[Question #660] HSV2 transmission

89 months ago
For Dr. HH Hansfield:

I reviewed this site and another site you answer questions but never saw this one.

Here is the quesition 2 married people are having an affair.  One has confirmed HSV2 infection with last out break 12 years ago. Currently on antivirals but doctor wants to take her off because she is not infectious.  Her husband is HSV1 with no HSV2 for over 18 years.

Partner has no known STIs but never tested beyond test required for marriage license. No known cold sores. Been married for 20 years. No signs of HSV2 infection  over the course of 3 months of affair. Know the risk of transmission rates for HSV2.

Condom use for intercourse all the time. Unprotected oral sex both sides with understanding that this activity is very low risk.

1. Should HSV2 partner stop antivirals?
2. Should non infected partner stop Unprotected sex with wife? 
3. Does the stopping of antivirals increase risk of transmission?
4. Does non infected partner need to be tested and how often?


Terri Warren, RN, Nurse Practitioner
89 months ago
Sorry, Dennis, it isn't possible to select a responder here on this board.  I'll take your herpes question. 
1.  The person with HSV 2 still sheds virus (gives off virus from their skin) from time to time even without an outbreak.  It is less likely because they have been infected for a long time and they are without outbreaks, but they likely still still shed virus from time to time.  Given that, I think if the uninfected person wants to do all they can to avoid infection, the infected person should continue on daily herpes medicine.  Do you know that the husband is HSV 2 negative or does he just not have herpes symptoms?  Those are actually two very different questions and it's totally possible that the husband has not been tested unless there was reason to do so. 
2.  Whether to stop having sex with your wife (I'm going to assume it's you for the moment) is a question only you can answer.  Is there some small risk that you could get infected and pass it along to your wife?  Yes.  How much risk you feel comfortable taking is up to you. 
3.  Yes, stopping antivirals may well increase the risk of transmission.
4.  Testing for HSV 2 in your situation is always going to be a moving target, assuming you continue to have sex with the infected person.  When you do test, (and I'm assuming you have tested to know that you are negative,not just guessing), know that you test is reflective of your condition about 12 weeks ago, but not last week.  The test looks for antibody, and that's something that you make, not something that you get from someone else.  It takes a while to make antibody - some as short as three weeks, some people as long as 12 weeks.  At 6 weeks post herpes exposure, about 70% of people will have made antibody that are going to. 

Please let me know what other questions you might have.

Terri Warren
88 months ago

Thank you for your reply. I have reviewed your reply along with the response of Dr. Handsfield at the MedHelp to dinch07 on 2-25-14 wherein he reviews the the risk of transmission involving unprotected sex, no outbreaks and no anti viral involving couples where one person is not infected to around 5% per year. He goes on to state that if the infected partner, in the question was having an outbreak 1 to 2 times a year and taking anti-viral and was infected 15 years ago and her partners were engaging in intercourse with condoms, partner taking anti virals and none of the infected partner's previous partners became infected as being "very, very low" risk your responses confuses me. Also,  I find Dr. Handsfield responses down to earth and to the point as well as Dr. Hook's response response to question number 678, at your site, wherein he states "even if the sexual partner is KNOWN to have herpes, the chance of acquisition of infection from unprotected sex if an obvious outbreak is not present is less than 1 in 1000 (1/10th of 1%) and likely close to 1 in 10,000 (1 100th of 1%). " I have also reviewed the the herpeslife.com "What's the Risk" pamphlet and their estimates of the risk of transmission. 

Now, this prompts my follow up questions along with your response to my original question:

1.  Are the risks factors by these experts inaccurate as to their calculation of the overall risk of engaging in sexual relations with the HSV2 infected partner who has had no known outbreaks in 12 years (been infected over 20 years) and is taking anti-viral medication and using condoms? The infected partner knows the pre-signs of any an outbreak and states that she has not had an outbreak in 12 years. Do you agree that the infected partner is minimally infectious given her history, lack of outbreaks and her taking of anti viral medication?
2.   If these experts are right then the risk factor of transmission on a single act of intercourse, with a condom and the anti-viral medication, would be somewhere in the 1 in 100,000 (1 1000th of 1%) or higher given the fact that the anti-viral medication cuts the rate of infection in half and the use of condoms cuts it in half again. In theory, correct? and repeat exposure over the course of a year increases the chances of infection? Correct? So what would be the chances of infection based on Dr. Hook's estimates of exposure for one act of unprotected intercourse?
3.   Now there are no guarantees in life but is the engaging in this affair a low risk event?
4.  is engaging in unprotected oral sex with this partner a low risk event  based upon the likelihood of an HSV2 infection occurring on the mouth is extremely rare, rare event according to both Dr. Hs? I believe their statements in other posts were that in their 30 years of practice they have seen only 5 cases of HSV2 occurring on the face? So is unprotected oral sex on the infected partner a low risk event? How about her engaging in oral sex on the non-infected partner? What is the chances of contracting nasal and eye herpes from this type of activity for the non-infected partner?

