[Question #1752] Dr. Hook, Closure on HSV-2 Screening

43 months ago
This one is for Dr. Hook. I submitted a post six days ago called "HSV-2 and HPV Questions" asking if HSV-2 screening was recommended in my case. You recommended against it; however, I think you forgot to respond to my second follow-up question.

I also submitted a post today titled "Does my case warrant HSV-2 screening?" and spoke with Terri Warren, who seemed to recommend screening. I gave her more detailed information about my sexual history. I'm wondering if in light of the follow-up question I asked and in light of the information given in the post with Terri Warren (if you don't mind reading it), if you still do not recommend herpes testing. Thanks again, it's just that the uncertainty regarding this matters is killing me. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
43 months ago
Welcome back to the forum. Dr. Hook and I take questions randomly, without consideration of particular requests. But it's probably good I got your question anyway, because I think I can mediate between the different perspectives you had from Ms. Warren and Dr. Hook. With apology for its length, I'm taking the opportunity for a blog-like reply that might be useful for many forum readers.

A few months ago, a major public health advisory committee, the US Preventive Services Task Force (USPSTF), recommended against routine testing for HSV2 in asymptomatic persons. The publication of that recommendation was accompanied by an editorial to put the recommendations into context for the average physician. That editorial was written by -- ta da, drum roll -- our own Dr. Hook. So you can be sure he has a broad understanding of the pros and cons of testing. He agreed with the main USPSTF recommendation. Obviously, Ms. Warren has a somewhat different perspective. But their differences can be resolved.

The USPSTF recommendation assumes the average patient seeking STD screening, with the average physician with a very basic understanding of herpes and other STDs. It advises that the current HSV blood tests are frought with too many problems, and too many doctors don't sufficiently understand either the disease or the tests, so that testing isn't recommended. But the "average patient" is basically clueless; for the most part they don't give a ####. Probably Terri would agree they shouldn't be tested. OTOH, some people are concerned about herpes and have thought about it a lot. That seems to include you. It's OK for you be tested if you wish, and I think Dr. Hook would agree. Just be aware of the limtations and risks. If you get a clear negative result, which is the likely outcome, it's a done deal and you'll feel good about it. If clear positive, you might regret knowing, but at least you would know and your fear of the unknown would be resolved.

But then there are all those gray zone, uncertain results. This is the outcome in several percent of patients. At a minimum, you'll be uncertain; you'll have to undergo additional testing to work it out; and even then it may not be clear. If you're prepared for that outcome and the anxiety, time, inconvenience, and expense of sorting it out with additional testing -- and the possibility of having to warn future partners, even though it isn't certain whether or not you are infected -- go ahead and get tested.

Why the different recommendations from my two esteemed colleagues? For 3 decades, Terri has run an STD clinic that largely emphasizes genital herpes, so she sees innumerable patients with concerns like yours, as well as people with uncertain and possibly herpetic symptoms. And she knows how to handle it when the tests or symptoms give unclear results. She has more understanding of the HSV blood tests, and more experience with them, than almost anybody in the world (literally). Dr. Hook and I, on the other hand, see mostly the former kind of patients -- those attending general STD clinics who don't givave a ####. We also consult frequently with the "average" physician who doesn't understand the details of test interpretation. So our experience leans toward caution in testing.

In fairness, uncertain test results occur in a fairly small minority. But across millions of tests in millions of persons, a lot of people (and their often clueless doctors) would be left scratching their heads. Hence the concerns of USPSTF and Dr. Hook. (None of this applies to people with especially high risk of HSV2, such as the regular partners of persons known to have HSV2, and others with symptoms that suggest genital herpes. They should be tested. But neither of these seems to apply to you.)

Bottom line:  None of us can give you a specific recommendaton. However, my inclination is that you should be tested. It's on your mind, and my guess is the issue will gnaw at you until you know. If you do it, just be aware of the downsides, especially if you're one of the minority with inconclusive test results.

Finally, back to your last question for Dr. Hook in your earlier discussion with him:  Having recently shaved your pubic area, with possible skin injury, probably has no significant effect on the risk of herpes from that particular exposure. Ignore than event in considering whether or not to be tested.

With apology again for the wordy reply, I hope this has helped. Best wishes--

HHH, MD
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43 months ago
Thank you for your long and detailed reply. I do want to say that in regard to the shaving the pubic area thing that cuts were a norm for me because I'm not very good at it.  I have a feeling this doesn't change your opinion about being tested though.

