Transmission to partner

[anon777]

Dear Terri,
I am a woman infected with genital HSV-2 about 7 years ago, generally asymptomatic but with occasional recurrences that typically involve tingling and bumps in the labia area but rarely open sores. Despite consistent condom use (but without acyclovir or valtrex use at the time) I infected a previous partner within a few months of the start of the relationship which made me feel terrible of course, and created a strain on that relationship since he had difficulty accepting his new status (we had discussed the risks prior to sex, but of course that doesn’t mean it’s easy to come to terms with having herpes). That relationship ended, and I am now, a few years later, starting a new relationship with a man who has no history of HSV. When I told him my status and what happened in my previous relationship, he was accepting and supportive. I am taking valacyclovir (500 mg once per day) and we have used condoms each time during intercourse (which has occurred only a few times so far). My concern comes from what happened the other day: We had intercourse with a condom and some hours later oral sex (him to me). A day after this, I felt tingling and one red bump on my outer labia. I think the sex (which was pretty active) might have acted as a trigger to get the virus shedding. I have not skipped any doses of valacyclovir so I’m worried if the dose I’m on is not preventing virus shedding. I can ask my doctor to up my valacyclovir dose to 1000 mg per day to further reduce this risk in future. But my most important concern is for my partner regarding this particular event:
1) If I started feeling symptoms 10 hours after the oral sex (so, ~20 hours after the intercourse), what is the likelihood that I was shedding virus when we were intimate, even though I felt no symptoms at that time?
2) If I was shedding virus while we were intimate, despite being on valacyclovir and using a condom, what is his risk of being infected?
3) Maybe the most likely transmission is from the oral sex, genital to oral, since we didn’t use any physical barrier method of protection then, and the oral sex came after the triggering event (the friction-heavy intercourse with condom), and the oral sex occurred only 10 hours before I started feeling symptoms. Can a person get HSV-2 orally, and would he have recurrences in his mouth? Would the oubreaks stay oral or can they manifest genitally?
4) If he does contract HSV-2 from me, either genital or oral, when would he be likely to experience symptoms (if at all)? Within a few days? A couple of weeks? I want to know when I can start breathing normally again… I know that he can get tested, but that would have to wait some weeks to be accurate.

[Terri Warren]

1) If I started feeling symptoms 10 hours after the oral sex (so, ~20 hours after the intercourse), what is the likelihood that I was shedding virus when we were intimate, even though I felt no symptoms at that time?

The individual shedding patterns of people are so variable, it is difficult to say but it is certainly possible that you were shedding virus 20 hours before an outbreak.

2) If I was shedding virus while we were intimate, despite being on valacyclovir and using a condom, what is his risk of being infected?
I think the risk are really quite low actually, with both of those “defenses” going on. Even with an outbreak, the medicine would also reduce the amount of virus present.

3) Maybe the most likely transmission is from the oral sex, genital to oral, since we didn’t use any physical barrier method of protection then, and the oral sex came after the triggering event (the friction-heavy intercourse with condom), and the oral sex occurred only 10 hours before I started feeling symptoms. Can a person get HSV-2 orally, and would he have recurrences in his mouth? Would the oubreaks stay oral or can they manifest genitally?
Yes, a person can get HSV 2 orally, though not common, and if that happened, he would be virtually vaccinated against genital infection. They would stay oral only and he would have rare recurrences.

4) If he does contract HSV-2 from me, either genital or oral, when would he be likely to experience symptoms (if at all)? Within a few days? A couple of weeks? I want to know when I can start breathing normally again… I know that he can get tested, but that would have to wait some weeks to be accurate
IF he was going to experience symptoms, it would likely be within 2-10 days of the encounter you describe.

In my opinion, he should be tested now if he has not already been tested. He may also be infected and not know it and then you wouldn’t have anything to worry about, right? Maybe he has already been tested and you just didn’t mention it but that is always my first recommendation in these situations.

Terri

[anon777]

Thank you Terri, that was really helpful information. We’re past 10 days now and no symptoms from my partner, so I’m feeling good about that. He hasn’t been tested before but is in the process of getting that done.

In the meantime, I had my dr. change my valacyclovir prescription to 1g, once per day (from 500mg). I’ve been on this increased dose for about a week. (Previously, for several years, I had taken acyclovir to treat outbreaks, which were mild and occurred only a few times per year; I switched to valacyclovir only in the last month with this new relationship, for preventive use). The outbreak I was worried about when I first contacted you went away after a few days as expected. The disconcerting thing is that today I am feeling another similar outbreak to the one 2 weeks ago. I have a red bump, not a cold sore, but it is tender to the touch, on a different part of my labia than last time. Since my partner and I haven’t had sexual contact in almost 2 weeks, sex was not a triggering event this time. But I’m shocked that with daily valacyclovir dosing, and no missed dosed, I’ve had 2 outbreaks in 2 weeks when in previous year I’ve gone many many months without any. My outbreaks are mild, to be sure, but my major concern is for my partner.

Is it possible that valacyclovir just doesn’t work for me, even though acyclovir seems to? I am aware that the active form of valacyclovir is indeed acyclovir, so they are effectively the same drug, but that valacyclovir is a masked form that reacts in the body to release acyclovir. Maybe I lack the enzyme to unmask the active form? I’ve never heard of such a thing.

Thanks again for your help.

[Terri Warren]

I’ve never heard of such a thing either really. Sometimes I think it is helpful for patients who seem to be having more outbreaks or outbreaks in clusters, to up their dose substantially for a little while, like a month or two, an see if they can knock back the virus a bit. That’s something you could run by your health care provider. Has this partner been tested yet to know if he might be infected and not know it?

Terri

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