Herpes Virus (HSV)#

Herpes is a virus that is passed to people through sexual and non-sexual contact. In many cases, herpes transmission occurs in childhood, either from a parent to a child (sharing a drink or a kiss when a family member has an active cold sore). It is also commonly passed through sexual contact, including kissing.

There are two herpes simplex viruses - HSV-1 and HSV-2. Both can cause either cold sores or genital herpes. The labels 'oral' and 'genital' refer to where on the body the infection appears, not which virus type caused it. Historically, people with genital outbreaks usually had HSV-2 and people with cold sores usually had HSV-1, but a growing share of genital infections are now caused by HSV-1. HSV-2 tends to cause more frequent symptomatic outbreaks than HSV-1, but the two viruses are nearly identical at the genetic level.

No. Both are caused by viruses in the same broad family (the Herpesviridae family), but they are different viruses with different behaviour:

• HSV (herpes simplex virus) causes cold sores and genital herpes. Outbreaks come and go in the same general area over time.
• VZV (varicella-zoster virus) causes chickenpox initially and, decades later, can reactivate as shingles - a painful, banded rash that follows a nerve pathway, usually on one side of the body.

Antiviral medications used for HSV can also treat shingles, but the conditions are distinct. A shingles vaccine exists for adults aged 50+; no licensed vaccine for HSV is available in clinical practice at this time.

The herpes virus is very common - more common than most people think. A 2003 study of 1,500 adults in Ontario found that by age 44, approximately 70% of adults tested positive for HSV-1, and 20% were positive for HSV-2. By age 25, approximately 40-50% of adults had tested positive for HSV-1.

The 2003 Ontario study remains a commonly cited Canadian seroprevalence reference, and more recent data continues to support similar patterns. The key takeaway: most adults who carry HSV have no idea they have it.

Herpes can vary in severity between very mild outbreaks that are barely noticeable and others that are very painful and debilitating. Symptoms include:

• Burning, tingling, or itching in the area before the rash appears (prodromal symptoms).
• A blistering rash that often groups in clusters; blisters may break, crust, and heal over 1-2 weeks.
• Burning when urinating if the rash is in the genital area.
• Swollen lymph nodes in the nearby area (groin for genital outbreaks; jaw/neck for cold sores).
• Fever and muscle aches, especially during a first outbreak.
• Changes in vaginal discharge in some patients.

First outbreaks are typically the most severe; later outbreaks are usually milder and shorter.

Most people who have genital herpes don't know they have the infection because they have mild, short-lived, or no symptoms at all, or they think the symptoms are due to another condition (e.g., yeast infection, boils, bug bites, friction burns). Many people who test positive for the herpes virus acquired it in childhood and cannot remember ever having symptoms.

A person can contract HSV by receiving oral sex, having genital-genital contact, or using sex toys with someone with either HSV-1 or HSV-2.

• If your partner has HSV-1 cold sores and performs oral sex on you, you can contract genital HSV-1 herpes.
• If your partner has HSV-2 genital herpes and you have genital-genital contact/sex, you can contract genital HSV-2 herpes.
• If your partner has HSV-2 genital herpes and you perform oral sex, you can contract oral HSV-2 herpes.

Condoms, if used consistently and correctly, will reduce - but will not eliminate - the risk of HSV transmission or acquisition. They need to protect or completely cover the infected area or the area of potential exposure. They can also be used as a barrier for oral-genital sex if your partner has a history of cold sores.

Daily suppressive antiviral medication taken by a patient with genital HSV-2 has been shown in studies to reduce transmission to a susceptible heterosexual partner by about 48%. The protective effect of condoms and suppressive antiviral therapy is likely additive.

No - this is one of the most common myths about herpes. The virus does not survive well outside the body on dry surfaces, and transmission requires close skin-to-skin contact with the area where the virus is active (a cold sore, a genital lesion, or skin shedding the virus asymptomatically).

• Toilet seats: the virus does not survive on hard, dry surfaces long enough to transmit. It's not a real risk.
• Shared drinks, utensils, lipstick: very low risk in practice. Theoretically possible during an active cold sore if shared immediately, but rarely reported in real life.
• Towels: very low risk; the virus needs moisture and warmth to remain viable.
• Hot tubs / swimming pools: no documented transmission - chlorinated water and skin barriers prevent it.

Herpes is overwhelmingly transmitted through intimate skin-to-skin contact (kissing, oral sex, genital contact, sex toys).

Yes. Herpes is transmitted through close skin-to-skin contact. If you have had cold sores (one HSV strain) and have sexual contact with someone whose genital area is shedding the virus (of a different HSV strain), you can develop a genital outbreak. Herpes antibodies are only partially protective against the same strain of herpes, not against a different strain.

