What Can The Herpes Test Reveal To Me?

"I don't understand what is happening. My doctor performed a swab test, which was positive, but every time my blood work comes back, it's either negative or inconclusive. This must be a new infection, and I know who did this!"  - Jessica.

"My doctor said my last STD screen was clean, but now I have herpes? Great, now I have to make some phone calls. How long did I have it?"  - David.

"My doctor said I was all good, but when I looked at my results on paper, it says HSV positive 4.25? I was positive the whole time? This was from 4 years ago...why didn't my doctor tell me?  - Robert.

I see this frustration within the herpes support groups quite often. Some days you will see posts like this up to three times a day and for so many, it is very aggravating and downright depressing. So, what is the quick answer to the question? Well, according to the experts, it's a No, you cannot tell how long you have had it, 

However, with that being said, there are a few reasons as to why the experts are saying this and you're probably not going to like the answers. 

The test is a terrible way to tell time.

 When it comes to testing for herpes a blood test is a common way of doing so. This type of test is for identifying herpes antibodies that are present in the blood. It's important to note that the herpes simplex virus does not live in the blood; but, you can test the blood for antibodies. As a general rule, after a person has been exposed to the virus it can take a few weeks and up to three months for one's body to make enough antibodies. Important note, these tests are looking for very high numbers of G and M antibodies, and these blood tests are notorious for showing false positives and false negatives. {1}

This is one of the few reasons why doctors will omit blood work and prefer to visually verify herpes, or physically swab a herpes lesion (within the first 48 hours of its formation). Albeit painful, this swab test (Polymerase Chain Reaction (PCR) will verify the presence of herpes DNA, and is the most accurate type of diagnostic test. Still confused? Below is a description of the many different tests that are available. 

Common Test Types- Credit to projectaccept.org

1. IgM (blood) – measures the "initial" antibodies found in the blood just after acquiring the HSV. Positive results may also reflect infection of chickenpox or other human herpesviruses besides HSV, so this test is not recommended. 
2. IgG type-specific (blood) - measures the "long term" antibodies found in the blood, most commonly 4-6 MONTHS after acquiring HSV. False negative results are common if tested less than 4 months after acquiring the virus, as there has not been time for the body to recognize the virus and produce sufficient antibodies. If you want to know if it is type 1 or 2, then you MUST ASK for the type-specific test.
3. PCR (swab) - the test that identifies the actual DNA of the HSV. This test is commonly referred to as a culture swab of an outbreak lesion. This test provides the most reliable "positive" result for HSV. A false negative is possible if you wait too long to swab the lesion after it first appears.
4. PCR (blood) – tests for the virus in the bloodstream which is a rare and serious occurrence. Healthcare providers may accidentally order this test. It is the WRONG TEST to screen for HSV and will give a misleading negative result.

Understanding blood tests

1. The IgG type-specific test is the more accurate blood test for an HSV diagnosis. The IgG antibodies are the body's more specific immune response after acquiring HSV. They are the immune system's long term sparring partner. IgG type-specific tests for antibodies in the blood. There should be a minimum 4-6 month wait from the initial exposure of HSV before you can rely on an accurate test result. This test looks for the "long term" antibodies the immune system creates to deal with HSV. Early testing can result in false negative results. 
2. The IgM test will show up positive shortly after acquiring HSV. These are the body's "greeter" antibodies. The problem is they may "greet" other viruses in the herpes family (chickenpox; EBV, which can cause mono; shingles, etc.) and those can also trigger a false positive result for HSV. The presence of IgM antibodies will diminish after the initial acquisition of HSV. A negative result can occur if the person has had HSV for a long time or is tested immediately after exposure (it takes at least a few days for IgM to show up). If the person has had HSV for a long time, an IgM antibody test will typically result negative as IgM antibodies have subsided and the IgG antibodies more specific to HSV are being made by the immune system. It produces unreliable results and should be followed up in 4-6 months with an IgG antibody blood test for a definitive diagnosis.
3. Do NOT accept an order for a PCR blood test for routine screening. Unless you are very sick with viremia (the virus IN the bloodstream), this test will come back NEGATIVE. 
4. Western Blot is a specialized IgG test done ONLY though the University of Washington Virology Department in Seattle, WA. To order the test, you must contact their lab.

