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Testing with symptoms: viral culture
If symptoms of herpes appear, they can vary widely from person to person. If a person does experience signs of infection, we recommend obtaining a culture test (a swab from the symptom) within the first 48 hours after a lesion appears. Results are usually available in about a week's time.
The major advantage of the culture is its accuracy in giving a positive result. A culture can also be “typed” to determine whether the infection is caused by HSV-1 or HSV-2. If you test positive by viral culture, you can be sure you have the virus.
The major disadvantage of the culture is its high rate of false negatives. Because a culture works by requiring virus that is active, if a lesion is very small, or is already beginning to heal, there may not be enough virus present for an accurate culture. Beyond 48 hours of the symptoms appearing, there is a risk of receiving a false negative test result. Viral culture is even less accurate during recurrences (positive in only about 30% of recurrent outbreaks).
Introduction to blood tests
Blood tests can be used when a person has no visible symptoms but has concerns about having herpes. Blood tests do not actually detect the virus; instead, they look for antibodies (the body's immune response) in the blood.
IgM vs. IgG
There are many older blood tests commercially available, but most are not accurate because they cannot accurately distinguish between antibodies for type-1 and type-2 herpes. This makes it possible to get a false positive result, especially for HSV-2.
When an individual contracts herpes, the immune system responds by developing antibodies to fight the virus: IgG and IgM. Blood tests can look for and detect these antibodies, as the virus itself is not in blood. IgG appears soon after infection and stays in the blood for life. IgM is actually the first antibody that appears after infection, but it may disappear thereafter.
IgM tests are not recommended because of three serious problems:
1.
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 (see reference 1).
2. 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.
3. 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.
The accurate herpes blood tests detect IgG antibodies. Unlike IgM, IgG antibodies can be accurately broken down to either HSV-1 or HSV-2. A recent study corroborates this finding: labs that used non-gG-based tests for herpes had high false-positive rates for HSV-2 antibodies (14-88% saying the blood sample was positive for HSV-2) in samples that were actually only positive for HSV-1 antibodies. But 100% of the labs using gG-based tests accurately reported that the blood sample was negative for HSV-2 (see reference 2).
The challenge here is that the time it takes for IgG antibodies to reach detectable levels can vary from person to person. For one person, it could take just a few weeks, while it could ta ke a few months for another. So even with the accurate tests, a person could receive a false negative if the test is taken too soon after contracting the virus. For the most accurate test result, it is recommended to wait 12 - 16 weeks from the last possible date of exposure before getting an accurate, type-specific blood test in order to allow enough time for antibodies to reach detectable levels.
Accurate blood tests
There are currently four FDA-approved, gG-based blood tests that can give accurate results for herpes. Like any blood test, these tests cannot determine whether the site of infection is oral or genital. However, since most cases of genital herpes are caused by HSV-2, a positive result for type-2 antibodies most likely indicates genital herpes.
It may be necessary to request on of these tests by name from your health care provider. These accurate, type-specific tests are:
- biokitHSV-2 Rapid Test
- HerpeSelect® HSV-1 and HSV-2 tests
- Herpes Western blot
- CAPTIA™ HSV IgG Type-Specific ELISAs
The biokitHSV-2 Rapid Test (manufactured by biokit USA) is a blood test that can be done in a doctor's office and provides results for HSV-2 in less than 10 minutes. For more information on the biokitHSV-2 Rapid Test, please have your health care provider call 1-800-926-3353 or log on to www.biokitusa.com. This test is also available under the name Sure-Vue™ HSV-2 Rapid Test from Fisher HealthCare. For more information on the Sure-Vue™ HSV-2 Rapid Test, please have your health care provider call 1-800-766-7000 or log on to www.fishersci.com.
There are two blood tests manufactured by Focus Diagnostics, Inc. under the name HerpeSelect®: the ELISA and the Immunoblot. Both of these tests require blood to be drawn by your health care provider and sent off to a lab that carries HerpeSelect® for results. If you are interested in HerpeSelect®, you can log on to www.herpeselect.com or call 1-800-505-0536.
The Herpes Western blot can also accurately distinguish between HSV-1and HSV-2. However, this test is primarily used for research purposes and is not readily available. If you are interested in the Herpes Western blot, your doctor will need to call the University of Washington in Seattle, WA at 1-206-598-6066 to order the test.
The CAPTIA™ HSV IgG Type Specific ELISAs can detect HSV-1 and/or HSV-2 antibodies. Blood drawn by your health care provider will be sent to a lab for results. For more information, have your health care provider contact the manufacturer, Trinity Biotech USA, at 1-800-325-3424 or log on to www.trinitybiotech.com.
Accurate Blood Test Quick Reference Guide
We have created the Blood Test Quick Reference Guide, a chart that outlines and compares the accurate, FDA-approved type-specific blood tests available for herpes simplex antibodies. To determine which test might be best for your situation - or to show your doctor which tests are available (since herpes is not routinely included in STD screenings), click here for our BLOOD TEST QUICK REFERENCE GUIDE (PDF, 108K).
For healthcare providers, we've developed the Herpes Testing Toolkit, which was reviewed by leading experts in this field. The 10-page guide explains the increasing role of type-specific herpes serologic assays, presents clinical scenarios in which serologic testing are beneficial, and reviews key factors in a differential diagnosis for genital herpes. To learn more about the toolkit, click here.>>
Other diagnostic tests
Polymerase chain reaction (PCR) tests are very sensitive tests (meaning they are very good at detecting the virus if it is present). While PCR testing is likely to replace the viral culture in the future, PCR are not as readily available as culture at many sites and there are no commercially available kits at this time.
Several other types of herpes diagnostic tests exist but have serious limitations. Some, such as viral antigen tests, while accurate, are not readily available and their accuracy drops as the lesion heals; others, such as the Tzanck test, involve a “judgment call” on the part of the health care provider or lab technician reading them.
For more information
For immediate assistance, you can speak to us directly by calling the National Herpes Hotline at (919) 361-8488. Our hours of operation are 9:00 am to 6:00 pm, ET, Monday through Friday. You can also learn more about herpes in ASHA's quarterly newsletter, The Helper.
If you would like to share your experiences with receiving a herpes diagnosis or any comments regarding herpes testing, please send them to commentstohrc@ashastd.org . ASHA sincerely appreciates all submissions, which are confidential and anonymous. It is ASHA's intent to collect these comments for use in our patient advocacy work. All submissions are property of ASHA and can be edited for length and clarity.
References
1. Ashley RL. Performance and use of HSV type-specific serology test kits. HERPES 2002;9(2):38-45.
2.
Ashley Morrow R, Brown ZA. Common use of inaccurate antibody assays to identify infection status with herpes simplex virus type 2. Am J Obstet Gynecol 2005;193:361-2.
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