[Question #656] A few follow up questions

89 months ago
I just had a few more questions. I appreciate Dr. Hook's replies from my previous thread and just had a few follow ups.  So I've done a lot of thinking and I might go back to restricting my sexual activity to just mutual masturbation until finding a committed partner.  

1) I know you guys advise against routine herpes testing in asymptomatic people due to imperfections of this type of testing.  If I find myself in a committed relationship, what is the best way to ensure both my partner and I don't have genital herpes before ultimately engaging in UNprotected vaginal sex? (Still haven't found that special someone, so this is hypothetical) 

2) Per Dr. Hook's advice, I plan to get the HPV vaccine. Just to confirm, this will only protect for subsequent exposures, but not past exposures?  Particularly, with respect to oropharyngeal squamous cell carcinoma, does this offer protection if exposure was before vaccination? 

3) This is sort of related to question 1) but more so from a scientific curiosity standpoint. Does it still stand that 1/5 adult Americans have genital herpes and the majority don't know it?  I know you guys say if genital sores  don't show up within 10-14 days of an exposure one is essentially in the clear.  Am I correct in concluding that for that large number of people with genital herpes that don't know  it,  most likely they did have an initial outbreak within 2 weeks of their exposure but it was mild so they didn't notice?  I know asymptomatic shedding is a big factor in transmitting herpes to others, but how do so many people not know they have genital herpes if an initial outbreak should occur within 2 weeks of exposure? 

Thank you. I'll say it again, you guys do truly amazing work. 
89 months ago
So I was debating whether to ask this question because I'm pretty sure I know the answer. But I guess I'll just ask..

4) So lo and behold I did engage in mutual masturbation with somebody yesterday, a new partner.  I didn't get to really inspect too closely, but I didn't see any obvious lesions on her vaginal labia, although  she did have a lot of what looked like razor burn in the pubic area. At one point she rubbed her vagina for maybe 5 seconds, then immediately touched my penis with the same hand for a fleeting moment, maybe a couple seconds, but then I stopped her and made her switch hands.  It goes without saying this is absolutely zero risk for anything, including herpes, correct?  
H. Hunter Handsfield, MD
89 months ago
Welcome back to the forum. Thanks for your kind words and confidence in our services.

I reviewed your recent discussion with Dr. Hook and agree with all he said. I'll go directly to your current questions.

1) The best method to assure that neither you nor your partner has HSV is for you both to be tested. It is true that the tests aren't perfect, which is why most experts don't recommend tesing asymptomatic persons after single exposures. However, this situation is different, and HSV testing often is done in this situation. Of course you would have to deal with the statistical likelihood that one or both of you will test positive for HSV1, since roughly half the adult population has it; and with the much lower but still real possibility of an an uncertain HSV2 result that requires additional testing to sort it out. OTOH, if neither of you has had particularly high risk sexual lifestyle or symptoms potentially suggestive of herpes, you may decide against it -- probably something to discuss with your partner and not decide entirely on your own. A lot of people don't care much if they get genital herpes, knowing that most cases are mild or even entirely asymptomatic; that effective treatment is available in the event of significant symptoms; and in a committed relationship, there no longer a concern about informing partners and its impact on dating, romance, etc.

2) Correct on all counts: protection against future exposures, with no effect on current HPV infections or past exposures; and highly effective in preventing the oral HPV infections that rarely lead to throat cancer. Of course that's such a rare cancer, even without immunization, that if that were the only problem with HPV, probably nobody would have felt the need or invested the resources to develop a vaccine.

3) All your understandings are correct. The only possible minor modification is that we really don't know what proportion of people with asymptomatic HSV2, detected by blood test, and who do not recall symptoms of an initial infection, in fact had symptoms at the time that they forgot or that were so mild they paid no attention. However, we have also said that people who are particularly anxious about herpes probably are more likely to notice mild symptoms. Therefore, my belief is that those most concerned about having herpes are probably the ones who need worry least about it, if they haven't had symptoms. Experience in STD clinics teaches that most people are in fact quite blase about all genital symptoms, including those of herpes. Probably only a small minority are all that concerned -- although of course those persons are greatly overrepresented on forums like this, where you can easiily get the false impression that everybody worries a lot about all this stuff. Which simply isn't the case.

4) Finally, your fourth question confirms that you're probably in the group of more anxious persons than normal. Most people would never think to a) worry about mutual masturbation at all or b) attempt to observe their partners' genitals for lesions. I can't comment on the possibility that yesterday's partner had a "razor burn", but even if that was a herpes lesion, you were not at risk. Hand-genital contact rarely if ever transmits herpes or any other STD.

