Genital herpes guide: Screening and diagnostic testing
Screening and diagnostic testing guidance for the genital herpes.
Note: This guide provides minimal information about neonatal herpes. For more information, refer to the Canadian Paediatric Society Position Statement about the prevention and management of neonatal herpes simplex virus infections.
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Screening
HSV
General population
Screening for HSV is not recommended in people with no history of anogenital lesionsFootnote 1Footnote 2Footnote 3.
Pregnancy
Healthcare providers should routinely inquire about any history of signs and symptoms that may suggest genital herpes. There is insufficient evidence to support screening during pregnancy when neither risk factors nor a history of genital lesions are identifiedFootnote 4Footnote 5. In pregnant persons with confirmed HSV-2, there is insufficient evidence to support routine testing to detect viral sheddingFootnote 3Footnote 4Footnote 5.
Other STBBIs
Screening for STBBIs varies by age, gender, sex, medical and sexual history. Screen anyone who presents with STBBI risk factors and treat as appropriate to prevent transmission and reinfection.
Genital herpes, particularly recently-acquired infection, can increase the risk of HIV acquisition and transmissionFootnote 6Footnote 7Footnote 8Footnote 9Footnote 10.
People being evaluated or treated for genital herpes should be screened for:
- Syphilis
- Gonorrhea
- Chlamydia
- HIV, as per the recommendations in the HIV Screening and Testing Guide
Differential diagnoses include other infectious causes of anogenital ulcer disease (AUD), such as syphilis, chancroid and lymphogranuloma venereum (especially in gbMSM)Footnote 11Footnote 12Footnote 13. AUD may also be due to non-sexually transmitted fungal, viral or bacterial infections, as well as non-infectious skin and mucosal conditions and diseasesFootnote 14Footnote 15Footnote 16Footnote 17Footnote 18Footnote 19.
Diagnostic testing
Herpes is diagnosed using viral identification techniques such as NAAT or viral cultureFootnote 20. Type specific serology (TSS) may also be helpful when viral identification techniques are negative in a person with a history compatible with genital herpes. Consult with the local laboratory regarding test availability, specimen collection and test performance.
When NAAT or culture is positive for HSV, the type of HSV should be determined, so that appropriate counseling can be providedFootnote 21.
Recommended specimens and tests in symptomatic people
NAAT
NAAT approaches sensitivity and specificity of 100%, with rapid turn-around of resultsFootnote 1Footnote 22Footnote 23.
Testing by NAAT is appropriate when:
- HSV infection is suspected
- Viral culture could fail to detect HSV (e.g. lesions have begun to heal)
- Neurologic (meningitis and encephalitis) or systemic manifestations are present
- Neonatal herpes is suspectedFootnote 21Footnote 24
Viral culture
Cultures from lesions caused by HSV can yield positive results within 24 hours.
Culture permits the identification of HSV typeFootnote 25Footnote 26. It also provides information on susceptibility, making it appropriate when antiviral resistance is suspectedFootnote 27.
Sensitivity varies depending on the lesion being sampled (94% in vesicles, 87% in pustular lesions, but only 70% in ulcers)Footnote 21. Sensitivity of culture declines when lesions start to heal and is low for recurrent lesionsFootnote 21. Due to its superior sensitivity, consider NAAT when a false negative culture result is suspectedFootnote 1Footnote 23. If NAAT is not available, viral culture can be repeated on fresh lesions.
Type-specific serology (TSS)
Consult the local laboratory for the availability of HSV TSS.
A study of TSS showed a sensitivity of 80.5% and specificity of 98.5% for HSV-2, and a sensitivity of 91% and specificity of 96.4% for HSV-1Footnote 28.
TSS testing can demonstrate whether partners are serodifferent (both partners have HSV, but different types) or serodiscordant (only one partner has HSV) or concordant (both partners have the same HSV type).
TSS may be useful in the following situations:
- When signs and symptoms (typical or atypical) of genital herpes are present but viral identification tests (NAAT or culture) are negative or not feasibleFootnote 29. Note: Repeat viral testing of fresh lesions is preferred over TSS.
- To identify the need for preventive measures when sexual partners are suspected to be serodifferent or serodiscordantFootnote 21.