Transmission is highest during a visible outbreak (rash, burning, tingling, pain), but it is now well-understood that most HSV transmission actually occurs without any symptoms.

This is called asymptomatic shedding - the virus is briefly present at the skin's surface without causing a visible rash. Some details:

• Almost 75% of shedding episodes happen without symptoms.
• Approximately 50% of shedding episodes last less than 12 hours, so you may shed the virus and not be aware.
• This is one of the main reasons partner transmission can happen even between long-term couples who have never seen a visible outbreak.

In short: a partner with herpes can transmit the virus when they look and feel completely well.

The herpes virus can survive outside the body on surfaces for a few hours to up to 8 weeks. The virus is, however, easily inactivated by keeping it at temperatures >56°C for 30 min, microwaving for more than 4 minutes, or exposure to a pH of < 4 (vinegar or lemon juice).

Routine herpes blood testing is generally not recommended in patients without symptoms or a specific clinical reason - see "5 reasons not to test for herpes" below for the rationale. There are specific scenarios (your partner has confirmed herpes, you've had a rash that swabs missed, you've had a known exposure) where blood testing can be useful - see "When might a herpes blood test be useful?" below.

• High false-positive rate. Between 1% and 10% of people who test positive on the antibody test have never actually had a herpes infection. This means some people are told they have herpes when they don't.

• Doesn't identify the location of the infection. A positive blood test tells you that you've been infected with that strain somewhere on your body, but not where. Testing positive for HSV-2 doesn't necessarily mean you have genital herpes - for example, you could have an oral HSV-2 infection.

• Doesn't confirm if a previous rash was herpes. A positive antibody result doesn't tell you whether the genital rash or rash around your lips you had previously was herpes. It may suggest it, but no clinician can confirm the diagnosis based on a positive blood result alone.

• Can have a false-negative result. Some people have swab-confirmed herpes but still test negative on the antibody test. This provides false reassurance and can make someone think they don't have herpes when they actually do.

• Causes anxiety and stress. Because HSV-1 is so common, more than half of adults test positive. A positive antibody test - especially one that may simply reflect childhood-acquired cold sores - can create disclosure decisions and anxiety that aren't well supported by the test itself. Many patients tell us they regret testing once they understand the limits of what the result actually means.

Scenario A

Your partner has genital or oral herpes confirmed by swab (HSV-1 or HSV-2). Type-specific blood testing is useful for you because if you have antibodies to the same strain of herpes they have, you cannot acquire genital or oral herpes from them through unprotected sex because you already carry that strain. Your partner therefore does not need to be on suppressive anti-viral medication or use condoms to prevent HSV transmission.

Caveat: if your blood test is a false-positive result and you haven't actually had herpes exposure, using this information to have unprotected sex with a partner who has genital herpes can result in your acquiring a genital herpes infection. This is a low-probability event, but possible.

Scenario B

You have a history of genital herpes or cold sores confirmed by a swab or bloodwork. You're thinking about going on daily anti-viral medication to reduce the likelihood of your partner contracting herpes. Your partner can get tested to see if they already have antibodies to the same strain you have. If they do, you don't need to be on anti-viral medication for transmission prevention - they can't acquire what they already carry.

Caveat: if your partner's blood test is a false-positive result and they haven't actually had herpes exposure, using this information to have unprotected sex can result in their acquiring a genital herpes infection. This is a low-probability event, but possible.

Scenario C

You have a rash that keeps showing up around your lips or genital area. The clinicians you see have done multiple swabs and tell you they think you have herpes, but the swabs keep coming back negative. Maybe you show up too late for the swab, or maybe the sample was inadequate. You can obtain type-specific blood testing. If you're positive, it suggests that the rash you have may have been herpes (no clinician can give you a 100% guarantee that the virus is the cause, however). If your bloodwork is negative, the rash is not herpes.

Caveat: herpes antibodies can take 3-6 months to develop; if your rash is new, you need to delay your bloodwork for 6 months after the start of your rash for a clearer answer.

Scenario D

You had a confirmed case of herpes exposure through protected or unprotected sex within the last 7-14 days. You currently have no symptoms. Completing bloodwork establishes your baseline antibody status (whether you have antibodies to the herpes virus already). It takes on average 21-42 days to form IgG HSV antibodies, with most people developing IgG antibodies 21-28 days post-exposure.

You repeat testing in 180 days (there can be a theoretical delay of up to 6 months to develop IgG antibodies). If there is no change in your antibody status, that indicates you do not have a new herpes infection.

Caveat: if your baseline HSV test is positive for one of the two strains, it is possible that you are positive unrelated to recent exposure but from an infection earlier in life.

