Is Herpes testing medically appropriate in my case?

[kelona1900]

I would like to know if Herpes testing is medically appropriate in my case. I have had zero symptoms––and I am very aware of my body––and quite low risk sexual encounters, which I’ll describe, but I have read some chatter in Herpes forums about how “everyone should get tested routinely,” though the medical professionals I have read on WebMD forums––Hunter Handsfield, Edward Hook––do not seem to agree. I just want to do the right thing, ethically speaking. I have been tested for all the things that are included in usual STD screenings and am negative for those.

My sexual history: I was with the same partner for 15 years. She had very rare cold sores on her mouth, so HSV 1, and she was very careful with me around times she had symptoms. She performed oral sex but never around the times she had symptoms and not very often in any case. Since then, I have been with four regular partners, each for a few months. With the first two I always used condoms. With the third, there were maybe a dozen times we didn’t use condoms. None of these women had herpes as far as they knew. The fourth woman I dated did have genital Herpes (HSV-2), and had had it for 15 + years, with only one outbreak per year. We had only protected sex––during which I was exceedingly careful, almost not allowing the base of my penis (beyond where condom was covering) to make contact with her vagina––and we only had sex about five times, after which we ended the relationship. I performed oral sex on her a few times as well. She never had any symptoms of outbreaks, which she would have noticed, being alert to them after having had herpes for so long. I have read about asymptomatic viral shedding, but by my math, the odds of my having caught HSV-2 in that case––while wearing condoms AND having sex only a handful of times AND being almost overly careful AND not having any symptoms even months later––is anywhere from about 1 in 2000 to about 1 in 10,000.

That last encounter is what made me begin to research herpes, and made me wonder if, ethically, for the sake of future partners, I should get tested. I read that it is possible to carry herpes asymptomatically, and I would hate to think that I picked it up somewhere and could transmit it in the future unawares. However, as I say, I have never had a single symptom, and I am also wary of testing because of what I’ve read about the relatively high rate of false positives with the current test. And in fact, both my GP and the Infectious Disease specialist she consulted advised against testing for that very reason. However, I know the medical community is not necessarily up to date on the latest Herpes recommendations.

I would be happy to forget testing and just go on with life and being careful as usual. I would prefer not to go through the ordeal of having a false positive that can’t be 100% clearly interpreted, and then not knowing what that means. But I want to be responsible as well. Your expertise in this areas would be appreciated.

• This topic was modified 6 years, 10 months ago by kelona1900.

[Terri Warren]

In our clinic, we run the ELISA and the rate of false positives is 2.7%. I don’t consider that high. 5.5% of people have what is called a low positive (1.1 to 3.5) and need clarification. Of those, half do not confirm as positive. If you look at the CDC STD treatment guidelines their comment about HSV antibody testing is this:

“Type-specific HSV serologic assays might be useful in the following scenarios: 1) recurrent genital symptoms or atypical symptoms with negative HSV PCR or culture; 2) clinical diagnosis of genital herpes without laboratory confirmation; and 3) a patient whose partner has genital herpes. HSV serologic testing should be considered for persons presenting for an STD evaluation (especially for those persons with multiple sex partners), persons with HIV infection, and MSM at increased risk for HIV acquisition. Screening for HSV-1 and HSV-2 in the general population is not indicated.”

Multiple partners is more than one.
We always include herpes testing in our STD screens, unless someone already has herpes or specifically declines herpes testing. It is the most prevalent STI in the US (not the most incident) and to leave it off of an STD screen in my mind is not appropriate. I know Drs. Hook and Handsfield and I may disagree about this point.

Terri

[kelona1900]

Thank you for your answer, and for some specific numbers. Just a bit of clarification:

– When you say the false positive rate on the ELISA is 2.7%, does that mean that 2.7% of people who take the test are ABOVE 3.5 and yet do NOT have HSV-2? If that is the case, does that mean that a result over 3.5 is not an absolute positive, but rather a 97.3% likely positive? Does that also mean that 2.7% of people who take the test are told they have genital herpes when in fact they don’t? (Also, curious how those 2.7% are eventually identified as having been false positives?)

– For the 5.5% “weak positives”––1.1 to 3.5–you mention that only half do not confirm as positive. Is that confirmation done through a second ELISA test or through Western Blot? And for the other half who continue to be a weak positive, is the positive considered definitive, even if it is weak, or is there still a possibility that it is false?

When you have had conversations with Drs. Hook and Handsfield (and others) about the question of when testing is appropriate, what is the source of the disagreement? I guess I’m asking, do you know what they would argue, what their basic points would be?

