[Question #8600] Risk of Transmission for HSV-1 Serioconcordant Couple & Chance of False Negative
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42 months ago
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I have oral hsv-1 from childhood, and I am dating a woman who has genital herpes that was contracted during a violent assault two years ago. Her medical examiners did not tell her what type she had, and she has had about seven recurrences since then, so she assumed she had HSV-2. She recently got an IGG antibody test, however, that said she was positive for HSV-1 and negative for HSV 2. I am trying to find out if it is completely safe for me to have sex with her if we both have HSV-1 in different locations.
I have seen The WHO say it is "unlikely" to get a new infection of the same type in a different location, and Dr. Handsfield and Terri Warren say it is "extremely unlikely." But I can't find any data to characterize just how unlikely it is. I also heard Dr. Handsfield say "Recent research has shown new infections with the same HSV type may occur a bit more frequently than was once thought." Can you give any data, rates or transmission, or papers (links?) to quantify just how unlikely/frequent it is? Are we talking 1 in a 100 or 1 in 100,000? Under what circumstances could it occur? I am pretty healthy, I have not had a cold sore in seven years, and my most recent HSV-1 IGG result was 64.
You've also said that none of you have seen any clear case of genital to genital HSV-1 transmission. Does that suggest it would be virtually impossible if the other person also had antibodies from (oral) HSV-1? If I have oral HSV-1, is it a greater risk to receive oral sex than to have genital sex with her (she has HSV-1 in both locations)? Are both activities nearly completely safe?
Since it is unusual for someone to have so many recurrences with genital HSV-1, I also wondered if we can trust her negative HSV2 IGG test. I understand IGG tests are not always accurate, but am I right in understanding that the negative predictive value of HSV-2 IGG tests, more than a year after exposure, is actually quite high, close to 99%.
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Terri Warren, RN, Nurse Practitioner
42 months ago
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I am not aware of any specific research related to getting HSV 1 in a new location after a well established infection.
I have never seen a case of genital to genital transmission - that is, I have not seen someone with a new diagnosis of HSV 1 genitally who has not received oral sex in the past two weeks. But just like getting HSV 1 in a new location, we don't have any data on this question specifically that I know of. I also can't provide you with the number value that you seek - how likely is it that you would get SHV 1 genitally. We do know, however, that someone who has had HSV 1 genital infection for about 2 years sheds virus on about 4 days out of the year. And people who have oral infection with HSV 1 shed more often. The number of recurrences that she has had is quite high for HSV 1, you are correct. So she has had full blown sores that often?
The IgG test misses about 8% of HSV 2 infections, compared to the gold standard herpes western blot, so if you both want to be certain that she only has HSV 1, the western blot would be your best bet.
Terri
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42 months ago
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Thank you, Terri. So all the statements of transmission being "extremely unlikely" then are purely anecdotal? What then led Dr. Handsfield to say "Recent research has shown" new infections with the same HSV type may occur more frequently than once thought. What research is he referring to?
It is shocking if there is no research. If half the population has oral HSV-1 and the majority of new cases of genital herpes are HSV-1, the situation of serioconcordant couples must be very common. If there is no statistically significant risk of transmission, that should be clearly established so these people can live without any stigma or fear. And, if there is any significant transmission, we should know what it is. In general, do you advise people with serioconcordance to not worry about HSV and lead a normal sex life without modification?
Under what conditions would a new infection of the same type (HSV-1) be more likely to occur?
I understand that in general someone sheds HSV-1 more from the mouth than the genitals, but she has had many more recurrences of it from the genitals than the mouth, so that does not seem to be true in her case at this point.
Yes, she had full blown sores each time. She contracted HSV from a traumatic assault (both genital and oral performed on her) and was in a state of heightened stress and emotional duress after, with a weak immune system to begin with, so that may contribute to the #of recurrences. Still, I'd like to make sure there is not a hidden HSV-2.
When you say IgG misses 8% of cases, is that equally true two years after exposure or is it more accurate at that point? I had the impression that many false negatives were from early tests before antibodies fully developed.
Also, related question, she had recently started taking acyclovir before IgG test—would that reduce antibodies to an extent to increase the chance of a false negative? Her HSV-1 IgG was 14, and HSV-2 IgG was recorded only as <0.9.
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Terri Warren, RN, Nurse Practitioner
41 months ago
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I'm so sorry that I missed your reply! Not sure how that happened but here is my response.
I don't know what Dr. Handsfield is referring to but I'll check on that for you.
