Background Serological testing for herpes simplex virus (HSV) type 2 in persons without a history of genital herpes is not recommended, partly because of concerns that an HSV-2 diagnosis would lead to negative psychosocial sequelae. This review aimed to examine the evidence regarding the psychosocial effects of HSV-2 serological testing.
Methods Eight electronic databases were searched for empirical studies indexed before March 2010. Abstracts from relevant conferences were reviewed and senior authors contacted to find unpublished materials. Eligible studies examined participants without a history of genital herpes who underwent HSV-2 serological testing and reported data from at least one quantitative or qualitative psychosocial assessment conducted after receiving HSV results.
Results Of nine studies that satisfied the inclusion criteria, seven reported that HSV-2 diagnosis by serological test did not have a persistent negative impact on 309 participants' mental health or sexual attitude and satisfaction. Two studies reported a negative impact of testing; one found that five HSV-2-seropositive college students had increased distress 3 months post-testing compared with HSV-2-negative individuals, and the other found self-reports of sexual undesirability up to 1 year after diagnosis in some people. The perceived severity of a genital herpes diagnosis was moderately severe for participants before testing; however, post-testing, the reported severity of a herpes diagnosis was lower among those testing HSV-2 positive.
Conclusions HSV-2 diagnosis by type-specific serological testing did not result in long-term psychosocial harm in most persons without an identified history of genital herpes. Concerns about sustained emotional impact should not deter clinicians from offering HSV-2 serological testing to appropriate patients.
- genital herpes
- herpes simplex (clinical)
- serological testing
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Herpes simplex virus (HSV) type 2 is one of the most common sexually transmitted diseases (STD), with an estimated 536 million people infected worldwide1 and 17% of the population aged 15–49 years living with HSV-2 in the USA.2 Similarly, in western Europe the HSV-2 prevalence rate is approximately 14% among women and 7% among men.1 HSV-2 is the main cause of recurrent genital herpes and increases the risk of HIV acquisition two to threefold.3 Most people infected with HSV-2 have not been diagnosed with genital herpes and do not recognise genital symptoms that may be related to HSV.4 Even without recognised outbreaks, such persons may transmit infection to sexual partners or neonates during subclinical viral shedding.5 Most transmission occurs from persons who are not symptomatic or diagnosed with genital herpes.6
Sensitive and specific HSV serological testing has become commercially available in the past decade.7 Many studies have found that patients, across a variety of settings, are interested in receiving HSV-2 testing.8–10 Despite patient interest, the appropriate application of HSV serological testing has been much debated.11–14 The Centers for Disease Control and Prevention and the USA Preventive Services Task Force do not recommend herpes screening among the general public15 16 partly due to concerns that HSV-2 diagnosis provides no benefit and could lead to psychosocial sequelae such as anxiety and sexual dissatisfaction. The distress that can result from a diagnosis of primary or recurrent genital herpes has been well documented;17–19 however, patients who lack clinical symptoms and are diagnosed by a serological test may not have the same reaction to HSV-2 diagnosis as would someone presenting with a first clinical episode of genital herpes infection.
This systematic review examines studies that measure the short and long-term psychosocial effects resulting from serological diagnosis of HSV-2 in persons without recognised symptoms of genital herpes infection.
Data sources and searches
Electronic databases were searched from their original start date to March 2010. The databases included Pubmed/Medline, PsycINFO, Web of Science, EMBASE (Ovid), CINAHL Plus and the Cochrane Library. Search terms used were: herpes AND testing AND psychosocial, herpes AND diagnosis AND psychosocial, herpes AND screening AND psychosocial, herpes simplex AND testing AND emotional, herpes simplex AND testing AND impact.
To identify unpublished studies, we searched the National Research Register and clinical trials.gov, hand reviewed abstracts from relevant conferences, and searched for articles that cited or were cited by articles identified by the inclusion criteria. In March 2010, we contacted corresponding authors and/or senior co-authors of the studies included in our systematic review, to determine if additional unpublished data were available. This strategy did not yield additional data to include in our systematic review.
Studies were included based on the following criteria: participants underwent a HSV-2 serological test as part of study procedures or had undergone a HSV-2 serological test in the past, and at least one psychosocial assessment of the participants was performed after serological results were provided. Case studies, review articles and studies that only tested symptomatic or previously diagnosed participants were excluded. Based on title and abstract, two authors independently reviewed identified references to determine whether the study met the inclusion criteria. The articles selected from this initial screening underwent full text review.
