I am a 26‑year‑old male with positive HSV‑1 IgG and HSV‑2 IgG serology and no current lesions; what management is recommended?

Management of Asymptomatic HSV-1 and HSV-2 Seropositivity

Your HSV-2 result with an index value of 1.17 is likely a false positive and should be confirmed with a second test using a different assay before making any clinical decisions, while your HSV-1 result is definitively positive and requires counseling but no treatment in the absence of symptoms. 1

Critical Issue: Your HSV-2 Result Requires Confirmation

The most important action is to obtain confirmatory testing for HSV-2 before accepting this diagnosis. Here's why:

• Index values between 1.1-2.9 have only 39.8% specificity, meaning approximately 60% are false positives 1
• Patients with HSV-1 infection (like you) are significantly more likely to have false-positive HSV-2 tests with low index values 1
• Your HSV-2 index of 1.17 falls squarely in this problematic range where false positives are common 1

Recommended Confirmatory Testing Approach

• Request a second HSV-2 IgG test using a different glycoprotein G antigen (e.g., Biokit HSV-2 rapid assay if HerpeSelect was used initially, or Western blot if available) 1
• Combining HerpeSelect with Biokit confirmatory testing improves positive predictive value from 80.5% to 95.6% 1
• Do not disclose HSV-2 results to the patient or initiate HSV-2-specific counseling until confirmation is obtained 1
• Index values ≥3.0 have 78.6% specificity and may be sufficient without confirmation, but your 1.17 value absolutely requires it 1

Management of Confirmed HSV-1 Seropositivity

Your HSV-1 index of 24.50 is definitively positive and does not require confirmation. 1

Counseling Points for HSV-1

• HSV-1 is extremely common (most adults are seropositive) and typically causes oral herpes, though it can cause genital herpes 2, 3
• You can transmit HSV-1 through asymptomatic viral shedding even without visible lesions, particularly through oral contact 1, 2
• No treatment is indicated in the absence of symptoms (no lesions, no outbreaks) 1
• If you develop cold sores or genital lesions in the future, episodic antiviral therapy can be initiated at the first sign of symptoms 1, 4

If HSV-2 is Confirmed After Repeat Testing

Counseling for Asymptomatic HSV-2

• Most HSV-2 infections (approximately 91%) are unrecognized because symptoms are absent or so mild they go unnoticed 2
• Asymptomatic viral shedding occurs and is responsible for most transmission to sexual partners 1, 2
• You should disclose your HSV-2 status to sexual partners and use safer sex practices 4
• Type-specific serologic testing of partners can determine if they are already HSV-2 positive or at risk for acquisition 4

Treatment Options for Confirmed Asymptomatic HSV-2

Two management strategies exist, and the choice depends on your sexual activity and transmission concerns:

1. Suppressive therapy (daily antiviral medication):

   • Reduces asymptomatic viral shedding and transmission risk to partners 1
   • Prevents future symptomatic outbreaks 1
   • Typical regimen: valacyclovir 500 mg daily 4
   • Consider this if you are sexually active with an HSV-2 negative partner 1

2. Episodic therapy (treatment only if symptoms develop):

   • Initiate antiviral therapy at first sign of genital lesions 1, 4
   • Must be started within 24 hours of symptom onset for recurrent episodes 4
   • Reasonable if you remain asymptomatic and partners are already HSV-2 positive or you are not sexually active 1

Common Pitfalls to Avoid

• Never accept a low-positive HSV-2 result (index <3.0) without confirmation, especially in HSV-1 positive patients 1
• Do not perform viral PCR or culture swabs in the absence of lesions—they are insensitive due to intermittent shedding 1, 2
• Do not assume absence of symptoms means absence of transmission risk—asymptomatic shedding is the primary mode of HSV-2 transmission 1, 2
• Remember the 12-week window period: if recent exposure is suspected and initial serology is negative, repeat testing after 12 weeks 1, 2

Immediate Next Steps

1. Order confirmatory HSV-2 testing with a different assay (Biokit or Western blot) 1
2. Provide definitive HSV-1 counseling regarding transmission risk and future episodic treatment options 2, 3
3. Defer HSV-2-specific counseling and treatment decisions until confirmatory results are available 1
4. If HSV-2 is confirmed, offer suppressive therapy if sexually active with seronegative partners 1, 4