Can a 64-Year-Old Woman with HSV-2 Resume Sexual Activity Without Active Lesions?
Yes, she can resume sexual activity, but she remains capable of transmitting HSV-2 to her partner even without active lesions or symptoms through asymptomatic viral shedding. 1
Understanding Transmission Risk Without Active Lesions
Sexual transmission of HSV occurs during periods without evidence of lesions, and many cases are transmitted during these asymptomatic periods. 1 This is a critical concept that distinguishes HSV-2 from many other sexually transmitted infections—the absence of symptoms does not mean absence of transmission risk.
- Asymptomatic viral shedding occurs frequently in persons with HSV-2, even when they have no visible lesions or prodromal symptoms 1, 2
- The virus can be detected throughout the genital tract during these asymptomatic periods 2
- Women transmit HSV-2 to male partners at a rate of 8.9 per 10,000 sex acts, even with counseling and awareness 3
Risk Reduction Strategies That Actually Work
Condom Use
Consistent condom use during more than 25% of sexual encounters provides significant protection, reducing HSV-2 transmission to female partners by approximately 91% (adjusted HR 0.085). 3 However, condoms provide only partial protection because HSV-2 can be shed from areas not covered by condoms 1.
Suppressive Antiviral Therapy
Daily suppressive therapy with valacyclovir 500 mg once daily reduces HSV-2 transmission to susceptible heterosexual partners by 50%. 1 This represents the single most effective intervention for reducing transmission risk beyond abstinence.
- Suppressive therapy does not totally eliminate asymptomatic viral shedding or the potential for transmission 1
- The combination of suppressive therapy plus condom use provides the greatest protection 1
- For this 64-year-old woman, valacyclovir 500 mg once daily would be the recommended suppressive regimen 4
Partner Disclosure and Counseling
Knowledge that a partner has genital herpes significantly protects against HSV-2 acquisition (hazard ratio 0.48), likely because it enables informed decision-making about sexual activity timing and barrier methods. 5
Specific Recommendations for This Patient
She Should:
- Inform her partner about her HSV-2 status before resuming sexual activity 1, 4
- Consider daily suppressive therapy with valacyclovir 500 mg once daily to reduce transmission risk by 50% 1, 4
- Use condoms consistently during all sexual encounters for additional protection 1
- Abstain from sexual contact if she develops any prodromal symptoms (tingling, burning) or visible lesions 1, 4
Her Partner Should:
- Undergo type-specific HSV-2 serologic testing to determine if already infected (many persons have asymptomatic infection) 1
- Understand that transmission can occur even with all precautions in place 1, 4
- Be counseled that they might become infected even if no symptoms ever develop 4
Critical Pitfalls to Avoid
Do not tell this patient she cannot have sex or that she must wait for some arbitrary period. The evidence clearly shows that timing of sexual activity based on absence of lesions alone does not eliminate transmission risk, since most transmission occurs during asymptomatic periods 1.
Do not falsely reassure that condoms alone provide complete protection. While condoms reduce transmission risk significantly in women receiving virus from men, they provide only partial protection because HSV-2 sheds from areas beyond what condoms cover 1, 3.
Do not overlook the option of suppressive therapy. Many clinicians only discuss episodic treatment, but for someone concerned about transmission, daily suppressive therapy represents the most effective medical intervention available 1, 4.
The Bottom Line on Safety
She is "okay to have sex" in the sense that sexual activity is medically permissible, but she will always remain a potential source of infection to her partner 1, 4. The goal is risk reduction, not risk elimination. The combination of partner disclosure, daily suppressive antiviral therapy, and consistent condom use provides the maximum protection currently achievable, reducing but not eliminating transmission risk. 1, 3