[Question #3406] Anxious Girl- Please Help!

37 months ago
Hello, 
Thank you so much for this service. I am looking very much forward to, hopefully, calming my anxiety.
I was diagnosed with Genital HSV-1 when I was 19, and High-Risk HPV last year as part of my pap smear.  I received the vaccine when I was younger, but it was the first Gardisil so some High-Risk strains were excluded that are now included. Do you know if I could get the new vaccine even though I am older than 26, to cover the additional strains? I am also on Remicade for Crohn's Disease- so technically immuno-suppressed. I am dating around, and I work as a live-in nanny. I am just wanting a really good understanding of what risk I present to both the children I care for (1.5 and 4.5,) housemates, and romantic partners. It's my understanding that my immuno-suppression puts me more at risk from others, than vice-versa, but wanted to double-check on that.  I currently disclose to romantic partners that I "have genital hsv-1 and have tested positive for hpv in the past." I don't say "I could also have these conditions orally or on my hands" or specify that it's "high-risk" hpv. or say "I've also been exposed to HSV-2 or someone with a history of Genital Warts in the past." Those exposures were limited. These things seem like overkill-to share possibilities that I haven't actually been diagnosed with. Hopefully you would agree. I am wondering what the current recommendations are for disclosure to both male and female partners for genital hsv-1 and high-risk hpv. 
Thanks!
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
37 months ago
Welcome to the forum. Thanks for your question and your confidence in our services. I'm glad to help. I'll first make a few general comments than address your specific questions.

First, although infliximab (Remicade) raises the risk of some infections, such as tuberculosis and others caused by similar bacteria, it does not increase the risk of most infection, including STDs. That is, no higher risk of catching herpes, gonorrhea, chlamydia, HIV, etc if exposed. It may increase the risk that such infections cause more symptoms, e.g. enhanced growth of warts or progression of cervical HPV toward dysplasia and cancer. However, these effects are very rare; I am not aware of any data of actual enhanced STD problems of any kind on infliximab or other cytokine inhibitors. (I know all this very well from a personal as well as professional standpoint. My wife took infliximab and later adalimumab [Humira] for over a decade.) (I hope it's working well to control your Crohn's, by the way.)

Second, genital herpes due to HSV1 is rarely transmitted sexually to partners. As you may have experienced, most people with genital HSV1 have few or no symptomatic outbreaks, and asymptomatic viral shedding is also infrequent. These features are very different than genital HSV2. Although it is always possible you could transmit HSV1, in my 40 years in the STD business I have never had a patient with new genital HSV1 who caught it by vaginal sex:  every case was from oral sex. This also is the experience of almost all STD and herpes experts. So while you are not wrong to inform partners of your genital herpes, you can legitimately present that information in a way that minimizes the transmission risk. (Some people would even say you have no obligation to disclose, but this is controversial. See this blog:  https://www.thehairpin.com/2013/11/how-i-found-out-i-didnt-have-the-herpes-id-been-living-with-for-four-years/

Third, although it is true that the current HPV vaccine covers 5 additional high risk HPV types, all together those types account for only around 20% of cervical cancer. So you remain well protected.

Now to some of your specific questions:

1) Bad luck that you have a current cervical HPV infection despite being immunized. Unless the specific HPV types is known, you probably won't ever know whether this is recurrence of an HPV infection you acquired before vaccination, or later infection with a type not coverd by the original vaccine. Either way, as you probably know already, most such infections clear up on their own without ever progressing to cancer. Follow your doctor's advice about follow-up paps and any recommended treatment, but most likely this will never be a serious health problem for you. Disclosure of current HPV infections, other than warts, is optional. On one hand, most males will never know if they are infected; will be at low risk of bad outcomes if they are; and many potential partners will already have been infected with and immune to the HPV strain you have. OTOH, some partners would expect to be notified, and you should consider your partners' potential feelings if they learn later you had exposed them without informing them. A lot of partners would be upset even if the risk is low. A middle ground is to not worry about it prior to first sex, but to reveal your status if the relationship develops promise of ocmmitment. One size doesn't fit all! Finally, don't forget that your HPV will clear up. Once your pap reverts to normal, which it will, for sure you need not disclose.

2) For the reasons above, I don't think you need the newer HPV vaccine. There's a good chance you've already been exposed to and infected with the additional 5 HPV types and hence immune to them if exposed in the future. Even if not, even with the high risk types, the large majority of infections do not progress to cancer. Finally, new HPV infections are uncommon after age 26, even in sexually active people who would seem to be at risk. (That's the main reason the initial research with the vaccine didn't include people and the vaccine isn't recommended for people over 26.) That said, it wouldn't be harmful, and if you want modestly enhanced protection and you're OK with the high cost (around $500, probably not covered by your health insurance), you certainly could do it.

3) Assuming you continue to inform partners of your genital HSV1, I agree you needn't say anything about past HSV2 exposures, hand-genital contact, or past exposure to partners with genital warts. Nobdy needs to warn about exposures, only about their own known active infections. As noted above, this also applies when your current HPV infection is gone.

I think that covers things and hope these comments are helpful. But let me know if I missed anything or if something isn't clear.