- When a first episode of genital herpes occurs during pregnancy. The presence or absence of type-specific antibodies can help to differentiate between primary and non-primary infection. This is important, given the higher risk of vertical transmission when genital herpes is acquired in late pregnancyFootnote 24.
TSS should not be used for screening asymptomatic people because:
- It frequently leads to false negative results in the early stages of infectionFootnote 28Footnote 30Footnote 31.
- Approximately 80% of people with HSV-2 will have seroconverted within 4 weeksFootnote 32. However, detection time can exceed 3 monthsFootnote 3.
- A positive serological result does not confirm a diagnosis of genital herpes: it could be due to orolabial infectionFootnote 3.
References
- Footnote 1
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Ratnam S, Severini A, Zahariadis G, Petric M, Romanowski B. The diagnosis of genital herpes - beyond culture: An evidence-based guide for the utilization of polymerase chain reaction and herpes simplex virus type-specific serology. Can J Infect Dis Med Microbiol. 2007;18(4):233-240.
- Footnote 2
-
Guerry SL, Bauer HM, Klausner JD, et al. Recommendations for the selective use of herpes simplex virus type 2 serological tests. Clin Infect Dis. 2005;40(1):38-45.
- Footnote 3
-
Marc S, Gabrielle L, Rachel CdM. Serology for Herpes Simplex Virus: tips, pitfalls and misconceptions. Institut National de Santé Publique du Québec (INSPQ) 2018(First published in French in the October 2016 issue of the journal Le médecin du Québec).
- Footnote 4
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Brown ZA, Gardella C, Wald A, Morrow RA, Corey L. Genital herpes complicating pregnancy [published correction appears in Obstet Gynecol. 2006 Feb;107(2 Pt 1):428] [published correction appears in Obstet Gynecol. 2007 Jan;109(1):207]. Obstet Gynecol. 2005;106(4):845-856.
- Footnote 5
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Kulhanjian JA, Soroush V, Au DS, et al. Identification of women at unsuspected risk of primary infection with herpes simplex virus type 2 during pregnancy. N Engl J Med. 1992; 326(14):916-920.
- Footnote 6
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Van de Perre P, Segondy M, Foulongne V, et al. Herpes simplex virus and HIV-1: deciphering viral synergy. Lancet Infect Dis. 2008;8(8):490-497.
- Footnote 7
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Gupta R, Warren T, Wald A. Genital herpes. Lancet. 2007;370(9605):2127-2137.
- Footnote 8
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Freeman EE, Weiss HA, Glynn JR, Cross PL, Whitworth JA, Hayes RJ. Herpes simplex virus 2 infection increases HIV acquisition in men and women: systematic review and meta-analysis of longitudinal studies. AIDS. 2006;20(1):73-83.
- Footnote 9
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Wald A, Link K. Risk of human immunodeficiency virus infection in herpes simplex virus type 2-seropositive persons: a meta-analysis. J Infect Dis. 2002;185(1):45-52.
- Footnote 10
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Smith CR, Pogany L, Auguste U, Steben M, Lau T. Does suppressive antiviral therapy for herpes simplex virus prevent transmission in an HIV-positive population? A systematic review. Can Commun Dis Rep. 2016;42(2):37-44.
- Footnote 11
-
Bong CT, Bauer ME, Spinola SM. Haemophilus ducreyi: clinical features, epidemiology, and prospects for disease control. Microbes Infect. 2002;4(11):1141-1148.
- Footnote 12
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Singh AE, Romanowski B. Syphilis: review with emphasis on clinical, epidemiologic, and some biologic features. Clin Microbiol Rev. 1999; 12(2):187-209.
- Footnote 13
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Schachter J, Osoba AO. Lymphogranuloma venereum. Br Med Bull. 1983;39(2):151-154.\
- Footnote 14
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Kropp RY, Wong T; Canadian LGV Working Group. Emergence of lymphogranuloma venereum in Canada. CMAJ. 2005;172(13):1674-1676.
- Footnote 15
-
Public Health Agency of Canada. Reported cases and rates of notifiable STI from January 1 to June 30, 2004, and January 1 to June 30, 2003. 2004.
