How is Genital Herpes Tested & Diagnosed?
Genital herpes is one of these conditions that are relatively complicated when it comes to its diagnosis as there are certain intricacies to the disease that somehow makes it slightly different than the rest in the sense that its testing options are relatively more specific to the disease itself as compared to the tests being performed for other sexually transmitted conditions.
While this could essentially make the tests more accurate and reliable as the results would relatively be funneled towards solely identifying the herpes simplex virus (HSV) during these tests, this would make it an issue, especially when it comes to the availability of tests that one could request for in this matter.
According to the Centers for Disease Control and Prevention, this issue is even more highlighted as herpes infections are some of the most common STIs in the United States – recording around 572,000 new genital herpes infection cases annually. With such a number, it is even more evident that the lack of a more accessible test would inevitably reduce the amount of adequately diagnosed cases – making it even more relevant for potentially affected individuals to know what types of tests to seek with regards to their potential condition, and have themselves imperatively diagnosed rather than wasting time and resources on other tests that might only produce untoward effects on top of wasting their resources that could have been utilized more efficiently and fruitfully.
With this in mind, one must not only be aware of how herpes infections behave but likewise be knowledgeable about how the disease itself is diagnosed professionally to help aid this gap between test accessibility and disease prevalence, further reducing the risk of having a full-blown infection that would either be left undiagnosed or improperly managed due to an ineffective diagnostic procedure. Do note, however, that while this outline will provide the necessary information that you might need regarding the tests that you could seek if you have a potential infection, this does not still encourage self-medication as the resolution of the condition itself would still require proper guidance from a licensed professional. Understanding the necessary tests is not a license to self-medicate; it is but a guide to steer you towards the right direction for your disease’s proper management and resolution.
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To have a general understanding of how genital herpes behaves within a patient with an active infection, the following short section highlights critical points regarding the disease itself – showing the typical manifestations of a symptomatic case, the well-known preventive measures against the condition, and the commonly used management strategies to either prevent the transmission of the virus and/or suppress the virus and limit its symptomatic presentations overall.
Genital herpes is a particular variation of a herpes infection that presents itself explicitly within the genital region – producing white-tipped blisters and sores that then burst to form ulcerations and scabbing as its hallmark diagnostic sign. These symptoms are not always present as herpes is a condition that is inherently recurrent, meaning that there are instances wherein the disease itself is asymptomatic, but it does have symptomatic presentations that mainly manifest as these set of symptoms.
These blisters and ulcerations have been known to last for around 2 to 4 weeks and are usually self-limiting. Specific systemic symptoms commonly accompany these symptoms during the first outbreak, including presentations like:
Meanwhile, recurrent outbreaks would often be coupled with prodromal symptoms days or hours before an outbreak occurs. These prodromal symptoms may include localized genital pain or a shooting or tingling sensation in the legs, hips, and buttocks.
Similar to how other sexually transmitted diseases are prevented from further transmission, the most common measure that can be employed in the case of genital herpes, where the virus itself is highly compatible with mucosal membranes, is abstinence. Abstinence essentially removes you from the equation and eliminates the source of infection – ensuring that no transmission will occur, whether the disease is from you or your partner during an interaction.
Of course, other less stringent measures such as using condoms, contraceptives, employing safe sex practices, and knowing the health status of your partner would all go a long way in ensuring that the risk of transmission is minimized as much as possible, but it still does not guarantee a 100% protection as the source of infection is still present nonetheless. Potential or not, the risk still exists and could inevitably still cause transmission given the right circumstances.
Unfortunately, herpes infections, genital or extra-genital alike, do not have an approved medication that could eliminate the virus from the infected patient’s system. As such, there is no “treatment” for the disease itself, but it could be effectively managed to the point where transmission is no longer possible as the medication is suppressing the viral load to manageable levels. This would commonly entail administering antiviral drugs to initially address the first outbreak of the patient, while a long-term antiviral therapy will then address the recurrent attacks, or rather, prevent the production of subsequent episodes and transmission of the virus during sexual intercourse.
As previously mentioned, the diagnosis of herpes infections is a little more complicated than other sexually transmitted infections, even with those with slightly similar presentations that herpes is commonly mistaken with. This is not saying that the diagnosis of different diseases is simple as the procedure itself still entails a relatively comprehensive process that aims to identify the patient’s condition accurately, but it does show that the diagnosis or detection of one pathogenic microorganism is complicated enough as it is – what more if there are two subtypes of the causative virus, such as in the case of HSV (HSV-1 and HSV-2).