Data extraction and quality assessment
We extracted standard data from each article, including study characteristics (year of publication, country, design, research setting), participant characteristics (number of subjects, age, gender, herpes history, co-morbidities), subject selection criteria, type of serological testing, testing acceptance, results of serological testing, psychosocial methods and results (types and timing of testing), study quality (limitations and bias) and study conclusion as summarised by study authors. Data extraction was done by one author and verified for accuracy and completeness by a second author. Methodological study quality was assessed utilising a modified Newcastle Ottawa quality assessment scale, which was specifically designed to assess the quality of non-randomised studies including case–control and cohort studies.20
We identified 173 articles using our search strategy (figure 1). The initial review process yielded 15 (9%) studies that met our predefined inclusion criteria and underwent a full text review.19 21–34 Four articles were excluded because HSV testing was not type-specific,19 21 24 34 and two articles were excluded due to lack of post-testing psychosocial assessment.22 23 The remaining nine articles were included in the systematic review.25–33 Co-authors independently concurred on which studies met the inclusion criteria.
Six studies were conducted in the USA, two in the UK and one in Australia; all studies were conducted between 2000 and 2008 (table 1). Of the 1355 participants included in the nine studies, 793 (56%) were men; ages ranged from 16 to 67 years. Of the 596 (44%) participants who were HSV-2 positive, 341 (57%) lacked a recognised previous history of genital herpes. Studies had a median of 180 participants (range 24–223).
Participants were recruited from primary care clinics (maternal infant care, family medicine and adolescent care), speciality clinics (including an HIV clinic, STD clinics, genitourinary clinic and an academic STD research clinic), three hospitals, a health maintenance organisation (HMO) and two college campuses.
There were eight prospective cohort studies and one qualitative study. Seven of the eight prospective cohort studies assessed psychosocial parameters at baseline and after type-specific HSV serological testing; one assessed testing regret after test results were delivered. Follow-up ranged from immediately after participant received serological results to 6 months afterwards.
Seven cohorts with baseline and follow-up measures used within-person measurements to assess scores on psychosocial scales over time (table 2). Four studies also compared participants who tested HSV-2 positive with participants who tested HSV-2 negative.25 28 31 32 Three studies compared responses in HSV-2-positive participants with and without a history of genital herpes.27 30 33
Several tools were employed to assess the psychosocial impact of HSV-2 testing. The qualitative study used a semistructured interview, including questions about sexual desire and reactions to diagnosis. For one prospective cohort, the psychosocial assessment consisted of asking the participant if he/she regretted having the test.29 The remaining seven prospective cohorts used a range of two to six validated scales and questionnaires. To analyse the results, the scales were grouped into six categories.
Mental health: Center for Epidemiological Studies of Depression scale (CES-D), general health questionnaire (GHQ-30 and GHQ-12), profile of mood states brief (POMS), Rand mental health inventory (MHI-5), Coopersmith self-esteem inventory, brief symptom inventory (BSI) subscales, state anxiety index, hospital anxiety and depression scale (HADS).
Coping and counselling: perceived social support subscale from the multidimensional scale of perceived social support, relationship quality scale, ways of coping scale.
Sexual satisfaction: the multidimensional sexual self concept questionnaire and a subset of the BSI were used to measure sexual optimism, sexual attitudes and perceived quality of sex. The sexual attitudes scale was also used.
Herpes-related quality of life: herpes-related quality of life scale (HRQoL).35
Perceived severity of HSV-2 and STD stigma: health belief model subscales (perceived severity of and susceptibility to genital herpes), perception of genital herpes instrument from the American Social Health Association, STD-related stigma.
Acceptance and acceptability of testing.
Individual study results
Melville et al26 conducted semistructured interviews with 24 participants, 1 month to 1 year following serological diagnosis of HSV-2 infection. Emotional responses ranged from surprise (50%) and denial (37%), to relief at knowing (20%). Ongoing themes at 1 year following diagnosis were acceptance (58%), concerns about telling partners (50%) and transmission (46%), and feeling sexually undesirable (42%).
Prospective cohort studies
Among the six studies that assessed mental health impact, four reported no mental health impact from HSV serological testing on 203 participants.27 28 32 33 There were no changes in mental health scores, depression, anxiety or mood scores when compared with baseline,28 32 when compared with HSV-2-seronegative participants28 32 or when compared with HSV-2-seropositive individuals with a previous diagnosis of genital herpes.33 Similarly, Meyer et al27 tested patients in an urban HIV clinic and found no significant changes in mood disturbance for patients who tested positive compared with pre-test baseline or when compared with those with a previous history of HSV-2.
Two studies reported a negative impact following an HSV-2 diagnosis.25 30 Three months after HSV serological testing, Mark et al25 found that five HSV-2-seropositive college students reported significantly higher levels of distress than 23 students who tested HSV-2 negative, but found no differences in depression. Similarly, among HMO enrollees, HSV-2-positive persons reported higher levels of mood disturbance at multiple time points compared with baseline (p=0.003), yet these mood scores were not significantly different from HSV-2-negative persons.30
Coping and counselling
Three studies measured changes in coping and relationship quality. Meyer et al27 found that newly diagnosed participants had a decrease over time in seeking social support, as measured by the ways of coping scale (p=0.018). Richards et al30 found that newly diagnosed patients were temporarily more likely to engage in avoidant coping at the 2-week follow-up compared with negative or previously diagnosed patients; however, this difference resolved by 3 months. In contrast, Rosenthal et al31 found that social support and relationship quality did not vary among newly diagnosed participants over time or in comparison to participants who tested negative for HSV-2.