The ideal method to test for herpes is a Viral PCR (DNA) swab of a rash or area where a clinician thinks you're having an outbreak. Testing is time sensitive - ideally, an area should be swabbed within 72 hours of getting symptoms. If you swab too late, you can get a false-negative result (you had a herpes outbreak but, because you swabbed too late, the test says no herpes is present).

Labs use a specific viral transport medium (VTM) swab that looks for the DNA of HSV-1 and HSV-2. This swab is taken directly from the location where a rash has erupted (a blister on the lip or in the genital area).

Despite our requests, community labs do not currently carry the correct swab for patient pickup. The only way to obtain a viral PCR swab of a rash is to visit a clinician in person while the outbreak is occurring. It's important the clinician uses the correct swab type - swabs intended for gonorrhea/chlamydia testing are not processed by the lab for HSV DNA testing.

Self-swab kits supplied by community labs (such as the Charcoal Swab for bacterial vaginosis and yeast infections) are not the right swab type for HSV - do not try to use those.

A herpes blood test cannot tell you if you have genital herpes specifically. It only indicates you have been infected with one or both strains of the herpes virus. The infection sites may be oral, genital, or both. The only way to determine if you have genital herpes is a swab of the site at the time of an outbreak, or based on a visual diagnosis by a clinician.

An HSV swab is the most accurate way to confirm whether the cold sore or genital lesion contains herpes virus, so no further testing is normally required once you have a positive swab result.

A blood (IgG) test looks for lifelong antibodies to HSV-1 or HSV-2. However, this test cannot show when or where you were infected, and false-positives are more common if you have never had genital symptoms. Because of these limits, national guidelines do not recommend it as a routine test.

It depends on the type of test:

• Swab of an active lesion - can give a result right away (the lab is detecting viral DNA directly).
• Blood test for IgG antibodies - takes time for the body to produce a measurable antibody response. Most people develop antibodies in 21-28 days; the published range is 21-42 days. The provincial public-health laboratory notes that it can take up to 3-6 months for a small percentage of people to develop detectable antibody levels.

Testing too early on the blood test can produce a false-negative result.

A type-specific blood test tells us what strain of herpes infection you have. Our herpes testing is done through the provincial public-health lab. Having antibodies to HSV-1 and HSV-2 means you have been infected somewhere on your body (face, eyes, arms, genitals, etc.). It doesn't tell us where. The virus is dormant, waiting to be reactivated in the form of a herpes outbreak.

Currently, the provincial public-health laboratories do not report an IgG titre the way many American laboratories do. The lab only reports the test as 'reactive' or 'non-reactive'. We've called the public-health lab and asked for an IgG titre as many patients have requested it, but they do not provide such a reading.

The provincial public-health laboratories use a type-specific IgG assay for HSV-1 and HSV-2. It has a sensitivity of 96.9-98.9% (misses 1.1-3.1% of infections) and a specificity of 91.3-96.8% (false-positive rate of 3.2-9.7%). The test result can be negative early in the course of an infection, which is why we encourage repeat testing if you are symptomatic at the 6-month point.

'Reactive' is how the lab reports a positive antibody result. It means antibodies to that strain of herpes were detected in your blood - in other words, you've been infected with that strain at some point.

What it does not tell you:

• Where on your body the infection is (oral, genital, or both).
• When you were infected.
• Whether your prior symptoms (if any) were caused by herpes.

For interpretation of specific result combinations (HSV-1 only, HSV-2 only, both reactive), see "Understanding your HSV test result combinations" below.

This is the most common combination. Approximately 70% of Canadian adults are HSV-1 reactive by their mid-40s - it is one of the most common chronic viral infections in the world.

Where is the infection most likely located?

• Most often the mouth (cold sores) - HSV-1 traditionally lives in the oral area.
• Sometimes genital - a growing share of new genital herpes cases are caused by HSV-1, usually transmitted through oral sex from a partner with cold sores.
• The blood test cannot tell you which site.

How did I likely acquire it?

Many people acquire HSV-1 in childhood from a parent or family member sharing a drink, utensil, or affectionate kiss while they had a cold sore. Adult acquisition through kissing or oral sex is also common. You may not remember a specific exposure.

Have I had cold sores?

• If yes → that's almost certainly where your HSV-1 lives.
• If no → you may have had a very mild outbreak you didn't recognize, or you may simply never develop a symptomatic outbreak. Many HSV-1 carriers never have a lifetime outbreak.

Transmission considerations:

• You can pass HSV-1 to others through kissing, oral sex, or asymptomatic shedding from the area where it lives.
• Performing oral sex on a partner can transmit HSV-1 to their genital area.
• Avoid intimate contact during active outbreaks (cold sore visible, or prodromal tingling).