HHH, MD



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37 months ago
Thank you. I think with my immuno-suppression, I am having a hard time not feeling like a bio-hazard that is constantly subtley symptomatic and contagious. I think I also worry because I've had many sexual partners. So I maybe feel like I don't deserve to be with anyone now, and I don't know what level of honesty is appropriate. However, I rarely have unprotected oral or vaginal sex and don't have anal sex. The only thing I really do unprotected is mutual masturbation. I am worried about having HPV or HSV orally or on my hands and not knowing. I have never had a stereotypical cold sore or whitlow-as far as I know. I read soap doesn't kill HPV and can live under nails. I do often get irritated/itchy/tingly skin, and cracks that sometimes bleed on my lips and  hands, like papercuts. I have an intestinal vaginal fistula due to Crohn's and I often have diarrhea due to no large intestine and no gallbladder, I also shave, so my genital skin is often unhappy so I don't know when I'm having outbreaks.  I do get frequent itching and sometime bumps.  After I had protected vaginal sex with someone with HSV-2, who was not symptomatic and on valtrex, I had a few itchy red bumps around my vaginal opening. I think they were pretty much gone in a week or two, and I'm pretty sure I've experienced them before the exposure as well. After I had sex with someone with genital warts, I've had some anal itching, but we only had vaginal sex twice and we used a condom, he hasn't had warts in 20 years.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
37 months ago
I don't see a new question here -- just a list of unnecessary precautions that apparently emanate from an exaggerated sense of risk and probably regret over some past sexual decisions and lifestyle you now regret. And probably some psychological impact as a result of having Crohn's. I'm not a psychologist, but I do believe you likely would benefit from professional counseling. YOu might discuss all this with the doctor(s) who manage your Crohn's disease; psychological overlay is very common and they might have helpful advice about all this.

I'll just add that hand-genital contact is risk free for all STDs, including HPV (regardless of finding HPV DNA under fingernails -- presence of DNA doens't necessarily mean transmissibility). Your transient genital symptoms are not suggestive of HSV2, and in any case it sounds like there was no serious risk from that exposure. (I have never had a patient who acquired HSV2 after sex with an infected partner who was on anti-HSV treatment, used a condom, and was not having an outbreak. It happens rarely if ever.) Gential warts or HPV do not itch or cause genital area itching or irritation.

I hope you're able to find a way to move on and find a way to rewarding and romantic sexuality and that this discussion is helping a little bit.
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37 months ago
I do have a therapist, I thought I said that. So, I am hearing you say that, if you were me, you wouldn’t worry about having hsv or hpv orally or on my hands, from what I’ve told you, not hsv-2 or genital warts, at this time? I take care of young children so my hands have contact with their mouths and genitals, and sometimes they touch my mouth because they are babies. I also share a toilet. My hand to genital question was if someone with an std touches their genitals and then touches mine, or I do. I just wanted to make sure that was clear and that I’m understanding. Trust me, I want to let go of this and enjoy my nannying job and continue to date, I just want to be a good person too. So just disclose the genital hsv-1 and history of hpv to romantic partners then? 
37 months ago
Oops! I pushed submit too fast, please respond to this one as my final, allowed, follow-up. Thank you! I do have a therapist, I thought I said that. So, I am hearing you say that, if you were me, you wouldn’t worry about having hsv or hpv orally or on my hands, from what I’ve told you, not hsv-2 or genital warts, at this time? I take care of young children so my hands have contact with their mouths and genitals, and sometimes they touch my mouth because they are babies. I also share a toilet. My hand to genital question was if someone with an std touches their genitals and then touches mine, or I do. I just wanted to make sure that was clear and that I’m understanding. Trust me, I want to let go of this and enjoy my nannying job and continue to date, I just want to be a good person too. So just disclose the genital hsv-1 and history of hpv to romantic partners then? I think it scared me when you said my immune suppression may make me more symptomatic, if I understood that correctly, because that makes it seem like I’m more risky to other people, and then I wasn’t sure what statistics to quote, or how to clarify with myself if something is or isn’t a symptom if it’s not a stereotypical symptoms and my body operates differently? Some clarity around that piece would be super helpful. Like I want to be an honest but normal person about this, but also know that I have a differently operating body than most...so that’s why I was wondering about potentially subtle symptoms. Thanks!!
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
37 months ago
Sorry, I missed a comment about seeing a therapist.

" you wouldn’t worry about having hsv or hpv orally or on my hands"  Correct. This is never a problem for anybody with genital HPV or herpes. Also neither of these, or any other STDs, are ever transmitted to children in routine care, household members via toilets, kitchens, etc. ONLY BY SEX, NO EXCEPTIONS!

"So just disclose the genital hsv-1 and history of hpv to romantic partners then?" Yes, and even these disclosures may be unnecessary, especially past HPV infection. See my original reply above.

I did not say your immune suppression may make you more symptomatic. I said that some immunosuppressed people may have more serious illnesses or symptoms from some kinds of infections. But I have never seen a patient or heard of this happening for herpes or HPV on account of infliximab or other cytokine inhibitors and you are not more infectious than otherwise for sex partners or anyone else.

You really should not view yourself as seriously immunosuppressed, and you do not "have a differently operating body than most". Thet's effect of such drugs on the immune system is limted to a few particular kinds of infection. It's nothing like being on cancer chemotherapy or high dose steroids, for example. The cytokine inhibitors are not known to have any effect whatsoever on herpes, HPV or any other STD. Also no effect on common infections like colds, inrluenza, urinary tract infections, and all the other common day to day infections experienced by all humans. And there are no non "stereotypical" symptoms of any STD, whether on these drugs or any other. That's an urban myth perpetuated on websites with an ax to grind or by anxious or frightened persons. No basis in reality.

That completes the two follow-up comments and replies included with each question and so concludes this thread. You might consider a discussion with your own doctors to confirm the things I have said about infliximab and other cytokine inhibitors. Remember my comments above about my personal experiences with these drugs (my wife) in addition to my professional knowledge of them.

 I hope the discussion has been helpful. Best wishes to you.


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