you are infected forever, even if subsequent antibody tests are negative. Terri herself has been one of the investigators on the studies that have looked most carefuly at HSV1 antibody testing. However, detection of antibody -- negative, positive, or if positive, the numerical value -- says nothing about "activity" of the infection, i.e. likelihood of symptoms, asymptomatic shedding, or sexual transmission risk.

It is true that in most people, asymptomatic viral shedding and recurrent outbreaks are uncommon for genital HSV1 and therefore 1) the benefits of suppressive treatment are low for most people and 2) therefore transmission risk is low for any single exposure (in absence of an obvious outbreak). However, there are exceptions; some people with HSV1 may shed virus frequently. The Hairpin blogger you quote correctly states "a valid argument" can be made for not always disclosing genital HSV1, but she doesn't say (or quote me, happily) to definitely not disclose. I agree with Terri that disclosure usually is best. For any single exposure, especially with a new partner, it comes down at least in part to how much of a risk you are willing to take on transmission occurring and having to explain it after the fact. Certainly if you ask most people at risk whether or not they would want to know ahead of time, the answer is obvious -- and if you put yourself in that person's position, what would you want

In the vernacular, and over-simplying: disclosure probably is wisest for most people, but exceptions may be OK somtimes. One size doesn't fit all.

Best wishes--  HHH, MD

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75 months ago

Thank you Dr. Handsfield and Terri for both of your responses!  It is invaluable to have such experts in the field care about us who are trying to cope and understand our diagnosis and disease. 

 Dr. Handsfiled, I completely agree, I disclosed to my potential new partner immediately.  I also provided all of my lab tests and recommended he get testing as well.  So that is where we stand now, I have had one noticeable outbreak a few months ago (hoping that I will not have another), and based on IgG testing he is negative for HSV1. 

 My question was misleading as the quote discussed disclosure, which is not my focus.  I was thinking if it’s something that some people are considering not disclosing then I was equating that to the low transmission rate (which time will tell with me, could it be assumed then that if I have another outbreak relatively soon than my asymptomatic viral shedding is greater as well, but overtime the outbreaks generally reduce as well? )  regarding the quote I was focused on the protection portion, ‘As long as I use protection,’ were you referring to people engaged in sexual activities with multiple partners?  What about a committed relationship? As I understood condoms don’t necessarily protect as the lesion can be outside of its protection.  In my case, it had a small outbreak on my perineum. 

 This diagnosis has been extremely upsetting and I’ve been trying to cope and not have it define me and it feels all-consuming and it makes a new relationship extremely difficult.  Some of the points of discussion you posed in the article reflected my frustrations with the current system.  G-herpes has such a stigma yet people with oral lesions (the ones spreading) are not disclosing and physicians are not educating the public on the matter.  I should have done my own research prior to proceeding in a relationship with someone with Oral Herpes but I was informed there was nearly no risk in transferring with from oral to genital, but now I know, after the fact that nearly half of new G-herpes cases are due to just that. 

 Sorry, I diverged, but thank you again both.  I believe I owe another payment? 

Terri Warren, RN, Nurse Practitioner
75 months ago
Yes you have used up all of your posts on this subscription.  If you have more questions, feel free to renew.  It looks like the post above it mostly discussion of previous questions and answers.  And yes, condoms are better at protecting women from infection from men who are infected than the reverse.

Terri
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H. Hunter Handsfield, MD
75 months ago
Hope Terri doesn't mind I reopened this, as apparently I didn't completely address your follow-up question. I'll ask the web administrator to credit you for the new question, which I will delete.

You asked about whether consistent condom use and/or sex with multiple partners influences the disclosure issue. Not really; the differences between HSV1 and 2 are more important. For each individual sexual encounter, the issues are the same already discussed above. On average, condoms reduce the likelihood of genital herpes transmission by about half. (Protection may be greater than that, probably 70-90%, for any single exposure. But over time, consistent condom users -- for example, the regular partners of infected persons -- reduce their risk of herpes by about 50%. (The reason is exactly as you state, that not all lesions or sites of viral shedding are covered by male condoms.) So if we assume roughly one chance in a thousand for HSV2 transmission for any single vaginal sex exposure to an infected person without an overt outbreak, and estimate HSV1 risk about one tenth as high, that would come to 1 chance in 10,000 per exposure. Or with a condom, maybe 1 in 20,000.

These are very rough numbers, not to hang your hat on -- and during some exposures, the risk is a lot higher (e.g. in the first few months after acquiring the virus). The point is that condom use doesn't really change the disclosure issue, in my opinion. You either diclose or not, whether or not condom use is planned.

Finally, I think you asked whether you might expect more frequent recurrent oubreaks, since you've already had one repeat outbreak. Probably not. For HSV2, and probably for HSV1, outbreaks often are more frequent in the first few months after initial infection, then settle down to a more predictable and lower rate as time goes on. At this point, there is no reason for you to expect more than 1-2 outbreaks a year, and many people with genital HSV1 have one or two recurrences then none ever again. But only time will tell for sure.

That should wind up this thread once and for all, so I'm closing this thread once again. Terri and I hope the discussion has been helpful. Best wishes to you.
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