What is the management approach for a sexually active adult with a positive serum Herpes Simplex Virus (HSV) screening result during STD screening?

Management of Positive Serum HSV Screening

If you have a positive serum HSV result from routine STD screening in an asymptomatic sexually active adult, you should first confirm the result if the index value is <3.0 using a second assay (Biokit or Western blot), then provide comprehensive counseling about transmission risk and offer suppressive therapy only if the patient has symptomatic disease or wishes to reduce transmission to a susceptible partner. 1

Critical First Step: Confirm the Diagnosis

The most important initial action is determining whether this is a true positive result, as commercially available HSV-2 serologic tests have poor specificity:

• Low positive results (index value 1.1-2.9) have only 39.8% specificity, meaning more than half are false positives 1
• Index values ≥3.0 have 78.6% specificity, which is better but still produces false positives 1
• Confirm any result with index value <3.0 using a second assay (Biokit HSV-2 rapid test or Western blot) before disclosing results to the patient 1
• This confirmatory strategy improves positive predictive value from 80.5% to 95.6% 1
• Patients with HSV-1 antibodies are MORE likely to have false-positive HSV-2 results, making confirmation even more critical 1

Determine If This Was Appropriate Screening

The USPSTF and CDC recommend AGAINST routine serologic screening for HSV-2 in asymptomatic adults because harms outweigh benefits 1, 2. Screening should only be performed in specific circumstances:

When HSV-2 serology IS appropriate:

• Persons with genital symptoms that could be consistent with herpes (classic or atypical) 1
• Persons told they have genital herpes without virologic confirmation 1
• Sexual partners of persons known to have HSV-2 infection 1
• HIV-infected persons seeking HIV care 1, 3
• Pregnant women at risk of acquiring HSV near delivery 3

When screening is NOT recommended:

• Asymptomatic persons with low pretest probability (few lifetime partners, no known HSV-2 positive partners, no genital symptoms) 1
• General population screening of pregnant women 1

Management Based on Symptoms

For Asymptomatic Patients with Confirmed Positive HSV-2 Serology:

No antiviral therapy is required for asymptomatic infection alone 4. However, management should include:

• Comprehensive counseling about natural history, recurrent episodes, asymptomatic viral shedding, and sexual transmission risk 3, 4
• Advise abstinence from sexual contact when prodromal symptoms or lesions are present 4
• Recommend consistent latex condom use, which reduces HSV-2 transmission 5, 4
• Discuss disclosure of HSV-2 status to partners, as this reduces transmission risk in discordant couples 5
• Consider suppressive therapy to reduce transmission if the patient is in a serodiscordant relationship: valacyclovir 500 mg once daily reduces transmission to susceptible heterosexual partners by 50% 1, 5, 4, 6

For Symptomatic Patients with Confirmed Positive HSV-2 Serology:

All symptomatic patients should be offered suppressive therapy as the preferred management approach 1, 4:

First Clinical Episode (if active lesions present):

• Valacyclovir 1 gram orally twice daily for 7-10 days (preferred regimen) 4
• Alternative: Acyclovir or famciclovir at appropriate doses 1

Recurrent Episodes (Episodic Therapy):

• Valacyclovir 500 mg orally twice daily for 5 days 4, 6
• Initiate during prodrome or within 24 hours of lesion onset 4, 6
• Median time to lesion healing: 4 days vs 6 days with placebo 6

Suppressive Therapy (Preferred for Symptomatic HSV-2):

• Valacyclovir 1 gram orally once daily for patients with frequent recurrences 4, 6
• Valacyclovir 500 mg once daily for patients with ≤9 recurrences per year 6
• At 12 months, 34% remain recurrence-free vs 4% with placebo 6
• Reduces transmission by 50% and improves quality of life 1, 5, 4

Special Populations

HIV-Infected Patients:

• Routine type-specific HSV-2 serologic testing is recommended for all persons seeking HIV care 1, 4
• Higher antiviral doses may be needed for severe mucocutaneous lesions 4
• Suppressive therapy: valacyclovir 500 mg twice daily in HIV-infected patients 6

Pregnant Women:

• Screening is NOT recommended 1, 4
• Type-specific serology only for women at risk of acquiring HSV near delivery 3

Monitoring and Safety

• No laboratory monitoring needed for episodic or suppressive therapy unless substantial renal impairment exists 1, 4
• Common adverse events: nausea, headache (generally mild) 1, 4
• Safety of chronic suppressive therapy beyond 1 year in immunocompetent patients has not been established 6

Common Pitfalls to Avoid

• Never disclose low positive results (<3.0 index value) without confirmatory testing - over 60% may be false positives 1
• Do not assume clinical diagnosis is accurate - even symptomatic presentations have a 1:4 ratio of false to true positives 7
• Remember that HSV-1 seropositivity increases false-positive HSV-2 risk 1
• Recognize the 12-week window period - negative results within 12 weeks of exposure may be falsely negative 1, 3
• Understand that asymptomatic viral shedding occurs - transmission can happen without visible lesions 6, 7
• Note that genital HSV-1 recurs much less frequently than HSV-2 (important for prognosis) 1, 5