Herpes – a complicated primer

When I tell people that I teach sex education, I often get a response along the lines of, “Well there isn’t really much to teach, is there?”  But the thing is, this content often IS complicated.  Perhaps at first glance the physical act of penile-vaginal intercourse is relatively straightforward, but many other things just aren’t.  Sexual arousal and pleasure (especially female arousal and pleasure), for example, are not straightforward even to scientists who have dedicated their careers to understanding this aspect of the human physiology.  Today I’m going to talk about herpes, which is so far from clearly explained in the education, medical, or popular media/news that it is often difficult to get any clear answers.

Here are the very basics about herpes: There are two strains: HSV1 and HSV2.  Typically HSV1 is thought of as oral herpes and HSV2 is thought of as genital herpes.  I spoke with a pharmacist yesterday who had only this level of knowledge, which suggests to me that this is the place where it starts to get complicated.

If you want to skip the details, drop down to the bottom of this post – I have a few bullet points that summarize the rest of the material relatively effectively.

While both of these herpes strains have their site of preference, as noted above, either can be present around the mouth or around the genitalia.  This means there is oral HSV1, genital HSV1, oral HSV2, and genital HSV2.  I am going to talk about the two strains (HSV1 and HSV2) separately and address both potential sites of infection for each strain.

Before we get to the specifics of the different strains, here are a few more details that we need to know: Herpes is a virus – this means we cannot cure it.  We do have anti-viral medication that can reduce outbreaks and shedding of the virus (which makes the individual more contagious), but the individual is still contagious even while taking an anti-viral.  Once you contract herpes of either sort, you have it for the rest of your life regardless of whether you have outbreaks or not.  In fact, 2/3 of all people who have herpes do not have outbreaks!  Combine this with the fact that STI testing usually does not include a herpes test unless the individual specifically requests it, and you have a situation where transmission is incredibly common!

HSV1

HSV1 typically expresses around the mouth and is often referred to as cold sores.  Most people don’t think twice about having cold sores around their mouth – while annoying, they’re just considered part of life.  But let me be very clear about this: cold sores = herpes.  A vast majority of the population has oral HSV1 – most people contract it as a child.

When HSV1 is an oral infection, it can reoccur relatively frequently depending on the individual’s immune system response, stress level, etc.  However, outbreaks tend to decrease in frequency and severity as the individual ages and their immune system becomes more effective at reducing the viral load in the body.  Cold sores are not generally considered a reason to alter sexual relationships or experiences.  However, HSV1 can and is transmitted sexually just like HSV2, either through kissing or oral sex.  HSV1 is more typically transmitted from an oral infection to a genital infection rather than genital-to-genital transmission.  When HSV1 is a genital infection, there is often only one outbreak.

HSV1 can be transmitted regardless of the presence or absence of a current outbreak, regardless of the safe sex measures, regardless of antiviral medication, and to either another individual’s oral or genital area.  Of course an individual will be more likely to contract HSV1 from their partner if they are having an outbreak, if there is not a condom or dental dam in use, or if the infected partner is not on antivirals.

Moving on to HSV2, which is closely tied to HSV1…

HSV2

HSV2 typically expresses around the genitalia, but it can be an oral infection.  HSV2 is less common than HSV1 because so many people contract HSV1 in childhood and this gives them an increased level of immunity to HSV2.

When HSV2 is a genital infection it can have a frequency of outbreak similar to oral HSV1 and is dependent on immune system functioning just like HSV1.  As an oral infection, HSV2 is less likely to reoccur as frequently, just like a genital HSV1 infection is less likely to reoccur.  People are much more likely to get type-tested for HSV1 or HSV2 when the outbreak is genital and are also much more likely to take antiviral medication when compared to oral outbreaks, regardless of the type.

The same transmission issues apply with HSV2, only focused more on genital-to-genital transmission than oral transmission of any kind.

HSV1 and HSV2 are incredibly similar – you can’t distinguish the two under a microscope.  Regardless of their similarity, HSV2 carries an intense social stigma that HSV1 simply doesn’t have.  My hypothesis is that this is due to three factors: 1. anything about our genitals squeeks Americans out and raises the gross factor immeasurably, 2. lots of people have oral herpes and we know this because we can see, but we can’t see how many people have genital herpes, so we stigmatize it, and 3. there is a common misconception that oral herpes and genital herpes are different even though they’re not.

So let me stress a few final points:

• Most people have herpes, but just aren’t expressing it and never have.
• A full STI panel rarely tests for herpes, so if you want to know, be sure and ask for it specifically.  However, you won’t be able to get type tested unless you have an outbreak.
• That means the people who you have a good talk with about their STI history probably don’t know if they have herpes.
• Herpes really isn’t that big of a deal.  Yeah, you’ll have it for life.  But people don’t freak out when you call it “cold sores,” so why freak out when you call it “herpes”?  They’re the same thing.

Leave questions in the comments!  I’ll try and get to them.