Understanding culture swabs

1. Culture swab PCR detects the VIRUS found at the site of the outbreak so should be done only in the presence of an outbreak.
2. If the lesion is old and has started to crust over, there may not be enough viral DNA to trigger a positive test result.
3. A positive culture swab is the MOST DEFINITIVE positive HSV test result, as it detects the presence of the actual virus. On the flip side, waiting even one day too long can result in a negative test result, even though the person has HSV and an active herpes outbreak. Unlike with an IgG blood test, there is no waiting period when testing a lesion for an accurate result.

From Asha sexual health:

IgM tests are not recommended because of three serious problems:

•  Many assume that if a test discovers IgM, they have recently acquired herpes. However, research shows that IgM can reappear in blood tests in up to a third of people during recurrences, while it will be negative in up to half of persons who recently acquired herpes but have culture-document first episodes. Therefore, IgM tests can lead to deceptive test results, as well as false assumptions about how and when a person actually acquired HSV. For this reason, we do not recommend using blood tests as a way to determine how long a person has had herpes. Unfortunately, most people who are diagnosed will not be able to determine how long they have had the infection.
•  In addition, IgM tests cannot accurately distinguish between HSV-1 and HSV-2 antibodies, and thus very easily provide a false-positive result for HSV-2. This is important in that most of the adult population in the U.S. already has antibodies to HSV-1, the primary cause of oral herpes. A person who only has HSV-1 may receive a false positive for HSV-2.
•  IgM tests sometimes cross-react with other viruses in the same family, such as varicella zoster virus (VZV) which causes chickenpox or cytomegalovirus (CMV) which causes mono, meaning that positive results may be misleading.

Credit: http://www.ashasexualhealth.org/stdsstis/herpes/herpes-testing/

It should be pretty obvious at this point that tryng to determine when you acquired herpes can be difficult. More info here: How Do I Prove I Got Herpes From My Last Partner? 

Why do some physicians omit herpes on the ten panel STD test? 

Many physicians do this frequently. If a patient comes in for an STD test, some will omit herpes entirely from the panel. But, if they do include it and the patient is not complaining of symptoms, a positive result may be followed by the physician doing nothing or stating "you're fine" or "you've been exposed, but you don't have it." This is of course a lie. If you've been exposed—you have it. There are many reasons why this takes place, and we may not like it, but...Here are a few. 

•   More than half of the planet has herpes simplex and if you don't, there's a good chance that eventually you will. {4}
•   Some tests are expensive, and the current testing method is 50% accurate. With exceptions to the western blot and if the PCR DNA swab test is performed within the proper time frame. 
•   Most of the population tolerates it very well except for approx 100+ million. Most of whom have an autoimmune issue or are immunocompromised. 
•   It has a very low mortality rate. 
•   Telling asymptomatic people that they have it can be very devastating/life-changing and this new information may not change their sexual behavior in any way. {2}
•   Your level of immunoglobulin G antibodies can fluctuate during your lifetime. This can take place during periods of being asymptomatic and symptomatic.{3}
•   A common thought is that your immunoglobulin M antibodies will die off and disappear after a few months. This is not correct. These antibodies simply becomes a naive response and the levels will drop very low - in fact, they will be too low to be measured on the test. There is also indications that these levels may fluctuate during your lifetime as well. Therefore an M response showing up on a Herpes Select IgG/IgM test may not be an indication that this is indeed a new infection. It's really just a guess until a new test comes out or you opt to pay $200+ for the Western Blot test.