Thanks for all of the information that this site provides. Also for the down to earth and no bullshit fact based information you and the doctors supply.

Terri Warren, RN, Nurse Practitioner
88 months ago
Thanks for your follow up question.  The problem with our herpes research studies identifying the risks of transmission is that we are always looking at what we call "survivors" - that is, we are looking at couples that have been involved sexually long enough to be interested in doing a clinical trial together but have not yet passed virus along. This population may be "selected" in ways that may or may not represent the whole population of discordant couples where one is infected and the other is not.  It also depends upon the gender of the person who has herpes and the one who does not - female to male transmission is more unlikely than the reverse, and I would agree that the risk of transmission from an infected female to an uninfected male which no outbreaks and no antiviral therapy and having sex about twice per week is around 4-5%.  This is the data we have seen in our discordant couples trials - remembering that these represent "survivors".  We also know that people who have outbreaks shed virus more than people who don't have outbreaks.  I would agree that your partner who has no outbreaks and takes daily antiviral medicine represents a low risk for transmission.  I personally don't know that we can calculate the per intercourse risk, other than to apply the above statistics that we have represented in our discordant couples trials. 
I would also agree that the risk of you contracting HSV 2 from the mouth of this person is extremely low as HSV 2 infrequently infects the mouth and it rarely recurs or sheds from the mouth. 
You would like, I think, a very firm number here and although it would be tempting to provide that, I am reluctant to do so.  Just this week, I received the shedding data from a study we just completed where people do daily home swabbing of the genitals as part of the study, looking at rates of viral shedding before any intervention is made and then after as well.  I am the investigator on this trial.  Many people shed little but a few people shed on a very high number of days.  More than 75% of days.  Granted, these people had to have 2-9 recurrences per year to be included in the study so they do not represent your lover.  But my point is that I am unwilling to make a blanket statement about the individual risk of transmission when there is such great variability to shedding rates between individuals. 
So my statements stand.  Daily antiviral therapy will reduce the risk of you becoming infected so I hope she can continue to be on this treatment.  Women are less likely to transmit virus than men.  The mouth is not a good source at all of HSV 2 infection.  And you giving her oral sex is also low risk, but we have no data on the risk of you acquiring HSV 2 from giving her oral sex and then having it facially or in the eye. 

88 months ago
Thank you for your response and your understanding of my confusion. Some follow up quesitions.

1. All of the studies you refer too involve couples who use no protection and no anti-viral meds and no sex during outbreaks to determine transmission rates, correct? There are varying studies on transmission rates involving condom usage in preventing transmission from female to male, correct? Any studies on transmission rates involving long term couples and ultimate transmission?
2. Can uti/yeast infection really be an outbreak instead of an uti/yeast infection? Partner says she knows the difference and cleared up with antibiotics and tested for uti/yeast infection. Partner is very aware of her body and outbreaks. Only outbreak she remembers  was singles in recent years different type of outbreak.
3. In your practice and the Dr. Hs practices have you ever seen an HSV2 infection of the mouth from oral sex alone? No studies on this form of transmission?
4. Does  a dental dam and saran wrap reduce the risk of transmission from oral sex? Is a female condom more effective then a male condom at preventing transmission? Would having sex with my underwear on and a condom reduce the risk of transmission? I know the last part is off the wall and crazy but seen it on some posts. Does the lack of pubic hair increase the risk transmission? Any studies on that form of transmission?
5. I assume from previous posts I have seen that you review your response with Dr. Hs? Any comments from them?
6. Considering going back to just oral sex due to my anxiety? I know I am practicing safe sex and from what I learned now sex is not a risk free undertaking. 

Terri Warren, RN, Nurse Practitioner
88 months ago
1.  No, the studies we do involve couples who do a variety of things in terms of transmission reduction strategies - some use condoms.  They aren't supposed to use daily antiviral therapy, however, if on an experimental treatment - they aren't supposed to anyway!  I don't believe we have studies on couples long term, no, most studies are 18 months or less.
2.  Yes, these things can be mixed up with herpes.  It's hard to say in her individual case, of course.  She might be right on target about what these things really are.
3.  I have seen perhaps a couple of cases of people who are truly HSV 2 positive by western blot who deny ever having intercourse and only have given oral sex, but two in 33 years is not many, for sure.
4.  These barriers certainly do reduce the risk of transmission, yes.  Shaving pubic hair likely causes microscopic breaks that could increase the risk of transmission, clipping is probably a better answer.  Female condoms likely to a better job of protection than male ones do though that is intuitive, not studied. 
5.  We don't review each others posts normally, no.  I think we trust each other's judgement about these things unless there is a question that one of us might have - then we ask each other.
6.  Sex is not risk free in your situation but I do believe it is low risk for transmission. 

Have you considered testing to see if you might already have HSV 2?