[Question #4567] Eithics of Testing

26 months ago
Hello Doctors. First, thank you so very much for everything you do. I have a pretty bad case of guilt-OCD and the work you do has helped me through it greatly. I have a question on the ethics of testing.  I am routinely tested for HIV, chlamydia, gonorrhea, and syphilis (and sometimes Hepatitis B). However, I have never been tested for herpes due to a lack of symptoms. I have a normal-ish sexual history for a 25 year old male - However in college I did have a year long sexual relationship with a woman who had many many previous partners, and we were most often unprotected (stupidly enough), though she also never had herpes symptoms. I didn't think about herpes much until recently -when  I had a one night stand, a few weeks after being tested negatively for the above STDs. We used a condom at her suggestion, but started without it (at my suggestion, in order to help me overcome horrible performance anxiety). We did this a couple times. I suddenly got horribly worried that maybe I gave her herpes and ruined her life because of my suggestion to start without protection, and herpes wasn't included in my recent testing. So first of all - if you were in my situation (or if i was your son, for example), would you recommend herpes testing despite a lack of symptoms. Part of me wants to know and part of me is worried that my dating life will be completely derailed if I am indeed positive. Secondly - in terms of transmission rates, I had read from Dr. Hook and Dr. Handsfield that HSV2 transmission is something like 1 in 1000 exposures. However, I had read elsewhere that the study that provided may have been flawed since the partners in the study had been together for mean 2 years, and that the median number of exposures before transmission is more like 40 - which is a more scary number! I'm just so scared that I potentially hurt someone with my thoughtlessness. And my guilt ocd only exacerbates the problem. Once again, I am so grateful for the work you do to keep us all safe. 
Edward W. Hook M.D.
Edward W. Hook M.D.
26 months ago
Welcome to the Forum and thanks for your question.  Your question has more to do with personal decisions than right or wrong. Obviously, all I know if you comes from your post but given your OCD (thanks for letting me know, this is an important consideration) I would suggest that testing for HSV is not a good idea.  First, I say this because it is more likely than not as a 25 YO male that you already have HSV-1 (over 50% of persons your age do) and the tests are just not good enough to be 100% confident in the results.  The most widely used HSV blood tests have a substantial false positive rate for HSV-2 and are unreliable for HSV-1 diagnosis.  When I consider your OCD, i do not think that would be such a good thing to grapple with.  Further, if you truly had HSV, I worry about its impact on your OCD. The fact is, while persons can acquire HSV-2 without knowing it, it is not all that common and given the absence of outbreaks or suspicious episodes on your part, your likelihood of transmitting an infection that you do not know you have is quite small.

Regarding the issue of how commonly HSV is transmitted, all figures are estimates.  We know for sure that far less than 1% of exposures to infected partners lead to infection which infection being somewhat more common among persons who have lesions present and who have relatively recently (in the past year or two) acquired infections.  I am confident that the estimate of 1 infection per 40 exposures is far, far too high.  Our estimate is that he risk is less than 1 in 1000 exposures to infected, asymptomatic partners.

Finally, should you decide to test, (I hope you will not) you should figure out how to get a Western blot test performed at the University of Washington virology laboratory.  It is the best lab for HSV blood tests.

I hope these responses are helpful.  As you probably know, if anything is unclear, we provide up to two follow-up questions to deal with anything that is unclear.  EWH
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26 months ago
Thanks so much for responding, it made me feel much better. As a follow up question, I suppose I would ask - is there anything to this idea that testing transmission rates on long-standing couples is possibly inaccurate due to some sort of immunity that develops with frequent long-term exposure? Or is that somewhat bogus? I keep reading these studies saying that the transmission rate is very low, but in the "comments" section they talk about how these numbers might be skewed low due to testing long-term couples. For the sake of my OCD, I definitely need to stop reading (and badly interpreting) scholarly articles, since I ultimately know nothing and you all are the experts. Thanks again (this will be my final follow up).  
Edward W. Hook M.D.
Edward W. Hook M.D.
26 months ago
I think you are overthinking things.  There is a sense, that the frequency of HSV recurrences and asymptomatic viral shedding gradually slow over a period of years in persons with longstanding infections.  Conversely, recurrences are most common in the initial year or two after infection.  The mechanism by which this subtle change in frequency occurs is unknown and, given the substantial person-to-person variation in rates of recurrence, is not something to worry about or focus on.  

I agree that it might be best to sop focusing on this.  Your knowledge is good but it is tempered by your OCD.  Focus on moving forward.  EWH.  
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26 months ago
Sorry I should clarify misleading wording in my last response. I meant that there is a hypothesis out there saying that testing transmission rates on long-term couples is perhaps useless , because if partner 1 ( seronegative) somehow doesn't catch hsv2 from partner 2 (seropositive) after a few months, then partner 1 has essentially built up a partial immunity to the virus, making it hard to ever catch it - I guess there was a study saying the following : 


RESULTS:

Among 199 persons with laboratory-documented newly acquired genital herpes, the median duration of the sexual relationship with the transmitting partner was 3.5 months, and the median number of sex acts before transmission was 40. The median time to HSV-2 acquisition was greater among participants whose partners disclosed that they had genital herpes, compared with participants whose partners did not disclose their status (270 vs. 60 days; P = .03). In multivariate models, having a partner who disclosed that he or she had genital herpes remained a strong protective factor against genital HSV-2 acquisition (hazard ratio, 0.48 [95% confidence interval, 0.25-0.91]).

However this study was predicated on people just ESTIMATING the number of exposures they had before they got hsv symptoms from their partner, which seems problematic. Not sure if this is total BS. I much prefer the < 1 in 1000 statistic that you and Dr. Handsfield provide :) That's a number I can feel good about! I understand this is my last message according to the rules, so thank you thank you THANK YOU!

Edward W. Hook M.D.
Edward W. Hook M.D.
26 months ago
I think you are focusing on the wrong part of the excerpt you pasted in.  While they state the figures for relationship duration and numbers of sex acts, it appears that those variable DID NOT remain significant when multiple possible variables were accounted for in the multivariate analysis.  I feel good and confident about our less than 1 in 1000 estimate.  

As you point out, this will conclude this thread.  I hope the information I provided was helpful.  Take care, please don't worry, fight your OCD and stay off the internet.  EWH
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