Screening for HSV-1 and HSV-2 IgG Antibodies in Asymptomatic Patients
Routine screening for HSV-1 and HSV-2 IgG antibodies in asymptomatic patients is not recommended and should be actively discouraged. 1, 2, 3
Why Screening Is Not Recommended
The U.S. Preventive Services Task Force explicitly recommends against routine serologic screening for HSV-2 infection in asymptomatic adolescents and adults with a Grade D recommendation, meaning the harms outweigh the benefits. 1, 3 This recommendation was reaffirmed as recently as 2023 after systematic review of the evidence. 3
Key reasons screening is discouraged:
No improvement in health outcomes: Although screening can identify asymptomatic infections, there is no evidence that treating asymptomatic patients improves long-term health outcomes. 1
High false-positive rates: Commercial HSV antibody tests have significant limitations, with false-positive rates that can be substantial, particularly at low-positive index values (1.1-2.9 have only 39.8% specificity, meaning 60% are false positives). 4, 5
Psychological harm without clinical benefit: The moderate certainty conclusion is that population-based screening causes more harm than benefit, including psychological distress from false-positive results and the stigma associated with HSV-2 diagnosis. 3
Poor test performance for HSV-1: HSV-1 IgG assays have particularly low sensitivity (<85% for most platforms), resulting in frequent false-negative results even in confirmed infections. 5, 6
Exceptions: When Type-Specific Serology May Be Appropriate
Type-specific HSV-2 serology using glycoprotein G-based assays should only be considered in specific high-risk populations: 2, 4
- Pregnant women at risk of acquiring HSV infection close to delivery 1, 2, 4
- Men who have sex with men 1, 2, 4
- People who are HIV-positive 1, 2, 4
- Sexual partners of individuals with known genital herpes 4
Critical Pitfalls to Avoid
Do not order HSV molecular assays (PCR/NAAT) or viral culture in asymptomatic patients without active lesions. 2, 4 These tests detect viral shedding, which is intermittent, making them insensitive and unreliable for screening purposes. 4
If serologic testing is performed despite recommendations against it:
Recognize the "window period": antibodies may take up to 12 weeks to develop after infection, so a negative result within this timeframe may be falsely negative. 4
Low-positive results (index value <3.0) require confirmation with a second test using different methodology due to high false-positive rates. 4
False-negative results occur in 12-30% of patients with confirmed recurrent HSV infections, even months after infection. 6
Different commercial platforms have varying performance characteristics, with some (like DiaSorin) having particularly poor specificity for HSV-2 (as low as 69% positive predictive value in general populations). 5
The Bottom Line
Widespread screening for HSV antibodies should be discouraged in asymptomatic patients. 1, 2, 7, 8 The appropriate use of HSV testing is for symptomatic patients with active genital lesions using PCR/NAAT, not for screening asymptomatic individuals. 2, 7, 8