Finally, in the encounter that I had with a woman with HSV-2, would you agree that my risk in that single encounter was indeed in the 1/1000 or less range? (I arrived at that figure by considering 0.04 risk of transmission for a year of unprotected sex in discordant couples times the much lower number of sexual encounters in our case times the extreme caution we took times the fact I have no symptoms, etc.)

Thanks again–this is all very much appreciated. I have found that a lot of advice online lacks the statistics and arguments to back it up, so I am grateful for the precision in your answer above.

[Terri Warren]

The 2.7 is the approximately half of the 5.5% of people who test in the low positive range (1.1 to 3.5) who do not confirm as being positive when their sample is also tested by western blot.
Most recent research has also found that even in those people who test over 3.5 index value, several do not confirm when also tested by western blot. I’m hoping to publish that soon.
I think Drs. Hood and Handsfield are reluctant to risk the false positive value. I chose not to live by the small number who need confirmation but by the majority who test either clearly positive or clearly negative.

I think your stats are about right, yes.

Terri

[kelona1900]

Thanks once again––these hard stats are extremely helpful, and challenging to find! (I am actually in the medical field, so I can read and understand academic journal articles; where do you personally keep up to date on the latest research?)

I have a couple of other questions that are more general that I will try to fit into this post, and if not, I’ll be happy to pay to follow up. One is to do with the latest research on asymptomatic viral shedding for genital HSV-2, and the other is on truly asymptomatic carriers of genital HSV-2 (or genital/oral HSV-1 for that matter).

Regarding asymptomatic viral shedding for genital HSV-2: I have read anything from asymptomatic viral shedding occurring 10-15% of the time to 30% of the time (with more sensitive tests) to “continuously” (Dr. Peter Leone). Dr. Leone describes HSV-2 as never in fact actually being dormant but travelling pretty much continually up the nerves towards the skin surface, where it is continually cleared by the immune system, though may spend several hours on the skin before it is cleared. It also seems HSV-2 could travel back up and appear anywhere on the skin that the dorsal root ganglion innervates. So, theoretically, the virus could be present almost anywhere, anytime. I’m more interested in clinical experience though than in theoretical possibilities (because all four tires could blow on my car at once, too, but it’s highly unlikely.) In your experience and that of your colleagues in your clinic, when protection (condoms) is used properly, and there are no symptoms present, what is the real risk of transmission of genital HSV-2? I know there is always and must be the disclaimer given that one can catch genital HSV-2 anytime, even without symptoms, even with condoms, but I wonder, in the clinical experience of physicians and nurses working in STD clinics, how often they actually see someone who has used condoms properly 100% of the time catch genital HSV-2 from an asymptomatic carrier, relative to how often they see patients catch genital HSV-2 from unprotected sex. I guess I’m trying to distinguish here between “anything is possible” and “how likely this is to occur.” Not for the purposes of tempting fate––I think it’s always best to be careful––but just to get a sense of what you actually see most of the time in your clinic.

Regarding truly asymptomatic carriers of HSV-2 or HSV-1, genitally or orally: of all the people with HSV-2 or HSV-1, how commonly would you say it is to see people who never had a first outbreak, never had a single symptom, and yet are carriers? It seems from what I’ve read that most people who don’t know they have Herpes can be taught to recognize certain mild symptoms they might otherwise have overlooked. And even among that remaining percentage who don’t seem to experience even mild symptoms, I wonder if they are perhaps not quite self-aware enough of their bodies to notice those symptoms. In other words, how often, in your clinical experience, and in the research, is herpes truly, truly invisible vs. just very, very mild? Again, I think I’m trying to get a sense of what the actual percentages are, versus what is just theoretically possible.

Thanks for all this very helpful information, and for your work.

[Terri Warren]

I think it is NOT common to see someone acquire HSV 2 when condoms are used with every single intercourse and it is even less common if the person with herpes is taking daily antiviral medicine. I have seen, in my practice, people who acquired herpes while using a condoms, most definitely, and that is most often right at the base of the penis when condoms do not cover. It is far more common to see herpes in people who have not used condoms.

In terms of the asymptomatic carriers: Most people can be taught to recognize the subtle presentations of herpes once they are diagnosed, most within 3-6 months. But I have patients who come back to me with every little ditzel on their genitals to try to sort out if this or that is an outbreak and they never can. So I would guess that most of the time, herpes symptoms are very subtle and easily missed rather than being truly asymptomatic completely. I don’t have percentages for you. but we do know that 80% of those who have HSV 2 would say they don’t have any symptoms of genital herpes. Lots of people don’t realize that outbreaks can be anywhere in the boxer shorts area and remember – asymptomatic shedding does not occur from thick skin like thighs, buttocks, belly, just very think skin or mucous membrane.

I use PubMed to stay up to date on herpes.

Terri

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