HSV2 or not HSV2

[rg91]

Thank you again for your service.  I received unprotected oral sex and protected vaginal sex from two escorts (two separate incidents).  Before this incident my life was pretty monogamous I had 3 sexual partners and sex with the exception of one long time relationship was almost always using a condom.  I would consider my 3 previous partners to be low risk.  The escorts (call girls) practiced some level of safe sex.  They required the use of a condom for vaginal sex and did a good job placing the rubber.  I didn't notice a lesion on either of them.  

After my escort exposures (21 after first and 18 after the second) I got on-line testing for Hepatitis B, Hepatitis C, HIV, HSV1, HSV2, Chlamydia and Gonorrhea.  All results were negative with the exception of HSV2 (Test HSV-2 aB lgG: result 2.9H).  I talked to my doctor and he explained that test HSV2 was very reliable and the result high.  He also gave me 1g of Azithromycin to avoid risk of NGU and Gono.  

Following this test (27 and 24 days after the potential exposure) I got a BioKit USA test.  This test was given by a Dermatologist who also examined me.  This test was negative.  This Dr. said I could go back to my regular life.  That BioKit was very reliable.  

I don't have any explicit symptoms.  I do have some anxiety over the test results and discomfort in my urethra.  However, I don't have any blisters, sores or discharge.  

Here are my questions

1.It is my understanding that unprotected oral is a risk for HSV- 1 not HSV-2.  What do you think is my risk of getting something from the escorts?  
2.Do I need to do any additional testing given the results so far?  How risky would it be for someone to have unprotected sex with me?  Should I notify new partners at this point?  
3.How about additional testing for risks other than HSV2?  

Please advice.  

[Edward W Hook, MD]

To summarize the situation as I understand it, following two exposures to CSWs which were, at least in part protected, you got tested for STD.  Of the tests you had, your test for HSV antibodies (I presume it was a type specific test such as the HerpeSelect) was positive for HSV-2 antibodies.  Several days later you had a second test, this time with the Biokit assay.  The question becomes what now?

First, if your initial test was not HerpeSelect or similar assay, it is likely to be false positive and I would not worry about it.  If it was HerpeSelect, the question becomes which of the two tests was the true value; false positive tests do occasionally occur with all tests.  To answer that, you need a tie-breaker and the best test for that is the Western Blot test performed at the University of Washington.  There are occasional false positive and false negative test results with both HerpeSelect and the Biokit.  You discordant results do make having a false positive a real concern however.  I think the Western Blot assay would be helpful.  As for your specific questions:

1.  If you have HSV, my guess is that it is a long standing infection and not necessarily something you got from one of the escorts (remember, 1 out of 12 adult Americans with a single lifetime sex partner have HSV-2).  If you were going to get something, HSV-1 from oral sex would be far more likely than HSV-2.
2.  I am inclined to thing that you have a false positive.  I would get the Western blot to reassure yourself.  In the interim, while be cannot be sure, my guess is that the risk of getting HSV from you is low.
3.  No, I would focus on the HSV-2.  Believe the tests you have.

Hope this helps.  Please let me know what brand of test your initial test was.   EWH

[rg91]

The test is described as "Herpes Simplex Virus (HSV) Types I and II Specific Antibodies, lgG".  The website describes their test as "Focus Technologies’ HerpeSelect® 1 and 2 ELISA IgG".  

It has been approximately 1 month since my last exposure.  Would the Western Blot be accurate at this point?  

Is there a way I can get the Western Blot directly in Seattle?  How can I find a Dr. and Lab to do this?  

[Edward W Hook, MD]

The test you mention is (typically) a reliable type-specific test.  Thanks for the clarification

Given that you already have a positve test and are in need of a "tie breaker" this would be an appropriate time to have the test.

Many labs have mechanisms for sending specimens to outside labs.  I suspect that you and your doctor can work out how to have your specimen sent to The University of Washington Virology laboratory.  EWH

[rg91]

1.  Would it be of value if I have another HerpeSelect?  

2.  What is a good way to find a doctor experienced in Herpes?  

Please advice.  

[Edward W Hook, MD]

1.  I doubt it.  If it came back negative that would be useful but I somehow find that unlikely unless your specimen was mixed up when it was taken.
2.  I would go to the American Social Health (ASHA) web site.  They have a good informational web site and may have a referral service.  Alternatively, and a little less sure would be to look for a local Infectious Diseases specialist or talk with the folks at your local Health department.  EWH

[rg91]

1.  I had another Herpeselect.  The result was 3.82.  

2.  I am going forward with the Western Blot but expect a positive result.  I will post my results when I get them.  

I am interpreting the increasing antibodies result as a rescent infection is that correct?  Did I just win the Herpes Lottery and got the virus even though I only had 2 protected encouters?  

I still don't have any explicit symptoms.  

Please comment.  

[Edward W Hook, MD]

Your newest HerpeSelect is strongly positive; the result is consistent with development of antibodies from a recently acquired infection.  I hope that is not the case and look forward to hearing about the result of your Western Blot.  EWH

[rg91]

Just got the results.  The WB had atypical results for HSV2.  They asked that I submit a second convalescent sample.  What do you recommend?  Do I need to accept I have HSV2 or wait a couple months and continue with the testing?  Please advice.  

FYI, I still don't have any explicit symptoms.  

Also, how long should I take supressive therapy before having sex to reduce the risk of transmission?  

Please advice.  

[rg91]

I got the actual document form UW.  It says "Low level antibody detected by Western Blot  assay.  Indeterminate".  "Atypical reactivity was noted against proteins on the HSV-2 Western Blot.  This reactivity may or may not be due to HSV-specific antiboty.  Full antibody profiles to HSV may take 12-16 weeks to develop especially if antiviral therapy was given".  

Please advice.  

[Edward W Hook, MD]

Your result from the UW suggests that you are seroconverting for HSV-2.  the Western blot can take longer to become positive that the HerpeSelect and your courrent result is "indeterminant"..  Their suggestion for re-testing is reasonable to be sure, but putting all that has been said above, I think you are likely to have gotten HSV-2.  

If you start suppressive therapy you should take it a minimum of a year.  As to how long after that, you need to discuss with your doctor.  EWH

[rg91]

Thank you again for your time and help.  I started taking Valtrex 1g daily and it has been tough on my stomach.  Specifically, I started having mild colitis.  Is this common reaction?  I noted on-line that there are some cases in which acyclovir appears to cause colitis.  In these cases they prescribed Famvir and the colitis issues dissapeared.  Please advice.  

[Edward W Hook, MD]

Last answer.  These are questions you need to talk about with your doctor.

Gastrointestinal side effectrs are unusual with valacyclovir.  Discuss this with your doctor and perhaps he/she will want to try famcyclovir. It is a reasonable thing to do.  EWH