In answering the question about why a potentially infected person should be tested for herpes, particularly those who are sexually active or those with an existing symptomatic manifestation akin to the symptoms of an active herpes infection, three primary responses could likewise be considered in the case of another potential sexually transmitted infections that a patient could contract during their sexual interactions.
The first one mainly deals with how herpes is a sexually transmitted infection. Apart from being an infection – which is, by itself, a matter of concern, especially when it comes to transmission – herpes is sexually transmitted, meaning that it is an infection that is often not widely talked about and may therefore remain undiagnosed unless you start looking for it. Add to that the fact that the area of sexual health is usually avoided in most discussions, and it becomes even harder to establish the sexual health status of a person, resulting in a wide-scale transmission of the disease, mainly coming from individuals who are unaware that they have the infection in the first place. This is one of the scenarios that occur with you, and inevitably, you may unknowingly transmit the virus to your partner. As such, even though it is not necessarily a mandate that should be strictly followed, having yourself tested is essentially ensuring that you and your partner are safe from any infection that you might have without knowing that you have it, particularly those conditions that are widely asymptomatic during its duration.
The second one can be associated with the symptoms usually present in active herpes infection. One thing that might have been overlooked in the description of herpetic lesions is that these blisters and ulcerations are extremely painful – making them uncomfortable if they happen to appear within your genital area. The problem with herpes is that it is a lifelong infection, meaning that these outbreaks would continuously reappear for as long as the condition is not managed correctly and suppressed while the pathogenic microorganism is within your system. Having yourself diagnosed will go a long way in ensuring that even though you have a herpes infection, the disease will not affect your quality of life as you will be provided with the necessary management measures that would help in preventing recurrent outbreaks as well as further transmission even if you partake in various sexual activities.
The last response would mainly tackle the issue of complications and long-term repercussions – a significant issue that is often raised within any infection, particularly systemic conditions that could cause irreversible damages in the long run. In the case of genital herpes infections, this disease has been previously shown to cause extra-genital manifestations as the virus proliferates within your system – causing manifestations within other mucosal membranes such as the mouth and the anal region. In addition to that, herpes infections have likewise been associated with a rare and life-threatening complication known as aseptic meningitis or the inflammation of the brain’s lining – an additional concern that should be noted on top of the discomfort and isolation that an actively infected individual may experience from their partners and peers.
The timing for the test that you should be taking will mainly depend on whether you are simply trying to determine the presence of a viral load or if you are trying to identify the type of HSV present within the patient’s systemic circulation. For instance, NAATs would often be less effective when the infection is asymptomatic, as these recurrent outbreaks would often reduce the viral load when there are no evident herpetic lesions during that duration. Meanwhile, virologic and serologic testing likewise have their limitation and should instead be consulted with the physician to help in your decision about what test to take for your potential condition.
Ultimately, the best response for this prompt is to have yourself tested when necessary, especially when sexually active, to prevent any missed diagnoses that might be attributed to poor testing conditions and circumstances. Again, always note that testing for herpes is more encouraged when the patient is symptomatic, as the CDC believes that consistent testing for herpes becomes inefficient in the long run.
Generally, the test might be uncomfortable as these tests would either require a swab from the herpetic lesions that are present within the genitalia or a blood sample obtained for antibody testing. Both procedures will always be performed in a secure and private laboratory, and the steps taken will always be explained to you by the professional conducting the test. Note that these tests are only performed in a laboratory by a licensed and knowledgeable professional.
There is no one guideline regarding the compatibility of the test or an individual's eligibility to take these tests, as some of these could be taken as a routine procedure for sexually active individuals. However, you should likewise note that some tests require specific testing conditions that have to be followed to ensure that your test results are conclusive and accurate. Some of these eligibilities include:
Overall, there are 3 primary tests and 2 confirmatory tests commonly employed to diagnose genital herpes. The section below highlights several key points regarding each test, including the sample necessary for each test, the waiting time for the results, the tool utilized to perform the test, and the indication with which the test is commonly associated.
Western Blot Assay
Blister swab, blood, or spinal fluid
Blood or spinal fluid sample
Ready in 1 to 3 days
Rapid culture may take 2 to 3 days to complete; Conventional methods may take at least a week
Can be collected within the day
Ready in 2 to 5 days
Swab and respective laboratory equipment
Swab and culture media
Swab and respective laboratory equipment. May be available with at-home kits as well
Biokit rapid test kit
Gel electrophoresis equipment and blotting paper
Can be utilized for any stage but may show false negatives due to intermittent viral shedding
Can be utilized for any stage but has low sensitivity and longer waiting time
Preferably used for recurrent outbreaks
As previously discussed, 3 primary tests variations are used to either identify the presence of HSV antibodies or determine the identity of the HSV strain present within the patient’s system. In addition to that, 2 rapid confirmatory tests are likewise recommended to ensure that the diagnosis of the patient – which is subject to irregularity due to the intermittent viral shedding of the disease – is as accurate as it needs to be to begin the management therapy.
