[Question #6155] HSV Expertise Needed

16 months ago

I am a 27 year old healthy female.

 In July of 2018, I was diagnosed with genital herpes based on a positive culture from an active lesion. As far as I've been told, this test did not distinguish between HSV 1 and 2. The outbreak occurred after having vaginal and oral sex with someone who I later found out has had oral cold sores. I have not had another outbreak since then. These things considered, my guess was always that it was HSV 1. 

 I recently became curious enough to get HSV 1 and 2 antibody tests, which were both negative. I repeated the tests and they were negative again, leaving me and my doctors pretty confused.

 I read an article written by a woman in a similar predicament that cited some great information from conversations she'd had with Dr. Handsfield and others, including that the HSV 1 antibody test has a 10-15% false negative rate. 

The most likely conclusion that I have come to is that I have HSV 1 with antibodies at an undetectable level. My questions are:

  • Would you agree with this? Are there other possible explanations?

  • How likely is it that I will transmit the virus to another person genitally to genitally? What about genitally to orally? 

  • Is the transmission rate high enough for either route of transmission that the best practice is to continue disclosing before every sexual encounter?

Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
16 months ago
I think you are likely spot on with your diagnosis.  In fact, the IgG test misses 30% of HSV 1 infection compared to the gold standard western blot.  However, the IgG also misses 8% of HSV 2 infections, so that's possible also but I think statistically, you would have had a recurrence of HSV 2 by now. 
Transmission via intercourse of HSV 1 genital infection is rare.  And after two years of having HSV 1 genitally, you only shed virus an average of 4 days per year!
I think once a person has had HSV 1 genitally for a couple of years, the trend is away from disclosure with every partner though if you are in a relationship with someone and don't disclose and the relationship becomes more serious, then trust can be an issue.  An alternative might be to disclose the very infrequent shedding rates and also, if you are having sex with someone who has ever had a cold sore, transmission is even less likely - very close to zero.  Hope that helps.

Terri
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16 months ago
Thanks so much Terri! This is very helpful. 

I just spoke with my doctor again and she mentioned that, since I tested negative twice, another explanation is that my body may have simply failed to create an antibody response.  She compared it to the way that a small fraction of people fail to develop antibodies in response to an immunization. Her hypothesis is that even if I were to take a gold standard Western Blot test, that would be negative as well.

Do you agree with this? In situations where the tests fail, will they consistently fail if repeated on the same person? In other words, does the HSV 1 IgG test miss positive results in 30% of people or in 30% of samples

I know I'm getting pretty into the weeds here but it's been hard to wrap my head around this!
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
16 months ago
In my experience, once the IgG misses an HSV 1 infection, it misses it every time.   It misses HSV 1 in 30% of people who do the test,but some people test more than once so in that case, it misses it in 30% of sample - splitting hairs, perhaps.  it isn't a function of you failing to make an antibody response because the blot picks it up in the person for whom the IgG is negative, so right?  It's the test.  Not you

Terri
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16 months ago
Got it. Last question - do you think it's worth the effort and money to get the Western Blot?  
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
16 months ago
The IgG misses 30% of HSV 1 but 8% of HSV 2.  The odds are certainly in favor of it being an HSV 1 infection, for more than this reason.  Would I do it?  With what I know?  no

Terri
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16 months ago
Okay, thanks again! You've provided so much clarity and I really appreciate it. 

It should really be called Herpes Complex Virus ;)
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
16 months ago
Ha!  I agree completely.

Terri
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