HSV2 Understanding WB vs HerpeSelect, exposure vs "having"

[neversayPi]

I have a long term history w/ cold sores. (I also had chicken pox 25 years ago, and shingles 3-4) No genital outbreaks observed.

Starting with a new partner I went to Planned Parenthood for STI screening, especially asking for HSV. The HSV 1/2 IGG Type Specific AB Herpeselect was run. The HSV 1 was > 5.00; the HSV 2 was 1.15.

Reading other posts here (http://www.medhelp.org/posts/Herpes/Confusing-HSV2-blood-tests/show/1031630 and http://www.medhelp.org/posts/Herpes/My-confirmatory-testing-story--/show/1585737 ) it seems like being that close to the 1.1 equivocal results should warrant further testing. Furthermore the Western Blot seems to be recognized as less likely to hit this ambiguity (with the caveat that it takes long from exposure to show up on WB)

My regular doctor is giving pushback on different tests, saying an antibody test can detect past exposure and immune response, but only a swab from an active lesion could know if I "had" HSV 2.  

Is this view correct? Could someone explain if the WB would suffer from the "exposed w/ immune response, but not currently infected" issue? (Or is that even a possibility, can there have been a "successful" immune response?)

In short is there a "civilian understandable" reason why WB is considered more definite... and what can false positives for HSV 2 via HerpeSelect "mean"? HSV 1 looking like HSV 2? Is a misreading more likely with high HSV 1 presence?

And although for the past few years I was seeing about one or two cold sore outbreaks annually, I have elected to use suppressive treatment; acyclovir just now upped to valacyclovir by my doctor. Would it make sense for my partner (who is about IGG 7.7 for HSV 1, nothing on) to take prophylactic doses?

[Terri Warren, RN, Adult Nurse Practitioner]

Yes they did it for years and then obtained another test that they think is as good for confirmation of low positive ELISAs.  I strongly disagree.  Quest, by the way, only transports blood samples to UW, they don't run it themselves.  

Yes, if you look at PubMed and look by my name and look at my publications, there are 28 in professional journals.  Perhaps she will be convinced.

Terri

[neversayPi]

Thanks for your continued dialog on this!

So for the time being I will plan on taking a "drug holiday" for 3 months, and then look for a Western Blot. I will also look for a local expert; the partner I am trying to convince is deeply skeptical of everything on the web, though I try to convince her that your credentials seem great...

I'm a little confused about the Quest/WB situation: did they do it for a while and then stop? Or is "Quest" ambiguous? It looks like in http://www.medhelp.org/posts/Herpes/Low-Positive-Herpeselect-test-34-weeks/show/1223612 you gave the # to order it through Quest?

[Terri Warren, RN, Adult Nurse Practitioner]

The antiviral therapy will keep the immune system from making antibody, or delay it, in some cases.  We have a patient who was put on suppression, with a positive swab test, and two years later, being on suppression all that time, was not yet positive on the western blot.  We pulled her off and in a couple of months was positive on the western blot.  Also, the University of Washington now notes on the test results that antiviral therapy can impact the western blot.  If you are asking if you are antibody positive already can the antiviral therapy impact an ELISA later, I think that is less likely though there is a study published indicating that the ELISA can move from positive to negative and back again, while the western blot did not.

You can certainly have your doctor try to order the western blot.  Perhaps they have started allowing other people to order again though I've not heard that.  If you are successful, let me know!  I've been pushing for that with Quest without success.  Would be nice to know they are now allowing it.

Terri

Terri

[neversayPi]

Frustrating!

So what I think I heard from your first reply is there is a reasonable chance the 1.15 is a false positive.

Does suppressive therapy depress what the ELISA result reads now on an ongoing basis? Or is it that an immune response to an initial exposure during suppression would have been less, and that's what the ELISA is reporting now? (i.e. even though I know the # can very over time, and might start low in early days and then go higher as the immune response gets steam, does it later veer downward when suppressive drugs are taken?)

And just trying to understand Quest a little better, doesn't http://www.questdiagnostics.com/testcenter/BUOrderInfo.action?tc=34534&labCode=AMD indicate a test my doctor could order?

[Terri Warren, RN, Adult Nurse Practitioner]

Here is what the CDC actually says about herpes testing:

" 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."

The problem in your situation is that you  are taking antiviral therapy which can impact your antibody test.  Until you come off of the therapy and either have an outbreak which can be swab tested using PCR or you redo the ELISA and/or western blot, you cannot know if you have HSV 2 or not.  Actually, you could do the western blot now and if it is positive, then you know you are infected.  The problem comes with a negative antibody test result.  You cannot know if this negative is real until you have been off therapy for at least three months.

Your doctor cannot order the western blot through Quest.  You can, however, send to the UW for a test kit which your doctor can draw and send back to them.

Terri

[neversayPi]

I would still love some advice on next steps, especially timing, though I know some of it has to be personal and subjective... I understand I couldn't get request a WB without my doctor, so I have some thinking to do with that. But I don't blame my partner for being hesitant to throw caution to the wind when there was a result technically outside of the "equivocal" range --

(Still, the aggregate pile of circumstance... not very high-risk group-wise, no physical manifestation, a very low reading (with the suppression acyclovir caveat...) )

I did a lot of reading from the CDC, and am really getting a feeling for why they don't suggest HSV2 as part of a general screening process... they're not kidding when they talk about the psychological distress part!

If you could give me thoughts about the timing for next steps... and also this one question if a low IGG number always means "early/recent immune response OR misread from HSV 1" or if it could also represent "exposure without infection" -- if the latter is even a thing with this virus I would appreciate it greatly.

[cantletgo2013]

Sorry to jump on to another users thread, but can you please elaborate or explain what you mean when you say "the screening test (the ELISA) only looks at one protein, albeit one that is different between HSV 1 and HSV 2."? Is it one protein per virus type? If it's just a single protein altogether, how does diagnosis of either type or even both work then? Thanks for the clarification.

[neversayPi]

Thank you Terri.

Since then my doctor has kind of doubled down; "no genital ulcer = don't have it", which I know is a limited view. (it's a bummer because I like this doctor a lot otherwise... frustrating because I hope he's correct in his final conclusion, and in fact he probably is, but maybe for some of the wrong reasons)

I've been on acyclovir for a few months, my last questionable activity (and that was still fairly safe) was 7-8 weeks ago.

Could you recommend a testing strategy to maximize assurance for me and my partner? Does one need a doctor to request a WB test from Quest? How long do I need to wait for antibody development in general?

Many thanks!

[Terri Warren, RN, Adult Nurse Practitioner]

I respectfully disagree with your doctor on this.  
A truly positive antibody test indicates infection, not something else, and when a person is infected they can be infectious to others, even if there is not outbreak present.

The western blot looks at the whole range of proteins associated with herpes antibody where the screening test (the ELISA) only looks at one protein, albeit one that is different between HSV 1 and HSV 2.  

Since you are HSV 1 positive, it is more likely that your very low HSV 2 result is a false positive, due to some cross reaction with HSV 1 antibody.

The fact that you take suppressive therapy for your cold sores complicates this a little because antiviral therapy can delay the time to antibody development.  

If you are both infected with HSV 1, as you both appear to be, there is no need for your partner to take suppressive therapy, no.

Terri