They call it the Scarlet H.
Highly stigmatized, genital herpes is one of the most common sexually transmitted infections that your doctor isn’t testing you for. Most people, in fact, don’t even realize that they aren’t being tested for herpes when they request a full STI screen.
Though the Centers for Disease Control and Prevention has screening guidelines for HIV, chlamydia, syphilis, human papilloma virus, and hepatitis B, it states that screening for herpes may be useful in some situations but does not recommend screening in the general population. Why?
Let’s start with the facts. When most people think of herpes infections—life-long and without a cure or vaccine—they think about herpes simplex virus 2 (HSV-2), which can cause recurrent and painful genital ulcers. Prevalence estimates indicate that approximately 16 percent of people in the United States have HSV-2, but most people are asymptomatic.
Most people don’t even realize that they aren’t being tested for herpes when they request a full STI screen.
Genital herpes can also be caused by HSV-1, which is associated with cold sores, is often acquired in childhood, and affects approximately 54 percent of U.S. adolescents and adults between 14 and 49 years of age. However, oral HSV-1 can be transmitted to the genitals by oral sex.
Up to 90 percent of individuals with genital herpes are unaware of their infection, and the majority of new infections are acquired from individuals who do not know they are infected. Given this, and given how common genital herpes is, wouldn't routine screening make sense?
From a public health standpoint, screening for any disease should only be recommended if there is a benefit of detection and treatment. In the case of HSV-2, the benefits are obvious.
Daily suppressive therapy with drugs like valacyclovir (the most recognizable brand name form of this treatment is Valtrex, but there are generic forms too) decreases the number and duration of HSV-2 outbreaks, and can reduce transmission to uninfected partners. Some argue, however, that the emotional harm of an HSV diagnosis may outweigh the benefits of knowing, especially if you don't experience outbreaks. But are clinicians perpetuating emotional harm by essentially treating this as in infection that you don’t want to know about? And wouldn’t most of us want to take steps to prevent transmitting HSV to those we care about?
An HSV diagnosis can cause anxiety about how herpes will affect relationships. Unfortunately, the stigma associated with genital herpes may make the problem worse; it increases the chance that infected individuals will not disclose their status to their partner. This is bad for public health; just knowing you have HSV and telling your partner can reduce the risk of transmission by 50 percent. This might seem counter-intuitive, but when partners are informed, everyone can take steps to reduce transmission. This includes avoiding sex during an outbreak, using condoms, and, in some cases, taking suppressive therapy.
Another argument against screening is that good tests aren’t available. But this isn’t completely true. Accurate blood tests, around since 1999, just aren’t widely used because the CDC doesn’t recommend routine screening for herpes.
While false-negatives and false-positives can occur with these tests, the sensitivity and specificity of type-specific serologic tests are high. The tests can tell you whether you have HSV-1 or HSV-2, but if you test positive for HSV-1, they cannot tell you whether you have genital or oral herpes. So, the argument goes, why would you want to know? While oral herpes may be less stigmatized, increases in the practice of oral sex over the past two decades have resulted in an increase in genital infections due to HSV-1. From a prevention standpoint, knowing whether or not you have HSV-1 also makes sense.
In an editorial in the Journal of Infectious Diseases, Dr. Edward Hook III writes: “[S]erological testing of those at risk would provide the foundation for more effective efforts to control HSV transmission to others, and that suppressive therapy should be the preferred approach for most sexually active persons with HSV-2 whose sex partners are not known to be infected.”
Whether to get screened or not is a personal decision, but if one does want to be screened for HSV, you can’t just request a “full STI screen.” HSV isn’t included in a full screen, which means that patients must discuss getting HSV-specific tests with their clinicians.
In order for any screening recommendations and increased availability of screening to make the desired impact—fewer infections, and a healthier, more informed public—we must decrease the stigma around HSV. Increasing awareness of how common this infection is may decrease the stigma around it, which will in turn help public health prevention efforts.
Stigma reveals itself in ways big and small, from people who don’t have herpes describing themselves as “clean,” to facile jokes about people who are infected. We’re all entitled to make any joke we please, but remember: If you make a herpes joke with more than just a couple of people in the room, there’s a good chance that at least one of them won’t be laughing.