Yes, Genital Herpes Can Be Transmitted Without Active Lesions
Genital herpes is frequently transmitted during asymptomatic periods through viral shedding, even when no visible lesions or symptoms are present. 1, 2, 3
Understanding Asymptomatic Transmission
The CDC explicitly states that sexual transmission of HSV can occur during asymptomatic shedding, which is a critical concept for patient counseling. 1 This asymptomatic viral shedding occurs more frequently in:
- Patients with HSV-2 infection compared to HSV-1 genital infection 1
- Patients who have had genital herpes for less than 12 months 1
- The majority of HSV transmissions actually occur when infected persons shed virus but lack visible lesions 4
Research demonstrates that HSV-2-seropositive men have a total viral shedding rate of 5%, with a subclinical (asymptomatic) shedding rate of 2.2%. 4 Among 79 men studied, 81% shed virus at least once, confirming that viral shedding is common even without symptoms. 4
Risk Reduction Strategies
For Uninfected Partners
Partners should avoid sexual contact when visible lesions are present, but must understand this alone does not eliminate transmission risk. 1 The CDC recommends:
- Consistent latex condom use reduces HSV-2 acquisition from women to men and from men to women 1, 5
- Request that sexual partners undergo type-specific serologic testing before initiating sexual activity 1, 5
- Understand that genital herpes can be transmitted in the absence of symptoms through asymptomatic viral shedding 2, 3
Suppressive Therapy for Infected Partners
Suppressive antiviral therapy with valacyclovir 500 mg once daily in the infected partner reduces HSV-2 transmission to susceptible heterosexual partners by 48-50%. 1, 5 This represents the most effective pharmacologic intervention to reduce transmission risk during asymptomatic periods, though it does not eliminate risk entirely. 1
Critical Counseling Points
Patients must be counseled that:
- HSV is not cured by antiviral therapy 2, 3
- Transmission can occur even when using condoms and suppressive therapy 1, 5
- Safer sex practices should be used in combination with suppressive therapy 3
- Sex partners of infected persons should be advised they might be infected even if they have no symptoms 3
Common Pitfall to Avoid
The most dangerous misconception is that transmission only occurs during visible outbreaks. Most sexual transmission of genital herpes occurs when persons shed virus but lack lesions. 4 Patients who believe they are only infectious during outbreaks will unknowingly transmit infection during asymptomatic periods, which account for the majority of new infections. 6, 4