The section below discusses the intricacies of each test, including the procedure, the cost, and the overall accuracy of the procedures. Do note that not all of these tests could be requested without a proper physician consultation as the sample collection would often be performed by a professional inside the clinic or laboratory. Costs may likewise vary depending on your country of origin, but the general price range would usually be similar within countries of similar income status.
A nucleic acid amplification test or NAAT is known as the most sensitive procedure that can be performed to diagnose herpes infections or even other sexually transmitted infections, for that matter. The procedure itself is considered the gold standard for most conditions due to its high sensitivity and specificity, albeit the accuracy of the test falls off a little bit in the case of herpes infections due to the intermittent viral shedding process of the virus. For this procedure, the standard sample collected is a swab or scraping from an active blister or lesion that is then processed to determine whether there is a presence of markers known as “antigens” within the sample that has been collected from the patient. It may likewise be performed using blood or even spinal fluid samples, especially in cases wherein there is suspected colonization of the cerebrospinal fluid in an infected individual.
While relatively complicated in theory, the tests themselves are becoming more and more available to the public and are now more accessible as a procedure that can be used to determine the presence of the virus within the active lesions. However, do note again that the test's sensitivity can vastly vary depending on the viral shedding of the pathogen – making it yield false-positive results in certain instances.
Depending on the processing time of the laboratory or facility where you performed your test, the release of results may take up to 3 days in total. However, this can likewise be released immediately depending on how urgent the results are necessary for your current condition.
The commonly collected sample for an HSV NAAT procedure is a swab from the active lesions present from the genitalia, but respective blood samples may likewise be obtained. In addition to that, a sample of the patient’s cerebrospinal fluid may similarly be requested if your physician suspects an infection within your meninges or around the lining of your brain. Consult your physician regarding the type of sample collected for your test before the procedure if you have particular concerns regarding the collection process.
The cost for a nucleic acid amplification test may be around $100, but this will still vary depending on the institution that you have selected for the test, as well as the various perks of the procedure offered within that testing site, i.e., heightened confidentiality, faster result turnover, etc.
Considering that the procedure is relatively more complicated than other procedures that can be requested, the insurance compatibility of the procedure may vary depending on the coverage of your insurance plan.
The specificity of the test may be tailored to be highly specific to HSV, but the sensitivity of the procedure may range from 90.9% to 100%, depending on whether the viral shedding process of the disease affects the overall accuracy of the test.
The viral culture test, despite its low sensitivity and inherent inefficiency, is still considered as the gold standard for HSV testing as it has a 100% specificity rate – meaning that the test itself can always result in the proliferation of HSV within the medium and thus resulting in an accurate positive or negative result for as long as the process was correctly performed by the professionals who were handling the procedure. In this process, fluid from the sores and blisters within the genitalia will be collected as a sample and then mixed with a cell mixture that could host HSV. If HSV colonized the cells throughout the testing process, the test could be considered positive, while no infection would be negative. However, note that certain instances wherein the virus does not attach to the host cell do not necessarily imply that the test is negative due to other factors that may result in the non-attachment of the virus within the mixture.
A rapid viral culture procedure may produce results within 2 to 3 days, but conventional culturing methods may require up to a week to deliver the results as the virus needs to be given time to attach to the cells with the culture medium.
The commonly utilized sample for a viral culture procedure is a swab or scraping from new lesions within the genitalia, as these have the highest chance of producing accurate results due to their guaranteed viral load. This, however, may still be affected by several factors that could still produce false-negative results.
Due to the declining use of viral cultures in diagnosing viral infections, there is no standard price for viral culture procedures. However, based on a 2007 study, the average cost of each cell culture tube is around $2 to $4 – with each test requiring about 6 tubes performed in a span of 5-10 days. Respective inflation factors would have to be considered for recent prices.
Depending on the coverage of the insurance plan that you have availed of, viral culture procedures may be included in the package and covered by your premium. Consult your insurance provider to inquire whether viral culture procedures are covered by their policy to ensure that you will be able to utilize it if you need the test to be performed.
A viral culture procedure has a 100% specificity rate, but its sensitivity depends on when the test has been conducted. The sensitivity could be around 75% during the first outbreak, but testing during recurring episodes could drop the overall sensitivity to about 50%.