- Footnote 16
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Centers for Disease Control and Prevention (CDC). Lymphogranuloma venereum among men who have sex with men--Netherlands, 2003-2004. MMWR Morb Mortal Wkly Rep. 2004; 53(42):985-988.
- Footnote 17
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Nieuwenhuis RF, Ossewaarde JM, Götz HM, et al. Resurgence of lymphogranuloma venereum in Western Europe: an outbreak of Chlamydia trachomatis serovar l2 proctitis in The Netherlands among men who have sex with men. Clin Infect Dis. 2004;39(7):996-1003.
- Footnote 18
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Shahin R, Sarwal S, Ackery J-A, Wong T. Infectious syphilis in MSM, Toronto, 2002: public health interventions. Paper presented at: Annual Meeting of the International Society for STD Research; July 2003; Ottawa, ON. Abstract 0685.
- Footnote 19
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Sarwal S, Shahin R, Ackery J-A, Wong T. Infectious syphilis in MSM, Toronto, 2002: outbreak investigation. Paper presented at: Annual Meeting of the International Society for STD Research; July 2003; Ottawa, ON. Abstract 0686.
- Footnote 20
-
Kimberlin DW. Herpes simplex virus infections of the newborn. Semin Perinatol. 2007;31(1):19-25.
- Footnote 21
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Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015 [published correction appears in MMWR Recomm Rep. 2015 Aug 28;64(33):924]. MMWR Recomm Rep. 2015;64(RR-03):1-137.
- Footnote 22
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Coyle PV, Desai A, Wyatt D, McCaughey C, O'Neill HJ. A comparison of virus isolation, indirect immunofluorescence and nested multiplex polymerase chain reaction for the diagnosis of primary and recurrent herpes simplex type 1 and type 2 infections. J Virol Methods. 1999; 83(1-2):75-82.
- Footnote 23
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Morse SA, Trees DL, Htun Y, et al. Comparison of clinical diagnosis and standard laboratory and molecular methods for the diagnosis of genital ulcer disease in Lesotho: association with human immunodeficiency virus infection. J Infect Dis. 1997;175(3):583-589.
- Footnote 24
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Corey L, Wald A. Maternal and neonatal herpes simplex virus infections [published correction appears in N Engl J Med. 2009 Dec 31;361(27):2681]. N Engl J Med. 2009;361(14):1376-1385.
- Footnote 25
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Money D, Steben M. No. 207-Genital Herpes: Gynaecological Aspects. J Obstet Gynaecol Can. 2017;39(7):e105-e111.
- Footnote 26
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Steben M. Genital herpes simplex virus infection. Clin Obstet Gynecol. 2005;48(4):838-844.
- Footnote 27
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Sarisky RT, Quail MR, Clark PE, et al. Characterization of herpes simplex viruses selected in culture for resistance to penciclovir or acyclovir. J Virol. 2001;75(4):1761-1769.
- Footnote 28
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Whittington WL, Celum CL, Cent A, Ashley RL. Use of a glycoprotein G-based type-specific assay to detect antibodies to herpes simplex virus type 2 among persons attending sexually transmitted disease clinics. Sex Transm Dis. 2001;28(2):99-104.
- Footnote 29
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Westhoff GL, Little SE, Caughey AB. Herpes simplex virus and pregnancy: a review of the management of antenatal and peripartum herpes infections. Obstet Gynecol Surv. 2011;66(10):629-638.
- Footnote 30
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Eing BR, Lippelt L, Lorentzen EU, et al. Evaluation of confirmatory strategies for detection of type-specific antibodies against herpes simplex virus type 2. J Clin Microbiol. 2002;40(2):407-413.
- Footnote 31
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Turner KR, Wong EH, Kent CK, Klausner JD. Serologic herpes testing in the real world: validation of new type-specific serologic herpes simplex virus tests in a public health laboratory. Sex Transm Dis. 2002;29(7):422-425.
- Footnote 32
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Ashley-Morrow R, Krantz E, Wald A. Time course of seroconversion by HerpeSelect ELISA after acquisition of genital herpes simplex virus type 1 (HSV-1) or HSV-2. Sex Transm Dis. 2003;30(4):310-314.
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