Genital Herpes Screening

[james_anonymous]

Hi Drs Handsfield or Hook

This is the link to a question I posted 6 months ago, in the answer Dr.Handsfield advised me to be confident I have not passed anything to my wife. However, there is a slim chance for HPV and herpes he says.

http://www.medhelp.org/posts/STDs/STD-concern/show/1957308#post_9174201

I have been reading CDC, American Preventive Task Force and other articles since. I now know there are no tests for HPV for men. Both CDC and APTF (as you already know) do not recommend for ROUTIN herpes screening. This is confusing me because I don’t know what that means (routine). I am thinking about going back and get tested for herpes but then I read testing can have negative psychological effects and basically the costs are more than the benefits. I am also not sure of the qualifications of ordinary GPs compared to your credentials.

Please answer the following questions. I do not seek reassurance, I want to know the most medically/ethically recommended thing to do regarding my past experience:

1 . Does my situation qualify me for testing for herpes (or anything else I have not mentioned in my previous post?) If I had come to your office what would you have advised me to do?

2. I read that there is a controversy about testing for genital herpes, what is the most common consensus? What do CDC and APTF say exactly?

I apologize for posting again, but I really cannot find the answer myself – there is so much I can learn from the internet when I have not studied medicine myself.

[james_anonymous]

Thank you. I will think more to see if it is right for me to get tested from USW I was hoping you'd give any other reason for not testing other than false positive.

The 80% was the percentage of sexually active people who come in contact with a person with an HSV2 infection, this was an estimate by Dr. Handsfield and I was wondering if you agreed on that.

[Edward W Hook, MD]

You are correct, I do think you are over reacting in your instance that you need to do further testing to rule out HSV infection. There is a big difference in the likelihood of a false positive test for HSV and for HIV.  In HSV that number is less than 1 in 100,000.  for HSV it is higher, perhaps as high as 1 in 50 or higher.   I will answer these questions and then this will complete this thread.  

1.  The Western Blot performed at USW is the accepted gold standard for antibody testing for HSV.  You have no indication for testing but if you feel you must be tested, that is the most reliable test.

2. Yes, my statements are consistent with the recommendations of other experts in the field. Dr. Wald is a friend and a colleague and we helped write the CDC guidelines recommending against routine testing together.

3.  The figures you quote are high.  60% of adults will have antibodies to HSV-1, about 16% will have antibodies to HSV-2. the presence of antibodies, unless they are a false positive test, indicate infection, not "exposure".  If there is exposure but not infection antibodies are not present.

This thread has now far exceeded the time and space we can make available.  If you want to test, do so.  There's not more to be said .  EWH  

[james_anonymous]

1. Would a Western Blot Test from U of Washington do me any good in terms of reducing the chance of false positive?

2. I read discussions like these http://commonhealth.wbur.org/2011/04/latest-genital-herpes that suggest well known herpes experts such as Anna Wald have disagreements whether to test or not (she seems to support widespread testing). Are these confusions on my misunderstanding or misunderstood reports? Are your recommendations consistent with the majority of experts and professionals (I know I am repeating this question - but this part is very important to me)?  

3. I read about the psychological costs (by CDC and APTF) that weigh the option of not testing and that since 80% of the population probably are going to be exposed (not necessarily infected - this is from Dr. HH in a post) the point of testing is moot. Do you agree with these statements? Did I understand  the number 80% right? http://www.medhelp.org/posts/STDs/Risk-assessment-for-herpes/show/1525385  Is HSV2 like HPV, part of sex life?

This is basically my dilemma, whether to unnecessarily upset my partner with a positive diagnosis that would have been very unlikely or be a responsible individual and take appropriate measures to prevent transmitting HSV2 to her. I did not hesitate testing for HIV although experts in this forum were not recommending for it for protected intercourse. Maybe I am a conservative person. But with HSV2 I am thrown off  with recommendations against testing that has gotten me to this point where I can't decide if testing is harmful or helpful to my partner.

I am sensing we are reaching a point where you will assume I am overly anxious about HSV2 - I am not (although keeping my emotions stable is not very pleasant). But think of me as someone who is trying to do the right thing given that his loved one is involved.

[Edward W Hook, MD]

1.  In relatively low risk persons such as yourself, testing for HSV is more likely to result in a falsely positve test than to lead to the discovery of a HSV infection that you did not know you had.  On this forum we can tell you the facts (testing is not recommended) and let you decide what you want to do with them.  My advice remains not to test.

2.  Repeated testing would not necessarily change the results.  EWH

[james_anonymous]

I imagine I must make another payment to receive a response for these questions?