Should I start daily medication?

Generally, no. Routine suppressive therapy is not offered for asymptomatic HSV-1 positivity - the risk-benefit balance does not favour it for the average patient. Episodic treatment of outbreaks (when they occur) is the standard approach.

Disclosure:

• HSV-1 is so common that some clinicians and patients consider it a routine sexual-health fact rather than something requiring formal disclosure to every partner.
• However, partners may still want to know, especially if you have a history of cold sores or are planning oral sex; they can make informed decisions about precautions.

HSV-2 is less common than HSV-1 - approximately 20% of Canadian adults are HSV-2 reactive by their mid-40s. HSV-2 is almost always sexually acquired (unlike HSV-1, which is often acquired in childhood).

Where is the infection most likely located?

• Most often the genital area - HSV-2 strongly favours genital tissues. Recurrent genital herpes is more commonly caused by HSV-2 than HSV-1.
• Sometimes the mouth - oral HSV-2 is uncommon but possible (usually from receiving oral sex from a partner with genital HSV-2).
• The blood test cannot tell you which site.

Have I had symptoms?

• If you have had clear genital outbreaks → that's where your HSV-2 lives.
• If you have not noticed outbreaks → you may have had mild outbreaks you attributed to something else (yeast, UTI, friction, ingrown hair), or your body may control the virus without producing obvious symptoms. Many HSV-2 carriers have never knowingly had an outbreak.

Transmission considerations:

• You can transmit HSV-2 to a partner through sexual contact, even when you have no symptoms (asymptomatic shedding).
• Risk is highest during active outbreaks but never zero between them.
• Condom use reduces transmission but does not eliminate it.
• If your partner is also HSV-2 reactive, no transmission concern between you for HSV-2.

Should I start daily medication?

This is the scenario where daily suppressive antiviral therapy is most often considered - usually for one of two reasons:

• Frequent outbreaks (commonly 6+ per year, or severe/prolonged outbreaks).
• Transmission reduction for a partner who is HSV-2 non-reactive. Suppressive therapy reduces transmission to a susceptible partner by about 48% (taken by you, the index partner - not by the partner).

If you have neither frequent outbreaks nor a non-reactive partner you want to protect, daily suppressive therapy is generally not necessary.

Disclosure:

• Disclosure to current and future sexual partners is strongly encouraged so they can make informed decisions about precautions and consider their own testing.
• Disclosure is not legally required in Canada (unlike HIV).

This means you've been exposed to both strains at some point in your life - they can have been acquired years apart, in different ways, at different sites.

Where are the infections located?

• HSV-1 is most likely in your mouth (cold sores) but possibly in the genital area.
• HSV-2 is most likely in the genital area but possibly oral.
• You may have had outbreaks at one site, both sites, or no site - the blood test cannot localize the infections.

Transmission considerations:

• You can shed and transmit either strain, including without symptoms.
• The risk to a partner depends on their strain status:
  • Partner reactive for both strains → no transmission concern between you (you both carry both strains).
  • Partner reactive for one strain only → they can still acquire the strain they don't have from you.
  • Partner non-reactive for both strains → they can acquire either strain from you.
• Type-specific blood testing of your partner can clarify which strains they already carry.

Should I start daily medication?

Decisions are individualized:

• If you have recurrent genital outbreaks (more likely from HSV-2), suppressive therapy may be appropriate.
• If you have frequent or severe cold sores, suppressive therapy can be used for HSV-1 as well.
• If you are asymptomatic for both strains, daily medication is generally not indicated.
• For partner-transmission reduction, suppressive therapy can reduce shedding of both strains.

The same antiviral medications work for both HSV-1 and HSV-2.

Disclosure:

• Discuss both strains with current and future partners so they can decide on precautions and their own testing.
• Suggest that partners get type-specific blood testing - their result will determine what (if any) precautions are most useful.

An indeterminate result means the antibody level was detected but didn't reach the cutoff to call it a clear positive. It can mean one of two things:

• An early antibody response - if you had recent exposure or new symptoms, the antibody level is building but hasn't yet reached a confident positive. A repeat test in 12 weeks can clarify; if it converts to 'reactive', the exposure was real and developing.
• A false-positive signal - if you've had no symptoms and no known exposure, an indeterminate result is more likely a false-positive. Repeat testing may not add useful information in this case.

Your clinician will help you decide whether to repeat the test based on your history.

Most patients with a positive blood test alone do not need to start medication. Antiviral medication is generally only used in two specific situations:

• You are having an active outbreak (genital or oral). A short course of antiviral medication can shorten the outbreak and reduce symptoms.
• You're in a relationship with a partner who has not been exposed (confirmed by their bloodwork) and you want to reduce the chance of passing the virus on. You (the partner with herpes) can take daily suppressive medication to reduce transmission.