Just to be clear, I'm not saying all of these are great reasons to omit herpes from the 10 panel test. In fact, if you do test with a number greater than 3.0, it's an indication of being truly positive; according to the experts. So, is it possible that you had two to three negative tests (over the years) and on your most recent test, it was very high and that means it's new infection? According to the data It's possible, but It's really just a guess...

Oh, and one more thing...

Immunoglobulin G deficiency.

After speaking with thousands of people over the past few years, the many weird and strange probabilities that we may have never contemplated can creep out of the woodwork and surprise us. It becomes evident why it is vital to change or adjust our previous views when we find new evidence to the contrary, or in the least, consider it and look deeper.

While the subject of IgG deficiency is unknown to most of us, it is generally well known to infectious diseases specialists, epidemiologists, or other virologists. Since most of us do not fall into any of these highly educated categories, it is obvious that we would be completely unaware of this subject or the plausible idea that it may be a contributing factor when speaking about a diagnosis or misdiagnosis of herpes simplex.

I have heard from many seropositive individuals that they know for a fact that they have herpes but always test negative on the blood test. Remember when we said how inaccurate these tests are and how they are looking for high levels of IgG and IgM?

 Many of these individuals have been diagnosed with either a swab test or a visual conformation, yet they continue to test negative on the IgG. One of the possibilities for this taking place is these individuals may be IgG deficient.

Dr. Antoine Azar from Johns Hopkins medical center describes this as:

•  An IgG deficiency is a health problem in which your body doesn't make enough Immunoglobulin G (IgG). People with IgG deficiency are more likely to get infections. IgG deficiencies can occur at any age.
•  When your body feels it is under attack, it makes special proteins called immunoglobulins or antibodies. These antibodies are made by B cells and plasma cells. They are let loose throughout the body to help kill bacteria, viruses, and other germs. The body makes 4 major types of immunoglobulins:
•   Immunoglobulin A
•   Immunoglobulin G
•   Immunoglobulin M
•   Immunoglobulin E
•  Immunoglobulin G (IgG) is the most common type. IgG is always there to help prevent infections. It's also ready to multiply and attack when foreign substances get into the body. When you don't have enough, you are more likely to get infections. 

Source Credit: IgG Deficiencies

Many who have this deficiency can also suffer from common ailments such as sinus infections, other respiratory infections, gastrointestinal infections, ear infections, pneumonia, bronchitis, and infections that can result in a sore throat. {5}

Now, suppose you believe that this IgG deficiency is directly related to your frequent herpes outbreaks and symptoms. If this is true, it may be wise to make an appointment with your doctor or an immunologist for a proper diagnosis. I wish you luck!

References 

{1}

In some people, these numbers may be lower than the igg/Igm test can verify. Other than the fact that the current testing methods are notorious for showing false positives and false negatives, these tests are specifically looking for very high numbers of immunoglobulin G and M, and if the numbers are not high enough, it will not register and will be seen as negative or inconclusive. 

Up to 50% of positive HerpeSelect ELISA IgG herpes test (which is the most common), can sometimes be false. In fact, results whose values were close to the threshold value, have a 90% chance of being false positives. So a test result that is very close to the threshold value (around or just above) 1.1 might be false positive. Tests 3.0 and above are considered positive. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1276011/

{2} Harms of Early Detection and Intervention

Based on evidence on potential harms from a small number of trials, the high false-positive rate of the screening tests, and the potential anxiety and disruption of personal relationships related to diagnosis, the USPSTF found that the evidence is adequate to bound the potential harms of screening in asymptomatic adolescents and adults, including those who are pregnant, as at least moderate.

The USPSTF concludes with moderate certainty that the harms outweigh the benefits for population-based screening for genital HSV infection in asymptomatic adolescents and adults, including those who are pregnant.

