Sexual Activity with Partner with Genital Herpes
If you have a partner with genital herpes, the infected partner should take daily suppressive valacyclovir 500 mg once daily, which reduces transmission risk by approximately 48-50%, and you should use condoms consistently, which provides additional protection—though neither strategy eliminates transmission risk entirely. 1, 2, 3
Understanding Transmission Risk
The most critical concept to grasp is that genital herpes transmits primarily during asymptomatic periods when no visible lesions are present—this is how most transmission occurs, not during obvious outbreaks. 3, 4 The CDC emphasizes that asymptomatic viral shedding is the predominant mode of HSV-2 spread, making it impossible to rely solely on avoiding sex during visible outbreaks. 3
Key Facts About Transmission:
- Only 13% of HSV-2 infected persons have been diagnosed, meaning most people don't know they have it 5
- Asymptomatic shedding occurs more frequently with HSV-2 than HSV-1 genital infections 3
- HSV-1 genital infections recur much less frequently than HSV-2 and are clinically less severe 1
Evidence-Based Prevention Strategy
Primary Intervention: Daily Suppressive Therapy
The infected partner must take valacyclovir 500 mg once daily as the single most effective intervention for reducing transmission. 1, 2, 3 This approach:
- Reduces transmission to uninfected heterosexual partners by 48-50% 1, 2, 6
- Reduces symptomatic disease in the susceptible partner by 75% 2, 3
- Decreases asymptomatic viral shedding from 10.8% of days to 2.9% of days 3
- Reduces recurrence rates from 0.40 to 0.11 per month 3
Critical caveat: Episodic treatment (taking antivirals only during outbreaks) does NOT reduce transmission risk to partners—only daily suppressive therapy has this effect. 2, 3
Secondary Intervention: Consistent Condom Use
Use latex condoms for every sexual encounter, as the CDC confirms this reduces HSV-2 acquisition in both directions (women to men and men to women). 1, 2, 3 However, understand that condoms reduce but do not eliminate transmission risk because HSV can be present on skin not covered by condoms. 2, 3
Behavioral Modifications:
- Avoid all sexual contact when visible genital or orolabial lesions are present 2, 3, 4
- Learn to recognize prodromal symptoms (tingling, itching, burning) that precede visible lesions and avoid contact during these periods as well 3
- Understand that even with both suppressive therapy and condoms, transmission can still occur 3
Partner Testing and Communication
Before initiating sexual activity, the uninfected partner should request that the infected partner undergo type-specific serologic testing to confirm whether the infection is HSV-1 or HSV-2. 2 This distinction has important prognostic value:
- HSV-1 genital infections recur significantly less frequently than HSV-2 1
- Type-specific identification helps with accurate counseling about transmission risk 1
Both partners must receive comprehensive counseling about the natural history of HSV, including the potential for asymptomatic transmission, as this is essential for informed decision-making. 2, 3
Special Populations
Women of Childbearing Age:
Any woman with genital herpes must inform obstetric providers during pregnancy due to risk of neonatal infection. 2, 3 The CDC recommends antiviral prophylaxis starting at 36 weeks of gestation. 7, 8
HIV-Infected Individuals:
Suppressive therapy does NOT reduce HSV-2 transmission from or to HIV-seropositive persons, according to the CDC. 2 Additionally, HSV-2 infection increases HIV acquisition risk 3-fold. 5
Common Pitfalls to Avoid
Do not assume that avoiding sex only during visible outbreaks is sufficient—the majority of transmission occurs during asymptomatic periods. 3
Do not rely on episodic treatment for transmission prevention—only daily suppressive therapy reduces transmission risk. 2, 3
Do not assume condoms provide complete protection—they reduce but do not eliminate risk. 2
Do not delay treatment initiation—if the infected partner experiences a recurrence, antiviral therapy should begin at the first sign or symptom, ideally within 24 hours. 4, 9
Medication Considerations
The FDA-approved valacyclovir labeling confirms that valacyclovir is not a cure for genital herpes and that transmission can occur even with treatment. 4 Patients should maintain adequate hydration while on therapy. 4, 9 There are no data on the safety or effectiveness of chronic suppressive therapy beyond 1 year in otherwise healthy patients. 4