If you have no active outbreak and no partner-protection reason, you don't need to take medication just because the antibody test is positive.

• First (primary) outbreak - typically the most severe, with symptoms lasting 2-4 weeks. Lesions may be widespread, painful, and associated with fever, body aches, and swollen lymph nodes.
• Recurrent outbreaks - usually much milder and shorter, typically lasting 5-10 days from the first tingle to full healing. Frequency tends to decrease over the years after the initial infection.
• Outbreaks while on suppressive antiviral therapy ("breakthrough" outbreaks) - usually milder and shorter still.

Starting antiviral medication as early as possible in an outbreak (at the first tingling, before lesions appear) gives the best results.

A first outbreak is usually the most severe and longest. Treatment goals are to shorten the outbreak, reduce symptom severity, and prevent complications.

Typical approach:

• Oral antiviral medication for 7-10 days (longer than the 1-5 day course used for recurrent outbreaks). The clinician chooses the specific medication and dose based on your kidney function, pregnancy status, and convenience.
• Starting as early as possible - ideally within 72 hours of symptom onset - gives the best results, but treatment is still worthwhile even later.
• Supportive care (see "Supportive care during an outbreak" below) for pain and discomfort while the medication works.

When in-person evaluation is needed:

• First-ever genital outbreak - in-person assessment with a swab confirms the diagnosis and rules out other causes.
• Severe outbreaks with urinary retention, high fever, severe headache, or other systemic symptoms.

After the first outbreak is treated, the clinician will discuss whether episodic treatment (treating future outbreaks one at a time) or suppressive therapy (daily medication) is the right longer-term approach for you.

Recurrent genital outbreaks are treated with a short course of oral antiviral medication - typically 1-5 days, depending on the specific medication chosen. The clinician chooses the regimen based on your symptom pattern, kidney function, prior response, and pregnancy status.

Episodic treatment principles:

• Start as early as possible - ideally at the first prodromal symptoms (tingling, burning, itching before lesions appear). Treatment started before lesions develop can sometimes prevent them entirely.
• Most effective within 24 hours of symptom onset.
• Have a prescription on hand if you have recurrent outbreaks - waiting to book a visit when an outbreak starts often delays treatment past the window of best effectiveness. Ask the clinician about a refill-on-hand for self-initiated treatment at the first sign.
• Most patients with infrequent outbreaks use this approach rather than daily medication.

For full clinical detail on the specific regimen, submit a consultation - the clinician will discuss options during your visit.

Recurrent cold sores are treated with a short course of oral antiviral medication - typically 1-5 days. The same medication class works for both cold sores and genital outbreaks.

Best practices:

• Start at the first tingle, before visible lesions appear. Cold-sore antivirals work best when started in the prodromal phase; once a fully formed blister has erupted, the benefit is smaller.
• Have a prescription on hand so you can start treatment within hours of feeling the tingle. Asking the pharmacy to fill it when an outbreak starts often delays treatment past the most effective window.
• Sun exposure is a common trigger - SPF lip balm in summer (and at altitude) can reduce recurrences.

Over-the-counter supportive options for cold sores:

• Topical antiviral creams are available without a prescription at most pharmacies. The clinical benefit is modest compared with oral antivirals, but they may help if used very early.
• Cold compresses can ease pain and reduce swelling.
• Lip balm with sunscreen as ongoing prevention.

If you experience frequent recurrences (commonly 6+ per year, or outbreaks that meaningfully affect quality of life), daily suppressive therapy can also be considered - see "Should I be on a suppressive dose?" below.

Antiviral medication is the main treatment, but a few comfort measures help while the outbreak heals:

For genital outbreaks:

• Sitz baths (sitting in a few inches of warm water) two or three times a day can soothe genital lesions.
• Loose, breathable underwear (cotton) reduces friction.
• Over-the-counter pain relief - acetaminophen or ibuprofen - for cramping and discomfort. Check with the clinician if you have other health conditions.
• Local anaesthetic gels (lidocaine 2%, available without prescription at many pharmacies) can help with painful urination - apply before urinating.
• Pour warm water over the area while urinating to dilute urine and reduce burning.

For cold sores:

• Cool compresses for pain and swelling.
• Lip balm to keep lesions moisturized and prevent cracking.
• Avoid picking at lesions - this slows healing and increases the risk of secondary bacterial infection.

General:

• Hydrate and rest - your immune system is working to control the outbreak.
• Avoid sexual contact until lesions are fully healed.

