What do you think about chronic suppressive therapy for HSV-2 in a patient with positive antibodies but no prior clinical outbreak?

The first challenge is often the reliability of the test result. HSV-2 serologies and their interpretation can be challenging. A strongly positive result for HSV2, i.e., an EIA or similar index value well above the minimal cut-off, usually is reliable. Lesser values often are false positives, even though officially positive. An HSV Western blot (still available only at my own institution, the University of Washington clinical lab) is the ultimate gold standard HSV serology if there is any doubt.

Second, it is important to have a discussion with the patient about subtle outbreaks anywhere in the "boxer shorts" anatomic distribution. Up to half of initially asymptomatic persons with confirmed HSV-2 antibody come to perceive previously unrecog...

This patient was likely infected with HSV-2 in the past despite the absence of symptoms and may potentially infect a partner who is not immune; since viral shedding begins before symptoms, this is definitely a risk. I would have an informed consent discussion on possible transmission prevention with suppressive therapy, assuming no contraindications. The burden of daily long-term medication use against the benefit of preventing what may become a lifelong infection for their HSV-2 negative partner. The alternative would be careful use of barrier methods long-term, which will be less protective. HSV-2 negative partners should be informed of your patient’s HSV-2 positive status.