STDs Expert Forum
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The STD Forum is intended only for questions and support pertaining to sexually transmitted diseases other than HIV/AIDS, including chlamydia, gonorrhea, syphilis, human papillomavirus, genital warts, trichomonas, other vaginal infections, nongonoccal urethritis (NGU), cervicitis, molluscum contagiosum, chancroid, and pelvic inflammatory disease (PID). All questions will be answered by H. Hunter Handsfield, M.D. or Edward W Hook, MD.

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I had protected vaginal sex and unprotected oral sex with a sex worker on Jul 19th (17 days ago, as of today). Oral sex lasted for a while, and I ejaculated inside her mouth. There was deep kissing. I did not notice any legions on her body or face. Have been in a long term monogamous relationship for about 15 years, and this is the only time I did something like this. I feel extremely guilty and worried. I set up tests. Specimens were collected on July 31st (12 days after exp.). (by LabCorp).

HBsAg Screen
Hep C Virus Ab - Neg

RPR - Non reactive
Chlamydia trachomatis - Neg
Neisseria gonorrhoeae - Neg
HSV 1 IgG, Type Spec - Neg (<0.91)
HSV 2 IgG, Type Spec - Equivocal (1.02)
HIV-1 DNA - Not detected
HIV 1/O/2 Abs-Index Value < 1.00
HIV 1/O/2 Abs, Qual - Non Reactive

Only one outside range is the Equivocal 1.02 HSV2 test. I am devastated, since as far as I understand, there is a high likelihood infection.

No visible symptoms on my genitals. Had a sore throat for the last 2-3 days, and there seemed to be an ulcer on one side of the throat. It is now gone. Had some minor muscle aches, a few days ago. Today I went to a dermatologist, who did not see any symptoms either.
1) How should I interpret the HSV2 result? What is the likelihood of me being positive for HSV2?
2) What should my next steps be? I am anxious to get more clarity as soon as I can, and the expense of tests etc. is not an issue.
3) Any doctors and/or clinics you would recommend in the Dallas/Forth Worth area? If not, I do not mind flying to another city either. The doctor I visited did not seem to be an expert on STD's.
4) Should I avoid unprotected vaginal and/or oral sex (both ways) with my wife? Kissing? Even if I have HSV2, I don't know where, right?
5) Should I start anti-virals? If yes, how much? Especially since I do not want to infect my wife.
6) Do you recommend tests for anything other than herpes?
Welcome to the forum.  Thanks for your question.

I'll dismiss your major concern first:  almost certainly you do not have HSV-2 and certainly did not catch it during your sexual exposure 2 weeks ago.  I'll come back to it.

You had a very low risk sexual experience.  Oral sex is safe sex -- not totally free of STD risk, but much lower chance of all infections than vaginal or anal sex, and zero risk for some.  Most pertinent to your major concern, oral sex ix zero risk for HSV-2.  Had you asked before being tested, I would have advised you not to have any STD tests at all. But because you did so, you are now confronted with a very frequent problem:  the HSV-2 blood test often gives false positive results.  That test should never have been done in this situation.  To your specific questions:

1) Your HSV-2 result is in the equivocal range.  Almost all such results turn out to be false.  Even though the official recommendation from the test manufacturer is that a result 0.9 - 1.1 is equivocal and over 1.1 is positive, in fact a result is not reliably positive unless the value is 3.5 or higher.  Almost certainly you do not have HSV-2.

2) From a strictly medical perspective, you need do nothing now.  As noted above, oral HS-2 is uncommon; and therefore oral to genital HSV-2 infection almost never occurs. If I were in your situation, I would continue unprotected sex with my wife, knowing there is no risk.  However, now that you have had this apparently frightening result, you could consider having an HSV Western blot test.  WB is the definitive tie-breaker for HSV testing.  I'm confident it would be negative for HSV-2, if you decide to do it.

3) I cannot make a specific referral.  But there are solid HSV/STD experts at the UT Dallas (Southwestern) medical center.  But frankly, I don't think you need to see anyone at all.

4) As suggested above, if I were in your situation, I would be continuing unprotected sex with my wife.  Nothing has changed since this sexual exposure or your blood test results.

5) There is no need for anti-HSV therapy.

6)  Your risk for all STDs was very low.  I see no need for any testing beyond what has already been done.

I hope this has been helpful.  Best wishes and stay safe--  HHH, MD
This is very helpful and encouraging, thank you.

1) I totally understand your point about the encounter being a low risk event, and this is great news. I am mostly relieved but still have a few questions in my mind. Hypothetically, suppose that I was one of these 1 in a 1000 people (of course I don't know what the exact stats are) that somehow got HSV2 from oral sex. Would then a 1.02 result possibly be because my body has started to build antibodies for the virus, but since it had been only 12 days at the time of blood collection, the concentration was low? I know this sounds paranoid but I just want to air out all that is in my mind. I hope you understand the perspective of someone who is completely new to this and is very worried, even if it is obvious to you that I am worrying unnecessarily. Just want to get information from an expert.

2) If I were to get the WB test, could I get it now? I am currently in day 17 after exposure.

3) As for an HSV/STD expert, would the physician be an infectious disease specialists, internist or urologist?

Thank you so much. I appreciate being able to talk to an expert.
It is theoretically possible that a result of 1.02 could be the start of developing antibodies to HSV-2.  However, this is a one in a million sort of possibility -- not something worth worrying about.  Rather than a Western blot, I would recommend you first just have another standard blood test.  Most likely the result will be truly negative (under 0.9), or at least no higher than it is now.  Such a result would prove you did not catch HSV-2.

I see no need for you to see any expert consultant at this point.  But if you decide you need to do so for further reassurance, I would suggest an internist or ID specialist, not a urologist.

If you have another HSV blood test, I'll be happy to comment once again.  But no other information you can think of is likely to change my opinion that you don't have HSV-2, or my advice -- so I won't have any other comments.  
Very informative MD. Im interested to see the outcome. But is the igm suppose to show recent infections? In that case it may explain why the igg gave a false negative as it is suppose to pick up igg at a later stage.
IgM antibody is useless for herpes and often misleading.  If and when anyone has HSV testing, they should request that their provider inform the lab not to do an IgM test.
Dr. Handsfield,

I followed your advise and got another standard blood test. As you had correctly predicted, the result was negative. This time I had the test done at a Quest Lab (instead of LabCorp), and it was a Herpeselect test. The document does not give an actual number, just indicates that it is below 0.90.

Thank you very much, doctor. You have been extremely helpful at a difficult time. During my visit to the dermatologist (the visit before I interacted with you), I got a chance to speak to two doctors (one resident and one attending), and both of them thought that the blood test I had (with 1.02) was positive confirmation of HSV2 infection, even though there were no visual symptoms. One also told me that it is impossible to transmit the virus while I am not having an outbreak (which I gather is not true, after reading posts in this forum). I am not trying to blame the two doctors, but it seems there are many physicians out there who are not well informed about this condition. I find this surprising, given the prevalence of the virus. You are providing a very valuable service.

As for the whole episode, it has been a good lesson for me.
Indeed the knowledge about herpes (beyond the most simple basics) is poor among many physicians.  Anyway, thanks for the thanks.  I'm glad to have helped.
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