Daily antiviral medication ("suppressive therapy") is taken every day - not just during outbreaks - to keep the virus quiet between outbreaks. It is considered in two main situations:

1. Frequent or severe outbreaks affecting quality of life

Daily medication reduces the number of symptomatic outbreaks by 70-80% and makes any breakthrough outbreaks shorter and milder. Suppressive therapy is generally offered when you have:

• 6 or more outbreaks per year, OR
• Severe or prolonged outbreaks that interfere with work, sleep, or sexual activity, OR
• Significant psychological distress related to the unpredictability of outbreaks.

If your outbreaks are infrequent and mild, episodic treatment (treating each outbreak as it happens) is usually a reasonable alternative to taking medication every day.

2. Reducing transmission to a non-reactive partner

If you have HSV-2 and your partner does not, daily suppressive therapy taken by you (the partner with herpes) has been shown to reduce transmission to a susceptible partner by about 48%. The effect adds to consistent condom use.

This is the only direct medical strategy for reducing partner transmission risk. The non-reactive partner does NOT take antiviral medication (see "Can I take daily antiviral medication to prevent catching herpes from my partner?" elsewhere on this page).

What suppressive therapy does NOT do:

• It doesn't cure herpes.
• It doesn't eliminate transmission risk - it reduces it.
• It doesn't replace the need to abstain during active outbreaks (even on suppressive therapy, transmission is highest during active lesions).

No - suppressive therapy is not necessarily lifelong. The body's pattern of herpes outbreaks tends to decrease over the years after the initial infection, so many patients can reassess whether they still need daily medication after a year or two.

A common approach:

• Start daily suppressive therapy when outbreaks are frequent or severe.
• After 12 months, consider a trial off the medication to see how your outbreak pattern has changed.
• If outbreaks return at a frequency that affects quality of life, restart suppressive therapy.
• If they stay infrequent or mild, you may not need ongoing daily medication.

The right cadence depends on your individual outbreak pattern, partner status, and preferences - your clinician will revisit this with you over time.

In some cases, the dose of your suppressive medication may need to be increased, or the clinician may switch you to a different antiviral medication in the same class. This is something to discuss in a new TeleTest consultation - the clinician will review your outbreak pattern and adjust accordingly.

Lab testing is not routinely required while on suppressive anti-viral therapy because adverse reactions are rare, outside of higher-risk groups (people with kidney disease, a kidney transplant, or advanced HIV/AIDS).

Approximately 90% of individuals with HSV-2 have another outbreak within their first year. The average number of repeat outbreaks in the first year after infection is between four and five. Recurrent episodes decrease in frequency over the first five years after the initial infection. Recurrent episodes are also much milder, and in many cases produce few symptoms. There is no way to predict how many episodes a person will get. It's reasonable to assume fewer than five in an average year.

Outbreaks tend to happen when the body's defences are temporarily down. Common triggers:

• Stress (physical or emotional).
• Illness - cold, flu, or other infection.
• Surgery or a medical procedure.
• Hormonal changes - menstrual periods, pregnancy.
• Friction or skin trauma in the affected area (vigorous sex, dental procedures for cold sores).
• Sun exposure - a very common trigger for cold sores; using SPF lip balm in summer can reduce recurrences.
• Fatigue or poor sleep.

Identifying your personal triggers can help you anticipate and manage outbreaks. Clinicians can provide anti-viral medication to shorten and reduce the severity of an outbreak.

The herpes virus cannot be cured, but we have very effective antiviral medication to treat an outbreak or prevent transmission. Some people never experience an outbreak in their lifetime, others may only experience an outbreak once every few years, and others may have outbreaks more frequently.

For most pregnant patients with known herpes, pregnancy is unaffected and vaginal delivery is safe with appropriate precautions:

• Recurrent genital herpes (you've had outbreaks before pregnancy): the risk of transmitting herpes to the baby during vaginal delivery is low because protective antibodies cross the placenta to the baby. Daily suppressive antiviral therapy is typically started around 36 weeks of pregnancy to reduce the chance of an outbreak at the time of delivery.
• First (primary) genital herpes outbreak during pregnancy - particularly in the third trimester - carries a higher risk of transmission to the baby because antibodies have not yet been passed on. Management is individualized and may include C-section if active lesions are present at labour.
• Active genital lesions at the time of labour are the main reason for a C-section delivery to reduce transmission risk.
• HSV-1 cold sores during pregnancy are low-risk to the baby. Avoid kissing the newborn if you have an active cold sore.

TeleTest does not manage pregnancy directly - if you become pregnant or are planning pregnancy, your prenatal-care provider (family doctor, midwife, or obstetrician) will coordinate the herpes plan with you in person.

Contact your prenatal-care provider promptly - especially if it might be a first outbreak. A swab to confirm the diagnosis and decisions about antiviral therapy and delivery plans need to happen with the team caring for your pregnancy.

