Transmission Risk – Acyclovir v Valtrex (Discordant Couple)

[Anonymous]

Hello Terri, first – thank you so much for your time.

My boyfriend and I (I am a female) had STD testing done before we were intimate a year ago, when we found out he was positive for HSV2 due to an Igg test. The clinician shared that it looked as if he had perhaps been infected for many years due to lab results/numerical data. I’m sorry to say I don’t have those numbers for you. However, he had never had any symptoms. I too was tested and was negative for everything but HSV1 (which I understand is very common).

He was advised to take and prescribed Acyclovir 400mg/twice per day for preventative purposes – in an effort not to pass HSV2 to me.

He was on the Acyclovir regimen mentioned above for at least 2 weeks before we were first intimate.

There has been 1 incident in which the condom has slipped – but I don’t believe that this occurred during any prolonged friction as it happened as he was withdrawing.

There have been 2 or 3 incidents in which his penis has accidentally grazed my mons pubis area prior to condom being put on, but never any type of prolonged friction/exposure skin-to-skin with his penis directly.

I went to pretty much the biggest name in sexual health care clinics (I don’t want to bash their name but I’m sure you know who I am referring to) today to have my first test for HSV2 done and I was shocked to hear the nurse tell me that Acyclovir is not effective for transmission prevention and he should have been using Valtrex. This is what was recommended to us initially (Acyclovir), and I’ve read several published studies indicating there is no significant difference in reduction of HSV shedding with acyclovir verses valocyclovir (which is Valtrex, right?).

Can you please help me to understand this conflicting information about acyclovir and valocyclovir for preventative measures for discordant couples? As I am sure you understand, this is very scary to me…I thought we had been well informed initially.

Also, this test is 8 weeks post our most recent intercourse. I know the recommended waiting period prior to testing is 12 weeks – how accurate will this test be though considering 8 weeks have elapsed from the most recent encounter? That is, what percentage of people begin to seroconvert by 8 weeks, roughly?

Given that he has NEVER had symptoms, we’ve ALWAYS (100%) used condoms and he is taking Acyclovir 400mg twice daily – can you share any numerical data about the risk for transmission to me?

**Also – I have been informed by this same provider I saw today that because I shave my genitalia I am more at risk. Is this so? I wish I had found this out through my research. However, from what I have read from Dr. Handsfield in a post is that transmission typically requires prolonged massaging into the skin and generally this occurs during intercourse (Presumably not the mons pubis area where I had mentioned the brief “grazing”).

I understand that herpes is relatively harmless but I am experiencing great anxiety at this point and would appreciate any information you may have to offer. I am shocked that more health professionals are not well versed about herpes specifically. I hope that I was clear without rambling and i look forward to your reply.

Thank you so much for your time and all the best to you!

[Terri WarrenKeymaster]

I’m really not sure what place you are describing – I sure hope it wasn’t my clinic!
Though the initial research was done on valacyclovir and not acyclovir, the only very specific transmission evidence we have is about valacyclovir. HOWEVER, having said that, we have done multiple studies on viral shedding (a reasonable “marker” for the possibility of transmission) and found NO difference between the two in the ability to reduce viral shedding. Dr. Christine Johnson at the University of Washington did a lovely study in the past few years about the ability of antiviral therapy to reduce viral shedding. Good old generic acyclovir did as well or better than the newer drugs, WHEN TAKEN AS DIRECTED. The value of valacyclovir for many people is that the dosing is once a day and they comply better. But if your boyfriend takes his medicines well, then he has nothing to worry about, taking the generic drug vs. valacyclovir. Having said all that, he is still shedding small amounts of virus from time to time. So far, we just can’t stop that completely.

I would agree that shaving opens up microscopic areas for virus to enter into your body. I think clipping your pubic hair if you would like it not to be there would be far less disruptive of skin cells. Hey you could turn it into some cool sexy thing you do as a couple, maybe? I’m not worried about your “grazing”. That’s too subtle for transmission, I would agree with Hunter on that.

How is this relationship for you? New, solid, iffy, terrific? Maybe too soon to know? Because if it is solid and longer term, it may be time for you to start working on yourself and your herpes fears and trying to turn down the volume on these fears just a bit. You guys are doing a great job of practicing all that you can to reduce this risk and there is really no more to do. I wish you both the best.

Terri

[Anonymous]

Hello Terri,

Thank you so much for your thorough and thoughtful reply. I want to assure you that the provider I mentioned was NOT at your clinic. It was a Planned Parenthood clinic which is why my anxiety shot up. I figured this individual knew what she was talking about and so I was afraid when she said we “should have” been using Valtrex and that Acyclovir “doesn’t do anything to protect” me. This was a nurse by the way…

Anyway, I have a couple brief follow up questions for you regarding your reply:

1-Since my boyfriend is very compliant with Acyclovir (he takes 400mg 1 time in the morning and 1 time in evening) AND we have ALWAYS used condoms, AND we are not intimate during outbreaks (he’s never had any) is the chance of transmission still around 3%-5% for me as I’ve seen referenced in some studies? **Even with the shaving? I will stop shaving now but I have to assume that some people in those studies shaved/waxed, right?

