[Question #6975] Anal Herpes Transmission/Viral Shedding

11 months ago
Hi,

I’m a gay male with HSV2 that was acquired anally likely 4 years ago now.   I’m on a daily valtrex routine for suppression.  

When I do get an outbreak, it’s mainly just redness/soreness around the anus, and I believe that the majority of any outbreak is inside the anal cavity, as I don’t get any classic  visual symptoms on the skin/anus itself.  Occasionally it just looks a bit red, but there aren’t bumps or sores.  If I didn’t have a blood test, I wouldn’t have ever had any idea I really had it.

My main question involves outbreaks/shedding.  If during an outbreak with active lesions (presumably) internally in the anus or very near it, am I also shedding during the active outbreak on my penis/thigh/other areas, or is the viral shedding most likely localised to the area of infection/recurrent outbreak?  I recently had sex and had symptoms prop up shortly after.  I was the insertive partner and wore a condom. But my outbreak is, as usual, in the anal area, with tailbone pain (which is also a common indicator for me).  Was the risk of transmission high in that circumstance?  Or is it more likely that I wasn’t shedding from the penis if my outbreak was coming in anally?  I very rarely get outbreaks now (sometimes over a year between), so if I had known, we obviously would have waited.

Additionally, regarding asymptomatic viral shedding, is it also more likely to occur at the infection site or will I shed completely randomly (sometimes penis, sometimes anus, sometimes elsewhere, etc).  Basically am I always more at risk of spreading it by be the receptive partner vs insertive partner?  Or is it impossible to know/not work like that?

Just trying to be as proactive in protecting my partner as I can be.

Thanks!
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
11 months ago
The risk of transmission in that situation is definitely NOT high as you were using a condom and condoms reduce transmission by 96%
Even if you have anal herpes, you will also shed from the penis shaft, the most common site of shedding in men.
So you mentioned that you were diagnosed by blood antibody test.  Was it an IgG antibody test and if yes, what was the index value associated with the positive result?
You've not had an actual outbreak anywhere, with sores or blisters?

Terri
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11 months ago
Hi Terri,

I definitely had a rough initial outbreak, though I was originally misdiagnosed with hemorrhoids and later prostatitis in January/February of 2016.  I was pain in my lower back, butt, scrotum, and was unable to urinate without the assistance of medication.  After settling on the diagnosis of prostatitis, I continued experiencing lower back/tailbone pain for a while, and I finally noticed what I thought was some left leg nerve pain and some perhaps small red marks (not really raised or bumps) in the anal region.  Both my doctor and dermatologist thought it was nothing in person, but I later insisted on an IgG blood test, and it came back as 13.2 for HSV2 in November of 2017.   The high IgG test seemingly was definitive, and we took it to mean I've had it a while. Thus, that's why I believe what my hemorrhoids/prostatitis actually was was my initial HSV outbreak.  I've had prostate exams since that have all been normal.  I've been on daily valtrex since receiving the diagnosis.  I've also had chronic constipation since the initial infection, and that continues through to today.

Flash forward to today, and I think I am experiencing an outbreak, but it's mostly just tailbone/anal pain that has not gone away for about a week now even with increased valtrex doses.   As far as my initial question, I'm mainly wondering if, for example, I was having an outbreak right now and it was in the anal area, is that where I'm shedding the virus (perhaps with internal sores), or can I also be shedding all over (e.g. from the penis)?  

You seemed to answer the other question that, even if my initial infection site was in the anal area, I will still between outbreaks asymptotically shed in the penile region, perhaps even more than the anal region.  Am I understanding this correctly?  There are not statistics for gay men, but I am trying to infer from statistics on straight sex.  For example, I assume a bottom has a higher risk of obtaining it from a positive partner who is the top, and vice versa (a top has a lower chance of acquiring it from a positive partner who is the bottom).  But given my initial infection point and seemingly "outbreak" area is the anal region only, am I more "risky" to my partner as the bottom or the top, or is that simply not a consideration and I would be shedding from both areas enough that the risk is fairly even for both activities?

Hopefully all those questions make sense.  I'm just trying to understand the risks my partner takes each time with different sexual acts (and how to balance risk versus a committed sex life), given the dearth of statistics specifically to gay sex and HSV.

Thanks!
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
11 months ago
If a person is having an anal outbreak, about 25% of the time they are shedding from the genitals.  The problem is, you cannot know when the 25% is. 
I am assuming here that your partner has been tested and is negative for HSV 2?  And thus your concern?
Though we don't have the data, as you know, I would say the bottom partner is more vulnerable to HSV acquisition.  But condom reduce transmission by 96% so that risk can definitely be made lower.  So regardless of who is bottom and who is top, condoms are doing to reduce the risk considerably.  Are you taking a daily antiviral?

Terri

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