Is there any benefit to treating herpes when someone has no symptoms?

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Question: Is there any benefit to treating my herpes if I rarely or never have symptoms? If I'm not using it to prevent outbreaks, is suppressive therapy worth it? 

Answer: Even if you don't ever have herpes outbreaks, there may be some benefit to using daily suppressive therapy. This is because even people who have never had a recognizable outbreak can transmit the virus to their partner.

Some people think they can only transmit herpes to their partner if they have an outbreak, or in the prodromal periods immediately before right after an outbreak.

They're wrong. Genital herpes can be transmitted at any time. This is why some individuals who have multiple sexual partners may decide to use suppressive therapy against HSV. People whose partners are not infected with the herpes virus may choose to do so as well, even though they do not have any symptoms.

Herpes can be transmitted at any time. However, people with herpes are not equally infectious at all times. In general, a person is most infectious during an outbreak. They're also highly infectious in the period immediately before and after an outbreak. Finally, they're most infectious in the first year after they are infected. However, they still can transmit the virus at other times. That's true ever if they haven't had an outbreak in years.

Furthermore, it's not just about being infectious when outbreaks aren't present. Some people don't even recognize when they are having an outbreak!

One study of 53 individuals who tested positive for genital herpes but who had said they did not actually have outbreaks looked at just that question. What did they find? Half of them actually were having outbreaks but didn't realize it. However, even those people who were right about their lack of outbreak were still infectious.

Six out of seven of the individuals who had no signs of clinical herpes were still found to be shedding virus.

Unfortunately, many patients and many physicians, are unaware of  the risk of asymptomatic transmission of herpes. Fortunately, suppressive treatment can be very effective in preventing it. You may just need to update your doctor on that news. If you are living with herpes and have one or more uninfected sexual partners, consider discussing the possible advantages of daily suppressive therapy with your doctor. Condoms aren't 100% effective at preventing the spread of herpes, since it is transmitted from skin to skin. Therefore, don't let your doctor gives you any grief. Instead, remind them that 70% of new herpes infections are acquired from people who have no symptoms at the time of transmission. Then let them know that suppressive therapy has been shown to reduce the likelihood of transmission by half or more. In other words, for some people, it's a very good idea.

Note: Suppressive therapy isn't 100 percent effective at eliminating asymptomatic shedding. That is particularly true for people with frequent outbreaks. As such, is no substitute for condom use. However, using medication and safe sex together may be the best way to protect your partner from your genital herpes infection.As a friend of mine likes to say... "Embrace the power of AND." 

Sources:

Wald et al. "Standard-dose and high-dose daily antiviral therapy for short episodes of genital HSV-2 reactivation: three randomised, open-label, cross-over trials." Lancet. Available online 4 January 2012
Corey L et al. "Once-daily valacyclovir to reduce the risk of transmission of genital herpes." N Engl J Med. 2004 Jan 1;350(1):11-20.
Romanowski B, Zdanowicz YM, Owens ST. "In search of optimal genital herpes management and standard of care (INSIGHTS): doctors' and patients' perceptions of genital herpes." Sex Transm Infect. 2008 Feb;84(1):51-6.
Wald, A. et al. "Reactivation of Genital Herpes Simplex Virus Type 2 Infection in Asymptomatic Seropositive Persons" N Engl J Med. 2000 342:844-850.

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