2-How accurate will the Igg blood test be for our most recent intimacy 8 weeks ago? I know 12 weeks is preferred but is it a fairly accurate picture?

3- I read somewhere that if a partner is on suppressive medication the likelihood that they will transmit the virus is only 50% and that if it does transmit the likelihood it will be asymptomatic is 75% is that true? That seems conflicting with what I have read several other times about male-female transmission which I mentioned above.

4) The nurse at PP said the numerical values on the Igg test mean “NOTHING” Is that true? The initial clinician had said from the numerical values it looked as if he had been infected for many years. Could this be an accurate assumption? If so, is this a protective factor for me?

Again, thanks so much Terri…

All the best to you and thank you so much for your helpful knowledge and devotion to this field.

[Terri WarrenKeymaster]

Whew, good to know it wasn’t us!
I would say, given your circumstances, yes, there is about a 2-3 % chance that you will contract herpes in a year and therefore, a 97-98% chance you won’t. This is not cumulative, by the way. Shaving was not included as a variable in the research project that sorted this out.

The blood test would be about 75% accurate at 8 weeks.

Correct, antiviral therapy will reduce the risk of transmission by about 48%. With you having HSV 1 already, a new HSV 2 acquisition would likely to minor or asymptomatic. All this means is that it would be good for your to be tested periodically or at the end of the relationship to see if you’ve become infected and didn’t know it.

I would disagree that the numbers don’t mean anything. If the index value on the test was 1.1 to 3.5, this could be a false positive. 50% of positives in the range are false positives. Number variability above that don’t mean anything in particular. Low numbers could also indicted new infection. I was wondering what your boyfriends values are, since he has had no symptoms. How about if you get those for me? If he’s been infected for a long times, he may be somewhat less infectious, very difficult to know in your particular situation.

Terri

[Anonymous]

Hi Terri,

Update – I tested negative. I am in the clear for most exposures I’ve had in the past year with the exception of my last exposure.
The test was taken 8 weeks past my final exposure.

1) How accurate is the test for the final exposure at 8 weeks given that I’m HSV1 positive?
I read that it can take longer to seroconvert for HSV2 if already positive for HSV1.

2) Before I ask this question I should say I am very anxious and may be overly sensitive to what I’m seeing.
I’ve never had symptoms but I now have a few red flat spots on my buttocks. I must say I’ve seen this before historically in my life and just assumed it’s from right clothing – folliculitis/normal skin irritation. There aren’t any typical clusters just a few spread out red flat spots. One is a little tender but again I may just be paranoid. No fluid or scabbing etc. I also had one red bump in my pubic area which seemed pretty typical for me in terms of normal bumps that can happen down there?This doesn’t sound like HSV2 does it? I think what I have doesn’t look like any online pics of herpes I’ve seen – but I am scared.

**Again, my partner has consistently used acyclovir correctly and we have always used condoms – he has never had symptoms.

I am having another test done and hoping for a final negative but I am very anxious and hoping you can help.

Thanks again!

[Terri WarrenKeymaster]

1) I don’t have an exact number for 8 weeks, but I would say it is around 70-75% accurate at that time frame. Yes it can take a little longer to serconvert if you are HSV 1 positive.
2) No, this does not sound like HSV. If you had HSV on the buttocks I really think you would describe something very very different. I would say that 90% of the patients that I see in my clinic have some sort of little red bumps on their buttocks or thighs, but when people are concerned about having herpes, these normal little bumps do raise unnecessary concerns.

If I had to guess, I would say that you will likely stay negative. You did all the right things and have tested negative so far so that’s great.

Terri

[Anonymous]

Terri,

I am having the Igg done tomorrow which is 15 weeks post final exposure
– will this result be definitive for me? (Even though having HSV1 can delay seroconversion of 2).

I have a group of tiny red flat dots on my buttocks – never seem this before.
They’re not raised at all and they are the size of a pin head- like if you touched a ball point pen to paper
That’s how small. They haven’t changed at all throughout the day either and they’re in an area the size of a small lemon.. They’re not like any pictures I’ve seen of herpes online. Does this sound like folliculitis?

I’ve never had symptoms before – wouldn’t an outbreak on the buttocks be rate for a primary outbreak? That’s what I’ve on Dr. Hansfields postings.

I know my questions seem silly but thank you , Terri.
This is a scary time.

Best Wishes and thank you so much.

[Terri WarrenKeymaster]

We are truly out of questions here.

15 weeks is fine. Herpes on the buttocks looks nothing at all like what you describe. I have seen it hundreds of times. It is raised large blister on a red base. Buttocks would not be the first site of infection no. I think you’re good.

Terri

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