Do we treat Herpes Simplex Virus type 2 (HSV-2) with Immunoglobulin G (IgG) levels over 10 in the absence of symptoms?

Do We Treat Asymptomatic HSV-2 IgG Positive Patients?

No, antiviral treatment is not routinely recommended for asymptomatic HSV-2 seropositive individuals (positive IgG regardless of titer level), but suppressive therapy should be offered if they develop symptoms or wish to reduce transmission risk to sexual partners. 1

Key Management Principles

The approach to HSV-2 IgG positive patients depends entirely on whether they have symptoms, not on the antibody titer level:

Asymptomatic HSV-2 Seropositive Patients

• Approximately 20% of HSV-2 seropositive persons never recognize genital symptoms consistent with herpes. 1

• Routine antiviral treatment is not indicated for truly asymptomatic patients - the IgG titer level (whether >10 or any other value) does not change this recommendation. 1

• However, suppressive therapy can be considered for asymptomatic patients who wish to reduce transmission risk to sexual partners, as the mechanism works through suppression of viral shedding. 1

• Suppressive therapy is NOT effective for reducing transmission among persons with HIV/HSV-2 coinfection. 1

Symptomatic HSV-2 Seropositive Patients

• All patients with symptomatic HSV-2 infection should be offered suppressive therapy as one of two management approaches (the other being episodic therapy). 1

• Suppressive therapy reduces recurrence frequency by ≥75% among patients with frequent recurrences (≥6 per year). 1

• Suppressive therapy also reduces transmission to sexual partners - this was demonstrated in heterosexual couples but applies to all populations through the same mechanism of viral shedding suppression. 1

Recommended Suppressive Therapy Regimens

If suppressive therapy is chosen (for symptomatic patients or asymptomatic patients wishing to reduce transmission):

• Valacyclovir 500 mg to 1 g daily 2
• Acyclovir 400 mg twice daily 1
• Famciclovir 250 mg twice daily 1

Safety and efficacy have been documented for up to 6 years of continuous therapy with acyclovir. 1

Critical Counseling Points

Regardless of treatment decision, all HSV-2 seropositive patients require comprehensive counseling:

• Asymptomatic viral shedding occurs even without visible lesions, and is more frequent with HSV-2 than HSV-1. 1, 2

• Transmission can occur during asymptomatic periods. 1

• Condom use should be encouraged with all sexual partners, especially new or uninfected partners. 1, 2

• Childbearing-aged women must inform obstetric providers due to neonatal transmission risk. 2, 3

Common Pitfalls to Avoid

• Do not treat based on IgG titer levels alone - the decision is based on symptoms and transmission risk reduction goals, not antibody levels. 1

• Do not screen asymptomatic low-risk populations - the USPSTF recommends against screening for HSV-2 among asymptomatic adolescents and adults with low pretest probability. 1

• Do not assume all seropositive patients need treatment - only those with symptoms or specific transmission prevention goals benefit from suppressive therapy. 1