[Question #7192] Good idea for asymptomatic hsv2-positive people to take antivirals?

6 months ago

Is it a good idea for hsv2-positive people who have not experienced noticeable symptoms to take daily antivirals (valcyclovir) to reduce the chance of transmission?

 

I am a 42m who recently tested positive for antibodies. I spoke with two doctors, both of whom said I didn’t fit the criteria for antivirals because I don’t get outbreaks, and that the meds aren’t appropriate/advisable for people with no history of symptoms who simply test positive for antibodies. I mentioned this on the Reddit herpes forum, however, and the moderator there claimed that many doctors routinely give the opposite advice. What is your take on this? I could try again to get the meds either by attempting to persuade my doctor or by going to another provider.

 

I haven’t had sex since my diagnosis because I’m anxious about transmitting. Minimizing the chance of transmission would make me feel more comfortable (not to mention, I'd like to prevent any outbreak from ever happening). But I’m also uncomfortable going against medical advice to not take the meds, and generally avoid drugs unless there’s a compelling reason to take them.

Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
6 months ago
First, I think if you've had no symptoms, you need to be certain that your antibody test is correct.  The IgG test has problems with false positives, particularly in the low positive range (1.1 to 3.5).  Please take a look at the index value associated with your positive result to be sure it is well above the 3.5 number.  If it isn't, you should have a better confirmatory test. 
The CDC and herpes experts all agree that people who have no symptoms but are truly infected definitely shed virus though not as often as people who do have symptoms.  On average, people who are truly positive but are asymptomatic shed virus on 10% of days measured (10 our 100 days) while those who do have symptoms shed virus on 20 out 100 days.  If you are concerned about transmission to a truly uninfected partner, then I think suppression is highly advisable.  Absolutely.

Terri
---
6 months ago
Thank you very much. The doctor said my IgG test is a "qualitative test" that doesn't have an index value. That's presumably unhelpful in determining the likelihood of a false positive? I've read that the western blot is more definitive and I'm considering getting that done.

In the meantime, I'll show your message to my doctor to try to persuade him to write me the prescription. I saw a NEJM study showing effectiveness at reducing transmission at a dosage of 500mg once a day -- is that what you'd advise? How many days of shedding would it reduce it to? No concerns about going on a daily forever medication that I don't officially meet the criteria for?
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
6 months ago
That's just not OK.  You need either the western blot and/or the IgG that give you an index value. 
IF and that's definitely an IF you have HSV 2, 500 mg once a day is fine for suppresion.  Daily suppression cuts transmission by almost 50%.  As you can see, I am an author on that paper.  There is no longer any criteria for going on suppression, none.

Terri
---
5 months ago
Thanks. I conveyed your comments to my doctor regarding Valcyclovir, and this was his response:

"While Valacyclovir is generally well tolerated, there have been no long term studies establishing safety for long term use.
For folks that take it for frequent recurrences, the FDA advises stopping after a year or so to see if still needed.
The medicine is not approved by the FDA in the absence of frequent recurrences."


He did agree to prescribe for one year. But I would like your thoughts on his concerns related to lack of FDA approval.
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
5 months ago
The FDA is not, I don't believe, in the habit of updating how clinicians should prescribe this medication.  The CDC suggests suppression to reduce transmission between partners, without distinguishing between people who have outbreaks and those who do not because we know that people who do not have recognized outbreaks shed virus on about 10% of days measures - so 10 days out of 100.  And I am not aware of the FDA advice about stopping after a year, but no one I know does that, and none of the herpes experts agree with that advice when one person has herpes and the other does not in a sexual relationship.  That's just common sense.  Stopping suppression simply opens an opportunity for transmission

Terri
---