Do patients with a history of Herpes Simplex Virus type 2 (HSV-2) outbreaks shed the virus continuously throughout the day?

Viral Shedding Pattern in HSV-2 Infection

No, patients with HSV-2 do not shed virus continuously throughout the day—viral shedding is intermittent and unpredictable, occurring on approximately 3-5% of days in immunocompetent individuals, though most transmission happens during these asymptomatic periods. 1, 2

Understanding Asymptomatic Viral Shedding

Viral shedding occurs episodically, not continuously:

• HSV-2 shedding happens on approximately 3% of days when measured by viral culture in immunocompetent individuals 1
• More sensitive PCR testing reveals viral DNA can be detected on up to 28% of days, though this doesn't necessarily mean infectious virus is present 3
• In HSV-2 seropositive persons without recognized genital herpes history, subclinical shedding still occurs on about 3.0% of days 2
• The shedding rate is similar between those with symptomatic disease (2.7% of days) and those without recognized symptoms (3.0% of days) 2

Critical Clinical Implications

Most transmission occurs during asymptomatic periods:

• The majority of horizontal and vertical HSV-2 transmission happens during unrecognized or asymptomatic shedding episodes 1
• Sexual transmission has been documented to occur during periods without visible lesions 4
• Many HSV-2 infected persons (72% in one study) who report no history of genital herpes still shed virus asymptomatically 2

Asymptomatic shedding is more frequent with HSV-2 than HSV-1:

• Patients with genital HSV-2 infection experience more frequent asymptomatic viral shedding compared to those with HSV-1 genital infection 4
• Shedding occurs more frequently in patients who have had genital herpes for less than 12 months 4

Impact of Suppressive Therapy on Shedding

Antiviral suppression dramatically reduces but does not eliminate shedding:

• Valacyclovir 1g daily reduces asymptomatic shedding by 71% (from 5.1% to 1.5% of subclinical days) 5
• Suppressive treatment does not totally eliminate symptomatic or asymptomatic viral shedding or the potential for transmission 4
• 84% of patients on valacyclovir had no detectable shedding versus 54% on placebo 5

Counseling Patients About Transmission Risk

Patients must understand the unpredictable nature of shedding:

• Asymptomatic viral shedding can occur at any time, making transmission possible even without visible lesions 4
• Patients should abstain from sexual activity when lesions or prodromal symptoms are present 4
• Condom use should be encouraged during all sexual exposures with new or uninfected partners, as shedding can occur unpredictably 4
• Patients should inform sex partners about their HSV-2 infection given the risk of asymptomatic transmission 4, 6

Common Pitfalls to Avoid

• Don't assume absence of lesions means no transmission risk—most transmission occurs during asymptomatic periods 1
• Don't tell patients suppressive therapy eliminates transmission risk—it reduces but does not eliminate viral shedding 4
• Don't overlook counseling for "asymptomatic" patients—62% of those reporting no genital herpes history eventually recognize typical lesions after education 2