Oral hsv-2: risks? Best practices?

[Eganan]

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Hi Terri,

In mid-July 2022, I got hsv-2 on my chin (established through swabbing a lesion) following sexual encounters with 2 men. One man I performed fellatio on, the other man I rimmed and also topped without protection. The sores developed ~5 days later. Neither my partner nor I ever had this before, and prior to this we were monogamous for 12 years. I also had swollen lymph nodes and a fever (plus a super-infection of staph in the lesions which required antibiotics). I did not develop genital lesions.

(I asked each man if he knew he had herpes and each told me he was unaware of having it.)

The sores closed over 4 weeks ago and my infectious disease Dr did not identify any more lesions/pustules when I saw him a week ago. My chin is still red where the outbreak occurred and I still feel faint sensations of burning/itching there, which are slowly receding. My ID Dr said that hsv-1 and -2 are basically the same, occurring at equal rates orally and genitally and behaving the same regardless of the site of infection. This conflicts with other information I have seen, but I’m not sure what’s correct.

My questions are:
1. How likely is it that this was an initial infection?
2. Is it reasonable to conclude that I do not have genital hsv-2 because I did not get genital lesions?
3. How should I think about the risk of spreading hsv-2 to others? I won’t put my mouth on someone if I have open sores — but what about now, where my sores have been closed for 4+ weeks but I still have some redness/sensations there? Am I still shedding virus, or is it just normal skin-healing? Assuming my chin clears up more, is the risk of spreading it very small because it’s oral hsv-2 (compared to oral hsv-1 or genital hsv-2)? Is risk different for kissing compared to oral sex?
4. I intend to continue to have a variety of sexual partners. Is there any clinical indication for using Valtrex to reduce asymptomatic spread of hsv-2 for oral infections, or is that overkill?

Thank you

[Terri Warren]

1. How likely is it that this was an initial infection?
Sounds from the duration of symptoms that it was a new infection. Also HSV 2 orally rarely recurs so I doubt it was a recurrence.

2. Is it reasonable to conclude that I do not have genital hsv-2 because I did not get genital lesions?
Reasonable yes, absolutely certain, no.

3. How should I think about the risk of spreading hsv-2 to others? I won’t put my mouth on someone if I have open sores — but what about now, where my sores have been closed for 4+ weeks but I still have some redness/sensations there? Am I still shedding virus, or is it just normal skin-healing? Assuming my chin clears up more, is the risk of spreading it very small because it’s oral hsv-2 (compared to oral hsv-1 or genital hsv-2)? Is risk different for kissing compared to oral sex?
HSV 2 oral infection is a rarity to start with but recurrences and viral shedding are also very rare. I think transmission to another person, either kissing or giving oral sex is highly unlikely. I would never say never about this, however.

4. I intend to continue to have a variety of sexual partners. Is there any clinical indication for using Valtrex to reduce asymptomatic spread of hsv-2 for oral infections, or is that overkill?
I do not think it is overkill, at least for the first 6 months or so. Because oral HSV 2 is rare, I don’t think we have good guidance on how much this will reduce transmission to another person.

Terri

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