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STDs (Expert Forum)
Herpes / asymptomatic shedding concern
Answered by
University of Washington
Seattle - WA
This forum is for questions and support regarding STD issues such as: Chlamydia, Crabs (pubic lice scabies), Gonorrhea, Hepatitis (viral), Herpes, HPV, Molluscum Contagiosum, PID, Rectal Infections, Syphilis, Trichomoniasis, Warts, Yeast Infection.All questions will be answered by H. Hunter Handsfield, M.D. or Edward W Hook, MD.
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Herpes / asymptomatic shedding concern
by Halifax1, Feb 10, 2007 12:00AM
3 years ago I had a brief sexual relationship with a woman. After a week, I noticed small white spots on my penis; single, scattered over the shaft, and around 6 or 8 in total after a couple more days. They would open in the shower, and were quite uncomfortable.
My doctor could only tell me "Its definitely something." He prescribed me cream and sent for blood/swab tests, which were negative. The spots healed within 2 weeks.
2 months later, I had a more severe outbreak of what seemed to be these same spots, except they formed in a cluster. My doctor told me this now looked like herpes. He said that he hadn't requested a herpes test before because the previous episode didn't look like herpes.
I’ve been on acilovir (2x400mg/day) since then, as I have recurrence with 2-4 weeks. I want to start a new relationship, but I'm concerned that my dependence on aciclovir means I might be more prone to asymptomatic shedding. Even on aciclovir, I occasionally experience some redness and irritation of the foreskin, ridge and head area, although no actual lesions appear.
So 2 parts to my question:
1) Does my description of the initial spots sound like it could have been an initial show of herpes, and may have just been missed by my doctor? What else could it have been? This is important for my peace of mind.
2) Given my susceptibility to recurrence and dependence on aciclovir, can I have a normal sexual relationship and be confident that I am unlikely to pass on the infection? Is there anything I can do to reduce or mitigate the risk of asymptomatic shedding?
My doctor could only tell me "Its definitely something." He prescribed me cream and sent for blood/swab tests, which were negative. The spots healed within 2 weeks.
2 months later, I had a more severe outbreak of what seemed to be these same spots, except they formed in a cluster. My doctor told me this now looked like herpes. He said that he hadn't requested a herpes test before because the previous episode didn't look like herpes.
I’ve been on acilovir (2x400mg/day) since then, as I have recurrence with 2-4 weeks. I want to start a new relationship, but I'm concerned that my dependence on aciclovir means I might be more prone to asymptomatic shedding. Even on aciclovir, I occasionally experience some redness and irritation of the foreskin, ridge and head area, although no actual lesions appear.
So 2 parts to my question:
1) Does my description of the initial spots sound like it could have been an initial show of herpes, and may have just been missed by my doctor? What else could it have been? This is important for my peace of mind.
2) Given my susceptibility to recurrence and dependence on aciclovir, can I have a normal sexual relationship and be confident that I am unlikely to pass on the infection? Is there anything I can do to reduce or mitigate the risk of asymptomatic shedding?
Doctor's Answer
by H. Hunter Handsfield, M.D., Feb 10, 2007 12:00AM
, Feb 10, 2007 12:00AM
From your description, herpes certainly is possible. But it certainly isn't definite. There are two ways to know for sure: 1) Stop taking acyclovir, and the next time symptoms recur, see a herpes-knowledgeable provider within 1-2 days of onset for a viral culture. If positive, herpes will be confirmed without doubt, although a negative result will not rule it out, because the culture misses some cases. 2) Have a blood test for antibody to HSV-2 (and preferably HSV-1 as well). If positive, especially for HSV-2, it will confirm the diagnosis. The advantage of this approach, of course, is that you don't have to wait for an outbreak.
Until there is confirmation of the diagnosis, it is not possible to clearly answer your questions. But the answer to no. 2 is yes, most people with genital herpes can have normal, healthy sexual relationships. You already know the main way to reduce viral shedding, i.e. antiviral therapy with acyclovir or its relatives, valacyclovir (Valtrex) or famciclovir (Famvir). However, you still will be ethically obligated to inform any and all future sex partners that you have genital herpes.
Bottom line: Return to your doc and talk about the necessary diagnostic tests.
Best wishes-- HHH, MD
Until there is confirmation of the diagnosis, it is not possible to clearly answer your questions. But the answer to no. 2 is yes, most people with genital herpes can have normal, healthy sexual relationships. You already know the main way to reduce viral shedding, i.e. antiviral therapy with acyclovir or its relatives, valacyclovir (Valtrex) or famciclovir (Famvir). However, you still will be ethically obligated to inform any and all future sex partners that you have genital herpes.
Bottom line: Return to your doc and talk about the necessary diagnostic tests.
Best wishes-- HHH, MD
grace
The basic strategies to reduce the risk of genital herpes transmission are 1) be careful to avoid sex when symptomatic, including that first day or two when you might only have a mild tingle or itch before lesions appear; 2) use condoms; and 3) take antiviral therapy. Valacyclovir (Valtrex) has been the most carefully studied, and has the advantage of requiring treatment only once a day. (Acyclovir probably works well if twice daily treatment isn't a problem for you, and it is quite a bit less expensive than valacyclovir.) As I said above, even with careful precautions, you need to inform any future partners you are infected before having sex with them.
HHH, MD
So assuming that I eventually achieve a long-term relationship where no precautions are taken, how likely is it that we will be able to sustain an active sexual relationship without her being infected? If it was me, that's what I'd be asking, and its the main thing I don't already know. How infectious is asymptomatic shedding?
And just out of curiosity, did my first experience sound like that could have been the first outbreak of herpes that was just not recognised by my Doctor? This question is really just for my own peace of mind. If that wasn't my point of infection, I wouldn't know what might have been..
The questions you ask about preventing transmission require more than quick advice from me or any other source. I suggest you follow up with your provider, and read the voluminous herpes information available at various places, such as CDC (www.cdc.gov/std), the American Social Health Association (www.ashastd.org), or the Westover Heights Clinic (Portland, OR) (www.westoverheights.com). Also, ASHA has a telephone counseling service.
HHH, MD
Best regards.