Negative, Low Positive, Equivocal: What does it mean?

[C. Cavernosa]

53 yo male, from teens-age 40 serial monogamy with some flings; mostly unprotected. Entire 40s in a monogamous relationship (she died in 2011). I recollect negative STD screens ca. 2001 and 2008, but don’t have the test results, don’t know the tests or screens then available, or if my memory is possibly playing tricks. No outbreaks or cold sores ever noted on myself or this close partner.

Began dating Dec. 2012, had unprotected mostly vaginal but some oral sex with one person, a few occasions a month. After 12 weeks was tested, igG both below reference level. No specific information about partner serostatus, but she wanted me tested. Relationship lasted one year. No sex for 11 months after that.

Six weeks ago began new relationship. Partner sexually active, but professes frequent testing, and worry over acquiring HSV. Had mostly protected vaginal sex and some unprotected oral sex on first two encounters, then unprotected oral and vaginal on three long weekends over last month.

Tested on 3/6/13 (10 weeks into prior relationship): below reference level.

Tested on 12/27/14 (three weeks into most recent relationship): HSV 1 Specific IgG 1.22 <0.90 Index

Retested on 1/8/15: HSV 1 Specific IgG 0.90 <0.90 Index

All tests were negative for HSV 2. All tests had these references:

Reference Range:
<0.90 Negative
0.90 – 1.10 Equivocal
>1.10 Positive

So I am left uncertain about my HSV 1 status. No outbreaks (that I recognized); no known history of childhood cold sores. Negative in 3/13, low positive last month, then very low equivocal upon retest. At times of all testings I was in a new relationship, and experienced some mild to moderate penile soreness, in the base or meat of the shaft, not on surface, more physical or urethral irritation, but the doctors tested and have attributed it to vigorous sexual activity after a fallow period–no discharge, no lesions, no pain upon urination, no burning, negative tests.

I assume you will suggest Western Blot for assurance, and I have started that process, and recognize that it may not reflect a recent transmission, and a negative result should be retested in a few months. I imagine you will say that the 2013 IgG test could have had a 10% chance (or more?) of being a false negative, and that I could possibly have had a long-standing exposure. Or that the recent low-positive might be a false positive (percentage likelihood same as for HSV 2, 75-85%?). Or that I recently contracted, and am in the process of seroconversion (but the low equivocal mitigates against that?).

I suppose I am just appealing to your 30+ years of clinical and research experience to get a reading of where I might be as I await the WB results from a draw later this week. Any insights? How should I address this with my current new partner that I have serious feelings for, and is concerned about HSV transmission? I recognize that if it is an HSV 1 positive, that the location will not be clear. Any way to determine if no visible outbreaks? How long will WB take to come back? What if WB is an indeterminate? If a WB is once indeterminate, does it usually always come back indeterminate? How would one proceed then?

[Terri Warren]

Well, you have done your reading, haven’t you?
Glad you are doing a western blot because that will give you more clarity particularly about your HSV 1 status. What do I think? I think you will be be positive for HSV 1 but who knows, really.

If you are positive, then you should tell your new partner. She’s worried about it. If you know you are positive, this should be a topic of discussion, IMHO. Has she been tested to determine that she is HSV 1 negative? And why would she be so concerned about being HSV 1 positive? More than half the population has this infection (which I’m sure you know).

I doubt that your penile symptoms have anything to do with herpes. If you are positive, you can start antiviral therapy daily if she is definitely negative for both. She’ll look a long time before find too many people who are HSV 1 negative, I think.

What didn’t I answer for you, Mr. Well Read?

Terri

[C. Cavernosa]

I plan to get an better understanding of her serostatus and she has said she will be retested. I don’t know for sure if she if HSV 1 negative, but I am making an assumption. Perhaps her concern is HSV 2. We are somewhat geographically inconvenient, so things are moving at a somewhat different rhythm. I will bring this up before the WB result even comes back.

I suppose I can wait to push for further info about what an inconclusive WB might mean; that bridge has not yet come in to view. But I wonder if it is around the corner.

I suppose I am looking for more granularity in considering these numbers. It seems you are saying that a negative result, a low positive, and a test just falling into the equivocal range could all indicate a previously unrecognized (or recently acquired?), positive status. Or that it could possibly be test noise, and blood proteins or whatnot interfering with the test. If a true positive, do the low numbers have any meaning for time period of acquisition or implications for shedding? Can shedding be tested in the absence of visible lesions? At what cost and procedure?

IF a true positive, what is the data about transmission for HSV 1 with/without suppression therapy?

Could someone acquire HSV 1 and not have any particularly noticeable symptoms?

[Terri Warren]

I’m not sure what you mean by granularity. I am saying that a negative result could be a new infection and not enough time has passed to make antibody OR it could be a false negative for HSV 1 (unlikely for HSV 2 if you have waited long enough from exposure to testing). an equivocal value could mean antibody is developing OR it is not developing and something else is tripping the test. Low positive numbers could be one of three things 1) antibody in the process of developing or 2) that’s just the value that someone has or 3) it is a false positive. A true positive cannot tell you duration of infection. The only way to know about the duration of infection is to have a positive swab test while having a negative antibody test followed by a positive antibody test. that can tell you that you have new infection.

Shedding can be evaluated by daily home swabbing of the genital area. It takes about 60 second a day for a male and each vial collected is $75. Some people collect seven swabs in one vial for expense purposes and that would let a person know if they were shedding at all in a given week but not how many days of shedding happen.

Transmission rates from male to female of HSV 2 without treatment having sex about twice per year without condoms is about 10% – on treatment, it is 5% approximately

Yes, someone could acquire HSV 2 or HSV 1 with no recognized symptoms

Terri

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