The USPSTF does not recommend serologic screening for genital HSV infection in asymptomatic persons.

https://jamanetwork.com/journals/jama/fullarticle/2593575

Use of "Biokit HSV-2 Rapid Assay" to Improve the Positive Predictive Value of Focus HerpeSelect HSV-2 ELISA

The Laboratory Diagnosis of Herpes Simplex Virus Infections

Diagnosis of Herpes Simplex Virus by Direct Immunofluorescence and Viral Isolation From Samples

{3}

http://www.ashasexualhealth.org/stdsstis/herpes/herpes-testing/

{4}

Prevelance of herpes 

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0140765#sec007

Genital herpes infection is common in the United States. CDC estimates that, annually, 776,000 people in the United States get new genital herpes infections. {1} Nationwide, 11.9 % of persons aged 14 to 49 years have HSV-2 infection (12.1% when adjusted for age).{2} However, the prevalence of genital herpes infection is higher than that because an increasing number of genital herpes infections are caused by HSV-1. {3} Oral HSV-1 infection is typically acquired in childhood; because the prevalence of oral HSV-1 infection has declined in recent decades, people may have become more susceptible to contracting a genital herpes infection from HSV-1. {4}

1. Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008. Sex Transm Dis, 2013. 40(30):187-93

2. McQuillan G, Kruszon-Moran D, Flagg EW, Paulose-Ram R. Prevalence of herpes simplex virus type 1 and type 2 in persons aged 14–49: United States, 2015–2016. NCHS Data Brief, no 304. Hyattsville, MD: National Center for Health Statistics. 2018

3. Xu F, Sternberg MR, Kottiri BJ, et al. Trends in herpes simplex virus type 1 and type 2 seroprevalence in the United States. JAMA, 2006. 296(8): 964–73.

4. Bradley H, Markowitz L, Gibson T, et al. Seroprevalence of herpes simplex virus types 1 and 2—United States, 1999–2010. J Infect Dis, 2014. 209(3):325-33.

https://www.cdc.gov/std/stats/STI-Estimates-Fact-Sheet-Feb-2013.pdf

https://www.cdc.gov/std/Herpes/default.htm

Herpes simplex virus (HSV) infection is one of the most common viral sexually transmitted diseases worldwide. The first time infection of the mother may lead to severe illness in pregnancy and may be associated with virus transmission from mother to fetus/newborn. Since the incidence of this sexually transmitted infection continues to rise and because the greatest incidence of herpes simplex virus infections occur in women of reproductive age, the risk of maternal transmission of the virus to the fetus or neonate has become a major health concern. On these purposes the Authors of this review looked for the medical literature and pertinent publications to define the status of art regarding the epidemiology, the diagnosis, the therapy and the prevention of HSV in pregnant women and neonate. Special emphasis is placed upon the importance of genital herpes simplex virus infection in pregnancy and on the its prevention to avoid neonatal HSV infections.

https://www.researchgate.net/publication/230584598_Herpes_simplex_virus_infection_in_pregnancy_and_in_neonate_status_of_art_of_epidemiology_diagnosis_therapy_and_prevention

How many people have herpes

Even though numbers can fluctuate from year to year; depending on many factors, these numbers are still pretty staggering. The prevalence of HSV type one is almost more than 80% of the worlds population. Almost everyone has herpes. 

https://www.webmd.com/genital-herpes/news/20081001/half-a-billion-have-genital-herpes

Genital herpes infection is common in the United States. CDC estimates that, annually, 776,000 people in the United States get new genital herpes infections

Thats over 2000 a day in the United States alone. https://www.cdc.gov/std/herpes/stdfact-herpes-detailed.htm#ref1 

Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008. Sex Transm Dis, 2013. 40(30):187-93

https://www.ncbi.nlm.nih.gov/books/NBK525769/

{5}. IgG

IgG Deficiencies Johns Hopkins 

IgG Subclass Deficiency

IgG Deficiencies

Immunoglobulin G deficiency NIH

Assessment and clinical interpretation of reduced IgG values