Can you transmit Herpes Simplex Virus (HSV) 2 without visible lesions?

HSV-2 Can Be Transmitted Without Visible Lesions

Yes, HSV-2 can definitely be transmitted in the absence of visible lesions through asymptomatic viral shedding. 1 This is one of the primary reasons why genital herpes continues to spread widely despite awareness of the disease.

Transmission Mechanisms

HSV-2 transmission without visible lesions occurs through:

1. Asymptomatic viral shedding:

   • HSV-2 can be shed from genital surfaces even when no symptoms are present
   • Many cases of genital herpes are transmitted during these asymptomatic periods 1
   • The virus can be present on mucosal or skin surfaces without causing noticeable symptoms

2. Subclinical infections:

   • 80-90% of genital herpes infections progress subclinically 1
   • Infected individuals may be unaware they carry the virus
   • These asymptomatic carriers represent a significant reservoir for transmission

Risk Reduction Strategies

To reduce transmission risk when no lesions are present:

• Consistent condom use: Latex condoms reduce HSV-2 acquisition from women to men and from men to women 1

• Suppressive antiviral therapy:

  • Daily suppressive therapy (valacyclovir 500mg once daily) reduced HSV-2 transmission to susceptible heterosexual partners by 50% 1
  • For those with frequent recurrences, suppressive therapy with valacyclovir 500mg twice daily is recommended for HIV-infected persons 1, 2

• Partner testing: HSV-2-seronegative individuals should ask partners to be tested using type-specific serology before initiating sexual activity 1

• Disclosure: Informing partners about HSV-2 status has been associated with reduced transmission risk 1

Important Clinical Considerations

1. Asymptomatic shedding patterns:

   • HSV-2 can spread locally within genital epithelium extremely rapidly (within hours) 3
   • Even without visible lesions, thousands of epithelial cells can be infected in <12 hours 3

2. Testing limitations:

   • Clinical diagnosis without laboratory confirmation is unreliable, especially in HIV-positive patients 1
   • PCR is the most sensitive method for detecting HSV in genital specimens 1
   • Type-specific serologic assays can identify asymptomatic carriers 1

3. Special populations:

   • HIV-infected individuals have higher rates of HSV-2 seropositivity (approximately 70%) 1
   • Immunocompromised patients may have more frequent asymptomatic shedding 2
   • Pregnant women should be counseled about the risk of transmission during pregnancy and delivery 1

Common Pitfalls in Managing Transmission Risk

1. Assuming no risk without lesions: Many healthcare providers and patients incorrectly believe transmission only occurs during symptomatic episodes

2. Inadequate counseling: Patients should be explicitly informed that genital herpes is frequently transmitted in the absence of symptoms through asymptomatic viral shedding 1, 4

3. Relying solely on episodic treatment: While episodic treatment helps with symptoms, it does not reduce asymptomatic shedding or transmission risk as effectively as suppressive therapy 1

4. Ignoring type-specific testing: Type-specific serologic testing should be considered for accurate diagnosis, as HSV-1 recurs less frequently than HSV-2 in the genital area 1

The evidence clearly demonstrates that HSV-2 transmission commonly occurs during periods without visible lesions, highlighting the importance of preventive measures beyond simply avoiding contact during symptomatic outbreaks.