No, I don't tell people who are discordant with HSV 1 just to ignore it and have a normal sex life. First of all, relying upon the IgG test to determine discordance is not all that accurate. The IgG test misses 30% of infections compared to the western blot. So that in itself presents a problem. I do recommend that, based on the information they have if they don't want to do a blot, they should decide between them how much they are concerned about transmission of HSV 1. We know that genital HSV 1 recurs far less often than HSV 2, with many never having another outbreak. So couples need to weigh out how they feel about giving up sexual practices that could transmit the virus. And how the infected person feels about taking daily antiviral medication. And they feel about condom use, that kind of thing. There isn't a one size fits all thing here because different people have different levels of concern about this.
I suppose conceptually, a person with oral herpes could receive oral sex and acquire it genitally. In my entire career, I have seen that one time - a person who reported having cold sores had a positive swab from a genital lesion.
I sure understand that you would like to be certain that she has genital HSV 1 vs. genital HSV 2 - the recurrence numbers are more consistent with HSV 2 but there are variations in how common outbreaks are for people who have genital HSV 1.
The miss-rate for HSV 2 detection by IgG is composed of lots of people with varying times of infection. However, in general, I don't order western blot testing until 12 weeks after someone has a concerning encounter, so at least 16 weeks for all the people that my practice contributed to the study where we get that number. And the vast majority ARE my patients.
No, taking acyclovir before the IgG test when she's been infected for two years would not impact her IgG test. She certainly has a robust HSV 1 immune response.
Please - ask more questions as much as you wish - again, so sorry, I missed your most recent response.
Terri
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41 months ago
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Hi Terri, Thank you for your reply. I am not sure, but I think you may have misunderstood part of my question.
You said: "No, I don't tell people who are *discordant* with HSV 1 just to ignore it and have a normal sex life. " **But, I was asking about people who are *concordant/congruent/accordant* with HSV1, serioaccordant, not discordant. That is, when both partners are HSV-1 positive, but one partner has it genitally, while the other only has it from cold sores from childhood. In that rather common situation, do you typically advise patients not to worry about it and to have a normal sex life?
If I understand you correctly, you are saying that you have only ever seen one person with prior HSV-1 cold sores ever get a new genital infection after that. I assume that is in the context of thousands of patients, if not tens of thousands; is that right?
Can one assume that the rate of genital transmission—with HSV-1 antibody agreement—would be lower by orders of magnitude (1/10th or 1/100 or less) in comparison to the transmission rate of discordant genital HSV-2 transmission, which is often quoted at 10% annually, 5% with condoms, 2% with antivirals and condoms? Based solely on your clinical observation, by how many orders of magnitude, would you estimate the threat of HSV-1 transmission with antibody agreement would be?
Thank you so much for saying you would check with Dr. Handsfield as to what research he was referring to in regards to possible new infection of the same type in a new area being a bit more common than was previously thought. I would love to be able to review that research or any data associated with it.
It's good to know that anti-virals would not affect an IgG test. Thank you for that.
I had seen that IgG tests has a 98-99% negative predictive accuracy for HSV-2 (when test is negative, it is this likely to be correct), and you said they miss 8% of positive HSV-2 cases. I believe that fits, however, because if it is only wrong for 1-2 tests out of 100 and the average is that there would be 12-20 positive results out of hundred, then that could come out to missing about 8%, yes. I was further trying to determine whether that statistic is constant at different time horizons, or if most of the missed positive IgG results are in the first 2-3 months, with even higher accuracy at the two year point she is at. Do you know if this is the case?
We'd be happy to do the Western Blot, but don't have good health care access here, and unlike the IgG tests, it cannot, to my knowledge, simply be independently ordered from a lab without a doctor. Is there a way to order it yourself, the way you can with an IgG test?
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Terri Warren, RN, Nurse Practitioner
41 months ago
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OK, now I understand your question. I tell people who are concordant that the risk of transmission to a new location is extremely low and that I have only seen it once in my career. And yes, thousands over the years - could be even more.
Now you are asking me math questions. Yikes. well, we know that people who have symptoms with HSV 2 shed virus on about 20% of days. People who are positive for HSV 2 but don't have symptoms shed virus on about 10% of days. And we know that once someone is infected with genital HSV 1 for about 2 years, on average, shed virus on 1.2% of days. So please do the math yourself here.
I will check with Dr. Handsfield, yes
I'm certain that there are more missed IgG positives during the first few months of being infected, including especially those who took antiviral medication daily right away.
I can help you with the blot, including finding labs to get your bloods drawn if that would be helpful. That happens at westoverheights.com
Terri
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Terri Warren, RN, Nurse Practitioner
41 months ago
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Good morning, I hope you will see this response.
I have now checked with Dr. Handsfield, Dr. Anna Wald at the University of Washington and Dr. Christine Johnston, also at UW. There is some sort of miscommunication here - none of them are aware of any recent research indicating a greater risk of getting HSV at a new location on your body once you have an established infection in one location. I understand that you've possibly been trying to reach out to Dr. Handsfield and Dr. Wald and I'm assuming it is about this question. I hope this answers your concern.
Terri Warren
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