I hope these comments have been helpful. Best wishes--  HHH, MD

89 months ago
Thank you for your thorough answers, Dr. Handsfield. They are indeed helpful.

With respect to STD/HIV testing in general,  I know you and Dr. Hook recommend HIV/syphilis/GC/CT testing every 1 to 2 years for those who are sexually active outside of a monogamous relationship, even with consistent condom use.  This would apply to me - multiple partners, I always use condoms for vaginal sex and I've never had a condom break on me. 

I plan on having a primary care check up in the summer and will integrate testing at that time with the other health maintenance things. I was wondering  though, why is testing recommended for HIV and other fluid transmitted STIs, even if all penetrative sex acts are properly condom protected?  Would a false positive be more likely than ever acquiring these diseases from properly condom protected penetrative sex regardless of number of partners and episodes? 

Also, in your extensive clinical experience, how often do you see people acquire skin to skin diseases despite consistent condom use? Have you ever seen anybody acquire fluid transmitted diseases despite proper condom use? 

Thank you kindly. 

H. Hunter Handsfield, MD
89 months ago
First, periodic testing isn't just my view; it reflects advice from all responsible public health agencies, e.g. CDC. Second, it doesn't mean testing for all STDs; gonorrhea, chlamydia, HIV, and syphilis are sufficient -- no herpes or hepatitis, except in special circumstances. Third, the chance any of these will give false positive results is zero for all practical purposes, so that's not a concern.

Why do it despite consistent and correct condom use? Because people who believe they have been entirely safe have higher frequencies of positive results than people at still lower risk, e.g. mutually monogamous. That means there have been undetected condom failures or other unrecognized or unremembered lapses is safety -- just as pregnancy rates are higher in couples who consistently use condoms for contraception compared with those using more effective forms of contraception. Some forget some exposures (drugs or alcohol often are involved). And when one person in a generally monogamous relationship feels a need for outside sexual experiences, often the other partner has done so as well, contributing to STD risk despite consistently safe sex outside the main relationship. Obviously you are in the best position to judge whether any of these might apply in your own situation, and to make your own choice about whether and how often to be tested. But those are the origins of the standard public health prevention recommendations.

I've seen plenty of patients with STDs, including fluid transmitted, despite claims of consistent condom use. Of course how accurate their information is about correct and consistent condom use is impossible to determine in most cases. Whatever the reasons, rare things happen, and of course such patients are represented among the 10,000 per year who visit my STD clinic.

89 months ago

Thank you for your prompt reply.

So am I correct in interpreting that most likely, despite what they reported, all of these people (including the many patients you've seen) acquired HIV or other fluid transmitted STD when a condom was not actually covering the head of the penis during the entirety of a penetrative sex act?

Or can fluid enter/exit the condom from below at the base of the penis during penetrative sex? (I know that microscopic leaks don't occur and if a condom tears it breaks wide open, right?) Is there a mechanism of transmission of HIV, gonorrhea, or chlamydia during penetrative sex if in fact the condom was worn the whole time and didn't break?

Dr. Hook told me you guys continue to have complete faith that consistently and correctly used condoms which do not break offer complete protection from HIV.  Does this apply with gonorrhea and chlamydia or any other fluid STD?

My apologies for the additional questions. I just want to make sure I have an accurate understanding of things.

H. Hunter Handsfield, MD
89 months ago
Those are possibilities about how such infections may occur despite correct condom use. But the biggest reason for reported failures probably is that the condoms in fact were not correctly used, i.e. either intentional or unintentional misreporting of what happened. Even with correct use, the risk of STD cannot be reduced to zero, even if sometimes in quick replies Dr. Hook and I forget to qualify our statements e.g. "zero risk for practical purposes" or "virtually zero". Nobody can make such absolute guarantees and nobody should interpret our advice in that way. There has been no research on this; we're going by common sense assumptions.

You have made a lifestyle choice that puts you at risk for STD which The chance you'll get infected with gonorrhea, chlamydia, or HIV during any single exposure with correct condom use use is extremely low, but nobody can say it is zero -- if only because condoms break, not to mention mechanisms like those you describe. And of course substantial risk for skin-to-skin transmission (syphilis, herpes, HPV) will always remain substantial. If you want an absolute guarantee you'll never get an STD and transmit it to your wife, you'll have to stop having sex with escorts. You cannot have it both ways.

That completes the two follow-up comments and replies included with each new question, and so finishes this thread. Best wishes and stay safe.