A BioKit is a rapid test kit that professionals can use as a confirmatory procedure to ensure that the previously utilized laboratory tests are accurate before the treatment plan for the patient is initiated. It is essentially a kit containing a testing device, vials, and blood capillary tubes used to check the presence of IgG antibodies specific for HSV. In simple terms, the procedure would commonly begin with collecting a blood sample using a finger blood drawing apparatus – adding the sample into the vials and using the buffers present in the kit to create a mixture. The mixture will then be placed on the device by squeezing the vial dispensing the mixture into the test window to generate the results.
Considering that the test is a rapid test kit, the overall waiting time would only be around 7 to 10 minutes.
The sample required to perform the procedure is a blood sample commonly collected from your fingers using a provided apparatus.
The confirmatory test would often have an average price of around $20 per test, but each kit/package usually contains 20 tests in total.
Since your physician commonly performs the procedure during a consultation, the price of the test, as well as its compatibility with your insurance, will depend on your consultation fee.
While it is not necessarily a viable primary test for the diagnosis of herpes, it does, however, have a 96% sensitivity rate and a 98% specificity rate compared to the western blot and viral culture procedures.
The western blot assay is a type of serologic procedure that detects the presence of HSV-1 and HSV-2 IgG antibodies within your sample to identify whether you indeed have an underlying infection or if the previous tests administered produced false negative or positive results. The western blot assay is commonly used as a confirmatory test for HSV diagnosis, and it utilizes the concept of gel electrophoresis using nitrocellulose strips of paper. The strips of paper would usually contain fixed proteins from both HSV-1 and HSV-2, and these strips would then be incubated with the provided patient’s sample. Following that, the antibodies that might be present in your sample will then bind to the viral proteins that have been attached to the strips – resulting in a color change due to the enzymes present within the setup. Once done, the pattern of blotting or the color changes that have been observed throughout the strip will then show the antibodies that are present within your system – simultaneously identifying whether you are positive for HSV-1, HSV-2, or both.
The result could often be interpreted and analyzed within 2 to 5 days, depending on the speed of the laboratory.
The test would usually require a blood sample, but your physician may likewise request CSF samples.
The average cost of the western blot assay would be around $125 without insurance.
Specific insurance policies may cover the test itself, but make sure that the test is included in your premium to avail of the test for free or at a discounted price.
The accuracy of the test could vary, but given the right conditions, the western blot assay may have an approximate sensitivity and specificity rate of around 94%.
Similar to how the western blot assay is performed, serologic tests likewise target the antibodies present in the patient’s system to determine whether the patient has an infection and identify the type of HSV strain causing the patient’s manifestations. Type-specific serologic tests are slightly different because they explicitly target certain HSV types within the serum sample – distinguishing between HSV-1 and HSV-2 upon testing. This is the standard procedure employed in traditional testing laboratories that can be processed online – making it more accessible to the public, especially to those who are very particular about their sexual health. In most cases, you would have to approach an FDA-approved testing laboratory to provide the sample, and the laboratory itself will then process the provided serum to determine the antibodies and the HSV strain that might be colonizing your genital region.
The waiting time would depend on the laboratory’s performance. In more accessible settings, the results may arrive in around 3 to 5 days, but if the test has been performed within the hospital during a consultation, your physician may request the results to be expedited – allowing you to receive your sample within the day.
A serologic test would require a blood sample to determine the presence of antibodies.
The test price would depend on the institution selected, but more accessible testing options would commonly provide the test at a price point of around $79 for a 2-in-1 HSV-1 and HSV-2 panel.
Your insurance program will not cover privately ordered tests, but tests requested within the hospital during admission or consultation may be integrated within your medical bills and be covered by your overall insurance package.
Type-specific serologic tests are not commonly used as they have a low sensitivity and specificity rate of 80-90% and 57.5$, respectively.
To provide a more concise outline of the costs of each diagnostic procedure, the table below shows the price and insurance compatibilities of the provided testing processes:
Western Blot Assay
Around $30.00 in total (not reflective of current prices)
$79.00 for a 2-panel test kit
$20.00 per test
Covered by Insurance?
Dependent on coverage of insurance policy
No for privately ordered tests
This is because routine testing could not be attributed to a lower prevalence rate and is simply inefficient from a macro perspective. In addition, the collection of samples would become more invasive without blisters than can be used as a simple source of specimen for testing.
Yes, vertical transmission is possible, and it is even more life-threatening when it comes to infected newborn babies.
Due to the blisters and skin openings caused by an HSV infection, there is an increased risk for a person with an HSV infection to contract an HIV infection.
More research is necessary to establish a relationship between the two conditions as Alzheimer’s disease has several triggering factors, but early investigations suggest a correlation between the two.
No, herpes is a lifetime infection that can only be managed and suppressed.
American Society for Microbiology
Written by Mark Riegel, MD
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