[james_anonymous]

in case number 1 is unclear: does "not recommended" and "no need" mean the same as " don't do it it is a bad idea" or "your call you decide"?

[james_anonymous]

Dr. Hook, I am very sorry to post again. I have been reading your answers multiple times, but I still struggle with these two questions:

1 - I know you say there is "no need" for testing (for HSV-2) and testing is not recommended for the general population (so says CDC for instance), does that mean that testing is an inappropriate choice, in that it can leave negative effects on the person? Would you emphasize that I do not get tested because it is a bad option or do you just find it unnecessary and leave it to my personal choice?

2 - Does testing multiple times (say 3 to even 5 times) reduce the possibility for false positive results?

[james_anonymous]

lower than for most "people"? Sorry I get confused by colloquial English. You can also go ahead and close the thread -  I have asked all my questions. Again thank you very much, I wish you and Dr. Handsfield well. Good bye.

[Edward W Hook, MD]

No, in fact, form what you say, if anything I would anticipate your risk to be, on average, lower than for most.  EWH

[james_anonymous]

Thank you Dr. Hook. I can and will move on now. As a final summary comment, you do not see any reason for me to think of myself any riskier for society (in terms of exposure to STIs) compared to the time I didn't have this particular encounter. Correct?

[Edward W Hook, MD]

Your assessment is correct.  And you are also correct, that of the 16% of persons who have HSV, they have it primarily as the result of bad luck, not that they are doing anything wrong or problematic. EWH

[james_anonymous]

Thank you for a very thorough response. Although I did not notice symptoms (not that I looked), I am very very suspicious with my past encounter (I thought condoms protect you from everything back then, which turned out to be not entirely true). But I imagine you, like Dr. Handsfield, stay on your conclusion even if my past partner had a confirmed diagnosis. I also take it that any doctor with familiarity with CDC and/or any other professional STD guidelines will give your advice (like I said I don't trust general physicians on this one). Correct me if I am wrong.

Throughout my debilitating amateurish research, I have heard arguments for and against testing and even made arguments myself. I don't want to do that anymore - it is a waste of time and effort. One thing I have been dying to know though is, if middle/upper class ordinary Americans (people I see around at work and my neighborhood) have the 16% possibility for HSV-2 and that the majority of that percentage is not adventurous (or thoughtless) people like me that got unlucky.

[Edward W Hook, MD]

Welcome back to the Forum.  I'm sorry to see that your pre-marital experiences continue to worry you.  I think you are worrying entirely too much.  As Dr. Handsfield told you your chances of infection, both because of the nature of the exposure (even most "very promiscuous persons" do not have STIs), that you used a condom, and that you have not had symptoms all make it most unlikely that you were infected.  The addition of the fact that there was hand to genital contact does not change this assessment.  I, like Dr. Handsfield would urge you not to worry further and to move forward without further concern.  I see no need for further testing, including for HSV.  

In answer to your specific questions:
1 . Does my situation qualify me for testing for herpes (or anything else I have not mentioned in my previous post?) If I had come to your office what would you have advised me to do?
If I saw you in my clinic I would tell you there is no need for testing, particularly for HSV (see below).   if you felt it was important I would perform visual inspection for visible warts and do what we call "screening" for the most common STIs, chlamydia and gonorrhea although I would also tell you that I do not feel strongly that they are needed and that if you chose not to have them, that would be OK for me as well.  I would tell you that if I tested, I would do so anticipating that the results of the tests would be negative.

2. I read that there is a controversy about testing for genital herpes, what is the most common consensus? What do CDC and APTF say exactly?
There is no controversy about HSV testing.  It is not recommended as a general screening test in persons who do not KNOW that their current, regular partner has HSV or who have not had a syndrome suggestive of HSV.  You have not.  Thus, in your situation, you might find that you had HSV-1, the virus that causes cold sores and a small amount of genital HSV but the result would do you little good since the result would not tell you where your infection was on your body or how long you had had it.  Most persons with HSV-1 do not get cold sores and have acquired their infections in childhood.  As for HSV-2 testing, this infection is far rarer than HSV-1 and as a result, multiple carefully conducted studies have shown that you would be more likely to have a falsely positive test (i.e. have a positive test but not have HSV) than to find out that you'd acquired HSV-2 and did not know it.

I hope these answers are helpful.  I really think you are worrying entirely too much. EWH

[james_anonymous]

I forgot to mention that I received hand-to-genital contact (handjob) from my female encounter too during the intercourse. I don't think this adds much since I also read this is very very low risk in your forum. I thought I let you know however.