What are the next steps in testing and management for someone who had intercourse with a person with known genital herpes (Herpes Simplex Virus, HSV) without active lesions at the time of intercourse?

Post-Exposure Management After Sexual Contact with Known HSV-Positive Partner Without Active Lesions

For an asymptomatic person exposed to a partner with known genital herpes (no active lesions present), immediate testing is not recommended; instead, obtain baseline type-specific HSV-2 serology now, repeat at 12 weeks post-exposure if initially negative, and monitor for any genital symptoms over the next several weeks. 1

Immediate Steps (Within Days of Exposure)

Baseline Serologic Testing

• Obtain type-specific HSV-2 serology (glycoprotein G-based assay) immediately to establish your baseline infection status, as this will help determine if any future positive result represents new acquisition versus pre-existing infection 1
• Be aware that if you test positive now, you likely had HSV-2 before this exposure, as antibodies take weeks to develop 1
• Do not perform genital swabs or PCR testing in the absence of lesions, as HSV molecular assays are not sensitive for diagnosis without active ulcers due to intermittent viral shedding 1, 2

Clinical Monitoring

• Watch carefully for any genital symptoms over the next 2-12 weeks, including vesicles, ulcers, painful lesions, dysuria, or flu-like symptoms with genital discomfort 1, 3
• Primary HSV infection typically manifests within 2-12 days of exposure but can occur later 3
• If any genital lesions develop, immediately seek testing with NAAT/PCR from the lesion, as this provides >90% sensitivity and specificity and is the gold standard for active disease 1, 2

Follow-Up Testing at 12 Weeks

Repeat Serology if Initially Negative

• If your baseline HSV-2 serology was negative, repeat type-specific HSV-2 serology at 12 weeks post-exposure to determine if seroconversion occurred 1
• The window period for HSV-2 antibody development can be up to 12 weeks, so testing before this timeframe may yield false-negative results 1
• If the index value is between 1.1-2.9 on HerpeSelect assay, request confirmatory testing with a second method (Biokit HSV-2 rapid assay or Western blot), as specificity in this range is only 39.8% 1
• Index values ≥3.0 are generally sufficient for diagnosis without confirmatory testing, though false positives can still occur 1

Management Based on Testing Results

If You Remain Seronegative at 12 Weeks

• No treatment is indicated if you remain asymptomatic and seronegative 1, 4
• Counsel about ongoing transmission risk, as asymptomatic viral shedding occurs in HSV-infected partners even without visible lesions and is the main factor of transmission 3, 5
• Recommend consistent condom use with your HSV-positive partner, as this reduces but does not eliminate transmission risk 3
• Consider discussing suppressive antiviral therapy for your partner (valacyclovir 500 mg daily), as this reduces viral shedding and transmission to serodiscordant partners 6, 3

If You Seroconvert (New Positive HSV-2)

• If asymptomatic with positive serology, treatment is generally not recommended based on CDC guidelines, which advise against treating based solely on positive serology without clinical symptoms 6
• Provide counseling about the chronic nature of HSV infection, potential for recurrent episodes, asymptomatic viral shedding, and sexual transmission risk 6, 4
• Advise abstaining from sexual activity during any future outbreaks and encourage condom use during all sexual exposures 6, 4
• If symptomatic lesions develop after seroconversion, initiate treatment promptly (ideally within 72 hours of symptom onset) with valacyclovir 1 g orally twice daily for 7-10 days 6

If You Develop Symptomatic Primary Infection

• Obtain NAAT/PCR with HSV typing from active lesions immediately, as this is critical for counseling—12-month recurrence rates differ dramatically: HSV-2 (90%) versus HSV-1 (55%) 2
• Initiate antiviral therapy immediately with valacyclovir 1 g orally twice daily for 7-10 days, or acyclovir 400 mg orally three times daily for 7-10 days 6
• Do not delay treatment beyond 72 hours of symptom onset, as this significantly reduces effectiveness 6
• Consider suppressive therapy (valacyclovir 500-1000 mg daily) if frequent recurrences develop (≥6 episodes per year) 6

Critical Pitfalls to Avoid

• Do not rely on clinical diagnosis alone without laboratory confirmation if lesions develop, as genital HSV is difficult to differentiate from other causes of genital ulceration including syphilis 1, 2
• Do not use topical acyclovir, as it is substantially less effective than oral therapy 6
• Do not assume negative serology rules out infection if tested before 12 weeks, as the window period can extend this long 1
• Do not screen with HSV-1 serology, as 70% of the population has oral HSV-1, and the test has only 70.2% sensitivity, making results difficult to interpret 1
• Be aware that systemic antivirals control symptoms but do not eradicate latent virus or prevent all recurrences 6