If you are pregnant and your partner has known herpes - but you do not - the priority is to avoid your acquiring a first herpes infection during pregnancy, especially in the third trimester, because that's when transmission risk to the baby is highest.

Strategies your prenatal team will commonly recommend:

• Daily suppressive antiviral therapy for the partner with herpes, particularly in the last trimester of pregnancy. This reduces shedding and transmission risk.
• Consistent condom use throughout pregnancy.
• Abstaining from sexual contact during any visible outbreaks or prodromal symptoms in the partner.
• Strongly consider abstaining from oral sex in the third trimester if your partner has a history of cold sores - oral HSV-1 transmitted to the genital area during late pregnancy is one of the higher-risk scenarios for newborn herpes.
• Your blood-test status (sero-status) for HSV-1 and HSV-2 may be checked early in pregnancy to clarify what strain your partner could potentially pass to you.

Coordinate this plan with your prenatal-care provider in person.

Yes, breastfeeding is safe with herpes as long as you do not have active lesions on the breast itself. The virus is not transmitted through breast milk.

If you do develop an outbreak on the breast or nipple area (rare but possible), express milk from the affected breast and discard it until lesions are healed; feed from the unaffected breast in the meantime. Avoid kissing the baby if you have an active cold sore, and wash your hands carefully before handling the baby.

No - abstain from sexual contact during an active outbreak (when you have visible lesions, or even prodromal symptoms like tingling/burning before lesions appear). Transmission risk is at its highest during an active outbreak.

Wait until lesions are fully healed (skin has returned to normal) before resuming sexual activity. Suppressive antiviral therapy does not eliminate the need to abstain during active outbreaks.

No - that's not how suppressive antiviral therapy works. This is one of the most common misconceptions about herpes.

Daily antiviral medication works by suppressing the virus in the body of the person who already has herpes - it does not prevent you from acquiring herpes from a partner if you are not yet infected.

The "index" partner (the one who has herpes) is the one who takes daily suppressive antiviral medication. Studies show this reduces transmission to a susceptible partner by about 48%, and the protective effect adds to consistent condom use.

If you are the partner without herpes, the right tools for you are:

• Ask your partner to consider daily suppressive antiviral therapy (taken by them, not you).
• Use condoms consistently - they reduce (but do not eliminate) transmission.
• Type-specific blood testing can clarify whether you already have antibodies to your partner's strain. If you do, you are protected against that strain and your partner does not need suppressive therapy.
• Avoid sexual contact during your partner's active outbreaks or prodromal symptoms (tingling, burning before lesions appear).

A common comparison patients raise: for HIV, pre-exposure prophylaxis (PrEP) is taken by the HIV-negative partner to prevent infection. Herpes does not work that way - there is no oral or injectable medication that the herpes-negative partner can take as pre-exposure protection. Research on herpes vaccines and PrEP-equivalent strategies is ongoing but not yet available in clinical practice.

There is no perfect script, but a few things help:

• Choose a calm, non-sexual moment - not in the heat of an intimate situation.
• Lead with facts, not apologies. Herpes is common, manageable, and transmissible mostly without symptoms - many people carry it without knowing.
• Share what your day-to-day looks like: how often you have outbreaks, whether you're on suppressive therapy, what precautions you take.
• Give them time to ask questions and decide what they're comfortable with. Many partners react better than expected.
• Offer resources - reputable sites like Sex & U (Society of Obstetricians and Gynaecologists of Canada) have plain-language partner-conversation tools.

Disclosure is encouraged but not legally required for herpes in Canada (unlike HIV).

Having a positive result for herpes does not legally require disclosure to future partners in Canada (unlike some conditions such as HIV). However, open discussion with a partner is encouraged so both partners can make informed decisions about testing, treatment, and safer-sex practices.

Many patients choose to disclose; some, for personal reasons, prefer not to. Disclosure is not legally required in Canada (unlike HIV). Either way, transmission-reduction strategies are available, and your clinician will support you in using them.

The most useful first step: have your partner get type-specific HSV blood testing.

If your partner already has antibodies to the same strain you have, they already carry it - there's no transmission concern for that strain between the two of you. This is called sero-concordance, and it's the simplest way to answer the question without changing the dynamic of disclosure. Partners can be tested through their own clinician or through a TeleTest consultation.

If your partner is sero-discordant (does not have antibodies to your strain), there are several ways to reduce transmission risk:

• Daily suppressive antiviral therapy taken by you (the index partner) reduces transmission to a susceptible partner by about 48% and reduces asymptomatic shedding. You can request this from your clinician even if you choose not to disclose - the prescription decision belongs to you and your clinician, and the medication is taken by you to protect your partner.
• Consistent condom or barrier use during all sexual contact. Reduces (but does not eliminate) transmission.
• Abstain from sexual contact during outbreaks or prodromal symptoms (tingling, burning before lesions appear). Risk is highest during active lesions.

