A patient with high HSV‑1 IgG and high HSV‑2 IgG and negative hepatitis B surface antigen, hepatitis C antibody, HIV antigen/antibody, RPR (syphilis), and negative urogenital Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Mycoplasma genitalium, Ureaplasma parvum, and Ureaplasma urealyticum—what is the appropriate management?

Management of Asymptomatic HSV-2 Infection

This patient has asymptomatic HSV-2 infection (high HSV-2 IgG) with no other sexually transmitted infections detected, and does not require routine antiviral treatment unless there is a specific indication such as HIV coinfection or risk of transmission to sexual partners. 1

Understanding the Test Results

• HSV-1 IgG 24.50 (high) and HSV-2 IgG 1.17 (high) indicate past infection with both HSV-1 and HSV-2, meaning the patient has been exposed to both viruses and has developed antibodies. 2, 3
• All other STI testing is negative, including HIV, hepatitis B, hepatitis C, syphilis, gonorrhea, chlamydia, trichomonas, mycoplasma genitalium, and ureaplasma species. 4, 5
• Approximately 20% of HSV-2 seropositive persons remain truly asymptomatic throughout their infection and may never develop visible lesions. 1

Primary Management Approach

For Immunocompetent Patients Without Partners at Risk

• Routine antiviral treatment is NOT recommended for asymptomatic immunocompetent individuals who are not at risk of transmitting to sexual partners. 1
• The patient should receive comprehensive counseling about the natural history of HSV-2 infection, including the potential for future symptomatic episodes even after years of being asymptomatic. 1, 6

If the Patient Has Sexual Partners at Risk

• Offer daily suppressive therapy with valacyclovir 500 mg once daily if the patient is in a serodiscordant relationship (partner is HSV-2 negative), as this reduces transmission risk by 48-50%. 1, 7
• Suppressive therapy reduces asymptomatic viral shedding from 10.8% of days to 2.9% of days. 7
• Important caveat: Suppressive therapy does NOT eliminate transmission risk entirely, and patients must understand that transmission can still occur. 7, 6

If the Patient is HIV-Positive

• HIV-infected individuals with HSV-2 should be offered suppressive therapy (acyclovir 400 mg orally twice daily OR valacyclovir 500 mg twice daily) because HSV lesions in this population are more frequent, severe, and prolonged. 4, 1
• Critical pitfall: Suppressive therapy is NOT effective for reducing HSV-2 transmission in HIV/HSV-2 coinfected individuals. 1

Essential Patient Counseling Points

Disease Education

• Asymptomatic viral shedding occurs frequently and is the primary mode of HSV-2 transmission—most transmission occurs when no visible lesions are present. 1, 7, 6
• The patient should be taught to recognize early prodromal symptoms (tingling, itching, burning) that may precede visible lesions, as these indicate periods of high infectivity. 1, 6
• HSV-2 is not curable, but it is manageable with antiviral therapy if symptomatic episodes develop. 6, 5

Transmission Prevention

• Consistent latex condom use reduces HSV-2 transmission risk and should be encouraged for all sexual encounters, though condoms do not provide complete protection. 8, 7
• Avoid all sexual contact when any visible genital or orolabial lesions are present. 8, 7, 6
• Sexual partners should be informed of the patient's HSV-2 status, and HSV-2 seronegative partners should consider type-specific serologic testing before initiating sexual activity. 8, 6

Special Considerations for Women

• Women of childbearing age must inform their obstetric providers about HSV-2 status during any pregnancy due to the risk of neonatal herpes infection. 1, 6
• The safety of systemic acyclovir treatment during pregnancy is not fully established, though it is commonly used. 1

When to Initiate Treatment

For Future Symptomatic Episodes

• If the patient develops symptomatic genital herpes in the future, treatment options include: 4
  • Episodic therapy: Acyclovir 400 mg orally three times daily for 5 days OR valacyclovir 500 mg orally twice daily for 5 days (initiated at first sign of outbreak)
  • Suppressive therapy: Acyclovir 400 mg orally twice daily OR valacyclovir 500 mg orally once daily (for patients with frequent recurrences, typically ≥6 episodes per year)

Treatment Initiation Timing

• For episodic treatment to be effective, it must be initiated at the earliest symptom (tingling, itching, burning) before visible lesions develop. 6
• There are no data on effectiveness of treatment initiated more than 24 hours after onset of recurrent episode symptoms. 6

Common Pitfalls to Avoid

• Do not assume that the absence of symptoms means the patient cannot transmit HSV-2 to partners—asymptomatic shedding is the primary mode of transmission. 1, 7
• Do not prescribe suppressive therapy solely for the patient's benefit if they are asymptomatic and immunocompetent—the indication is transmission prevention to partners. 1
• Do not tell patients that condoms or suppressive therapy eliminate transmission risk—both reduce but do not eliminate risk. 7, 6
• Do not forget that HSV-2 infection increases HIV acquisition risk 3-fold, making HIV prevention counseling important. 4, 7

Follow-Up Recommendations

• No routine follow-up testing is needed for asymptomatic HSV-2 infection. 1
• The patient should return if symptomatic episodes develop or if they wish to discuss suppressive therapy for transmission prevention. 1
• Partners of the patient should be offered evaluation, counseling, and consideration of type-specific HSV-2 serologic testing. 4, 8