I think the biggest issue with worrying about STIs in general, as seen by spending countless hours reading the forum, is a constant anxiety-riddled drive in the mind to think of exceptions and possibilities for why one ought to worry, even when the experts here provide reassurance. For example, even though you have clearly stated that I could or could not be tested quite clearly, I worry that because you do not have all the information available about my sexual history that there may be room for error. For instance, I thought maybe having multiple sex partners, smoking, living in Korea for a couple years (which has a slightly higher seroprevalence levels of HSV-2 I think) or even going so far as to think about who has had sex with whom who was promiscuous (in particular a girl who slept with 100 guys) in a sort of chain-like reasoning could have gotten me HSV-2. For example in Korea I slept with a promiscuous girl who never uses condoms and I slept with her when I had shaving cuts and also a strange rash. We only slept together maybe 10 times and in between she may have sex with someone else. I've even had thoughts that because she had a long term boyfriend before who was in his 30s (men in their 30s have HSV-2 in high rates in South Korea), that it made me more likely for me to catch the disease.  But my guess is that you'll say none of these in particular are reasons for pursuing a test any more than you have already stated. 

It's this kind of thinking that torments us here on the forums as I have seen, and I guess what I'm asking is if there's a catch-all bottom line about when you should be tested that provides no room for this anxiety-riddled exception seeking behavior.

Dr. Hook has said that he thinks my chances of having it are at about a 1 out of 3 or 4, but Warren seems to me to think I probably have the virus. So I'm a little confused.  Also Warren's recommendation to always wear condoms -- is that a strict rule for my particular case or just a guideline for sexual behavior in general. I will of course try to practice safe sex in general from this point on, given obvious fears.  Anyway, I hope I am speaking for everyone on here and I want to tell all of you thanks a million for the work that goes on here.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
43 months ago
The moderators of this forum are very cognizant of the thought processes you describe. We see them frequently in our clinical practices as well as among forum participants. That said, people with such fears are clearly a small minority of people at risk for STD. Indeed, far more energy is spent in public health prevention circles about getting people to care and to get tested than in convincing persons at low or average risk they don't need to worry. The former kinds of persons (and personalities) of course are greatly overrepresented on forums like this and on most websites. After all, the non-worried have little motivation to ask questions or see information. But reading this forum gives a very wrong impression of how most people think and feel about STD risks.

The fact is that your particular sexual history is really middle of the road compared with many people, especially those who attend STD clinics. Could you have been infected with HSV2, and might your risk be higher than average for much of the population? Yes, of course. Almost any sexually active person can have HSV2. However, positive results for HSV2 are only slighly more common in people with, say, 50 lifetime partners than those with, say, 10 partners. And not all that much higher than those with only 2-5 partners. The reasons are complex, but the data are strong.

Anyway, there definitely is no such thing as a "catch-all bottom line" about when to be tested for HSV2. The only situations that come close don't apparently apply to you:  I would recommend testing for almost all regular partners of persons known to have HSV2, and for most with symptoms suggestive of herpes but without visible outbreaks at times when they can be tested by swabbing their lesions.

I didn't interpret Terri's beliefs as you describe, i.e. that you "probably" have it.  But I only scanned that discussion, without a careful read. I'm not sure I would put your risk even as high as Dr. Hook did; I'd have guessed a 10-20% chance. But these numbers all are pretty much meaningless -- all three of our estimates are a bit better than guesswork, but not much.

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43 months ago
Thank you for all your thought and consideration. I think I'm just going to go with the rest of the herd and not test, unless I get symptoms somehow. I have enough anxiety already. It's just that I'm afraid some little baby might die from neonatal herpes or someone will get HIV because of herpes from me etc etc.

Also I did mention something about Warren's condom recommendation, but I forgot to write a question mark. It's fixed as follows:

"Also Warren's recommendation to always wear condoms -- is that a strict rule for my particular case or just a guideline for sexual behavior in general? I will of course try to practice safe sex in general from this point on, given obvious fears. 


H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
43 months ago
Condoms are a common sense guideline for all vaginal sex (or anal) sex with new partners or other non-mutually monogamous relationships. I'm sure her recommendation was independent of whether or not you might have HSV2.

That completes the two follow-up comments and replies included with each question, and so ends this thread. I hope the discussion has been helfpul. Take care and stay safe.

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