A few honest considerations:

• These strategies reduce transmission risk but do not eliminate it. Any sexual contact with a partner who has HSV carries some risk.
• If a partner asks directly about your STI status, honesty matters - both ethically and to maintain trust in the relationship long-term.
• Many patients find the disclosure conversation is less difficult than expected, especially when framed with the facts about how common herpes is (around 70% of adults carry HSV-1; about 20% carry HSV-2).

This is a personal decision. Your clinician's role is to support harm reduction regardless of which path you choose.

Yes - it's possible. Herpes transmission can occur without symptoms. Two common scenarios:

• If you have genital HSV but have never had a noticeable outbreak yourself, you can still shed the virus and transmit it to a partner who has not previously been exposed to that strain.
• If you have a history of cold sores (oral HSV-1) and performed oral sex on your partner, you can transmit HSV-1 to their genital area - your partner may develop a genital HSV-1 outbreak even though you have never had a genital outbreak yourself.

This is one reason herpes is complicated to "track back": many people are unaware they carry the virus, and partner transmission can occur even between long-term partners who have never had a visible outbreak.

A herpes outbreak can look like several other things, and at-home self-diagnosis is unreliable. Many conditions cause similar-looking genital or oral rashes:

• Yeast infection - more common in patients with vaginas; usually itchy with thick discharge rather than blisters.
• Bacterial vaginosis - thin, fishy-smelling discharge; not associated with blisters.
• Friction or chafing - from tight clothing, vigorous sex, or shaving; usually resolves on its own without recurrence.
• Ingrown hair / folliculitis - red bumps centred on hair follicles; common after shaving.
• Contact dermatitis - reaction to soap, detergent, condoms, or lubricants; itchy and red but not usually blistered in clusters.
• Genital warts (HPV) - flesh-coloured raised growths, not blisters.
• Molluscum contagiosum - small, dome-shaped bumps with a central dimple.
• Syphilis - a single painless sore (chancre) in early infection.
• Insect bites or boils - usually solitary; not clustered like herpes.

The only reliable way to confirm herpes is a swab during an active outbreak. If you have a new rash and aren't sure what it is, see a clinician in person while the rash is present - timing matters because the swab is most accurate in the first 72 hours.

Most herpes outbreaks can be managed remotely through a TeleTest consultation. See a clinician in person promptly if any of the following apply:

• A first-ever genital outbreak - in-person assessment helps confirm the diagnosis with a swab and rule out other causes.
• Severe pain or inability to urinate - severe outbreaks can cause urinary retention.
• Fever, headache, neck stiffness, or feeling very unwell - these can suggest a more serious infection.
• Outbreak near the eye or eye involvement (pain, light sensitivity, blurred vision) - this is an ophthalmology emergency. Go to a walk-in clinic or emergency department immediately.
• You are pregnant with a possible first genital outbreak.
• You are immunocompromised (HIV, transplant, ongoing chemotherapy) and develop a new or unusual outbreak.

A swab during an outbreak at an in-person clinic (walk-in, family doctor, sexual-health clinic) is covered by your provincial health plan for eligible residents - this is the most clinically useful test.

A herpes blood test (IgG antibodies) is also covered by your provincial health plan when ordered by a clinician for an eligible resident. The lab fee for the test itself is not billed to you.

TeleTest's consultation fee is paid out-of-pocket - this covers the asynchronous clinician review that authorizes the requisition. The blood test you do at the lab (LifeLabs, Dynacare, or Alpha Labs) remains covered by your provincial plan in the usual way.

If you're not an eligible resident (no provincial health card or out-of-province), additional uninsured lab fees may apply.

Please select the HSV Testing panel under the STI category for a separate consultation. We review additional information related to the appropriateness of herpes testing for your situation - your history of rashes (location, appearance, timing), prior exposures, partner status, and whether a swab during an active outbreak (more accurate) or a blood test (when there's no active rash) is the right next step for you.

A few things to know:

• Herpes testing is not routinely included in the standard STI testing panel - it is a separate test for the reasons explained in the "5 reasons not to test for herpes routinely" accordion above.
• We cannot modify an existing requisition once it has been issued. A new consultation is required to add herpes testing.
• Submitting a new consultation: select the HSV Test panel, complete the updated intake (the rash and exposure questions help the clinician decide on the best test), and submit. Your next consultation may not be with the same clinician you originally spoke with, but they will have access to your medical record.