[Question #3075] G-HSV1

39 months ago
I know not always possible, but I would love for Dr. Handsfield to answer my question, if possible, as I've read a good amount of his literature online. I am GHSV-1 positive, and was diagnosed by swab test 7 years ago. I've had one outbreak (primary), none since, and to my knowledge, I've never transmitted to anyone via viral shedding. I'm now having sex with someone who is HSV-1 negative (by IGG, admittedly not Western blot, so I suppose there's a small chance it's incorrect). 

1. He knows my GHSV status, but how likely is it that I'll transmit to him? I know the data on HSV-2 is approx. 4% per year for female to male before condoms and antiviral therapy - is there any data on HSV1? Comparatively, how likely is it?  How many cases of G-HSV1 transmission genital to genital have you seen before, and how many have your peers seen, to the best of your knowledge? And when we talk about transmission rates per year, does that mean it's the chance you have for every sexual encounter, or does it really mean over a year meaning the chance per sexual encounter is in fact smaller? 
2. What measures should I be putting in place to protect my boyfriend? If we don't use condoms or valtrex, is it likely he'll be infected? 
3. I'm worried about this affecting a potential baby. Could you comment on the relative risks? 
3. How big a deal is this?  I feel tremendously sad about it on a daily basis. 

Thank you.  


Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
39 months ago
Sorry, I answer the herpes questions on this forum.
1.  We have no research on transmission of HSV 1 to sex partners.  We do know that the shedding rate for HSV 1 is about 1/3 that of HSV 2. There is more research being done right now on HSV 1 genital infection so these numbers could change.  I personally have never seen a case of HSV 1 transmitted via intercourse and I don't believe that Dr. Handsfield has either.  However, it has been documented in the professional literature so it can happen though rarely.  The transmission rates per  year that we see quoted and generally based on studies where the average number of intercourses per year are 104 - twice weekly. 
2.  Condoms and antiviral medicine will greatly reduce transmission though we do not have that statistic, as I mentioned. 
3.  We know that neonatal transmission is uncommon in general - perhaps 1500 cases per year in the US though the statistics are not easy to gather.  We also know that a person with genital HSV 1 is slightly more likely to infect their baby at delivery than a person with HSV 2 but the baby is less likely to get critically ill. 

I would say this is NOT a big deal medically, though I hear that it is for you.  It is rarely transmitted via intercourse, it is shed infrequently, most people in the US already have HSV 1 (most oral) so once you are infected in one location, you are extremely unlikely to get infected at a new location.  As you seem to know, his IGG test may be incorrect.  It might be worth obtaining the western blot to really know where he stands. 
With antiviral therapy and condoms, the risk of infected him will be incredibly low. 
Please let me know what other questions you might have.

Terri Warren
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39 months ago
Thank you so much, Terri. A few follow up questions:

1. Great to know you've never seen a case to your knowledge. To be clear, does that mean that to your knowledge none of your patients with confirmed G-HSV1 have transferred the infection to a partner? I would imagine sometimes it's difficult to tell how an infection was transmitted because people have both oral and vaginal intercourse. Can you comment on how tell if an  infection was received orally vs genitally? Beyond Dr. Handsfield, I would imagine that among your other colleagues seeing genital-genital transmission is also rare? 

2. Is oral-genital hsv1 transmission much more common than genital-genital? If so, why aren't people being better educated about the comparative risks? Similarly, are hsv2 transmissions much more common? 

3.Could you comment on the amount of viral shedding decreasing over time? Does this happen in hsv1 as with hsv2? 

4. If i were to use condoms OR meds but not both, would you imagine the risk of transmission would still be low? This seems to be the consensus among other literature I've read (including Dr. handsfield), etc. 

5.  Can you comment on the likelihood of a vaccine being developed in the near-ish future (next 5-6 years or so?) 





Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
39 months ago
1.  Yes.  When I diagnose someone with genital HSV  I always asked if they had received oral sex from someone.  In all cases that I recall of HSV 1, the answer was yes.  That's not to say that it isn't possible that the transmission was genital to genital but because HSV 1 sheds rarely I suspect it is rare indeed.  However, genital to genital transmission has been documented in the literature.
2.  Yes, much more common - by far.  We know now that HSV 1 oral infection in symptomatic people shed virus about 25% of the time.  I just think most people with HSV 1 don't know it and the other part is that most people don't understand that cold sores are caused by herpes and can be transmitted from mouths to genitals through oral sex.
3.  I don't think we have data on HSV 1 shedding decreasing over time but there is no reason I know of that it would be different than HSV 2 in that respect
4.  Yes, all things reduce transmission, when used in combination or alone
5.  Wow, that I don't know.  There are some interesting things going on out there with vaccines but 5-6 years?  I'm guessing not.

Terri
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39 months ago
Thank you Terri. On daily suppressive therapy, I've read elsewhere that valtrex is likely less effective against hsv1 than hsv2. I've read that your recommend 0.5mg in other threads, can you explain a bit more about what you base this recommendation on? I'd certainly like to take as low a dose as possible, so if you really believe that 0.5mg is sufficient I'd love for you to explain a bit more about why. 

And Overall, what is the risk of transmission compared to HSV2? Thank you


Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
39 months ago
There is some research showing that Valtrex is slightly less effective against HSV 1 than HSV 2 but from a practical real life perspective, I've not personally seen that.
The recommendation for Valtrex originally was based on the frequency of recurrences - 9 or more per year, 1 gram daily.  Fewer than 9, 500 mg.  Those recommendations were made when we knew less about viral shedding and it's important role in transmission.  So now, when I prescribe antivirals, I routinely start with 500 mg  and if people do well on it, we stay at that dose.  If they are having break throughs, I bump it up to 1 gram daily.  500 really works fine for the majority of people and a nice paper by a physician at UW shows that higher doses routinely aren't much better at all than the normal doses for reducing viral shedding. 
We think that people with HSV 1 genital infection shed on about 5% of days measured  while people with HSV 2 shed on about 15% of days, on average, so perhaps the risk is about 2/3 less.

Terri
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