Three studies noted that some participants required further counselling or information after receiving a HSV-2 diagnosis. Mark et al25 found that six (75%) of eight HSV-2-positive college students contacted study staff for additional counselling. In the other two studies, few participants requested additional counselling (one (4%) of 2533 and four (2%) of 223).29
Five studies measured the impact of HSV-2 diagnosis on sexual health and attitudes.27 28 30–32 Miyai et al28 found a temporary decrease in multidimensional sexual self-concept questionnaire assessed sexual attitude scores for HSV-2-positive subjects compared with seronegative subjects at 1 week (p=0.01), which resolved by 3 months (p=0.74). The other four studies found no significant decline for 214 newly diagnosed participants in sexual satisfaction or sexual optimism for HSV-2-positive participants compared with baseline or seronegative participants.27 30–32
Herpes-related quality of life
Three studies assessed herpes-related quality of life.27 30 31 Rosenthal et al31 reported that at 3 months post-HSV-2 diagnosis, most participants endorsed that ‘it is difficult to forget that I have herpes’ (63%). The least endorsed item was ‘Herpes is making my life miserable’ (4%). Rosenthal et al31 further noted that greater baseline interpersonal sensitivity (p<0.05), lower sexual satisfaction (p<0.01) and lower social support (p<0.05) were associated with lower herpes-related quality of life scores at 3 months. The authors concluded that ‘individuals who are already vulnerable with regard to their sexual and interpersonal experiences appear to be most impacted by an HSV diagnosis’. Two studies found that the herpes-related quality of life scores remained consistent throughout the 6-month follow-up for persons who tested HSV-2 positive and found no difference in scores between newly diagnosed and previously diagnosed participants.27 30
HSV-2 perception and stigma
In examining perceptions about the severity of having HSV-2, Meyer et al27 and Richards et al30 reported that participants found a genital herpes diagnosis as traumatic as being diagnosed with high blood pressure or being involved in a car crash without hospitalisation. HSV-2 diagnoses were rated less severe among HMO enrollees who reported a previous HSV-2 diagnosis compared with newly diagnosed participants (p<0.001), suggesting that persons who have lived with HSV-2 perceive the infection as less of a burden.30 Similarly, Miyai et al28 found that HSV-2-positive participants perceived genital herpes to be less traumatic than did participants who were seronegative (p<0.001). No differences in perception of stigma were found for HSV-2-positive participants compared with baseline or HSV-2-negative persons.31
The nine studies were ranked on the Newcastle Ottawa Scale, which assesses quality based on the selection of the comparison groups, study comparability and outcomes.20 The methodological quality of the studies was moderate to high, with a median score of seven out of nine stars and a range of five to eight (table 3).
This systematic review thoroughly examined the findings and quality of the literature reporting the psychosocial impact of HSV-2 diagnosis by serological testing. We found that most persons without a recognised history of genital herpes who tested positive for HSV-2 did not experience longstanding mental health problems, have persistent sexual attitude problems, or regret being tested. Of the nine studies included in this review, two reported a negative impact of testing. One reported higher levels of distress but not depression in a small number of college students who tested positive for HSV-2 3 months earlier, and a qualitative study found self-reports of sexual undesirability in some people up to 1 year after diagnosis. Most participants anticipated the trauma of a genital herpes diagnosis to be moderately severe; however, this did not translate into measurable mental health or psychosexual sequelae post-diagnosis. As such, the published literature indicates that HSV-2 diagnosis by serological testing does not cause adverse long-term psychosocial effects.25–33 36
Our findings contrast with literature describing heightened rates of anxiety, distress and sexual dissatisfaction after a clinical diagnosis of primary and recurrent genital herpes,17–19 suggesting that it is not the experience of being diagnosed with HSV-2 infection that causes psychosocial harm, but perhaps the experience of painful lesions and the uncertainty of frequent recurrences that accompany a clinical HSV-2 diagnosis. We found HSV-2 diagnosis appeared to have less psychosocial impact when the diagnosis was made at a STD clinic, perhaps because people already perceive themselves to be at higher risk of sexually transmitted infections. Conversely, college students may have an increased risk of negative sequelae, as a population with heightened interpersonal sensitivity and vulnerability.31
Current STD treatment guidelines do not recommend routine testing for genital herpes among asymptomatic persons.15 16 One reason is the perceived risk of psychosocial harm.16 Our findings suggest that the potential risk of psychological harm is not a valid reason to withhold serological HSV-2 testing from patients without a reported history of herpes symptoms. In fact, one study found that once diagnosed, HSV-2-positive participants perceived genital herpes to be less traumatic than HSV-2-negative participants,28 suggesting that the preconceived distress of a hypothetical HSV-2 diagnosis is overinflated when compared with the actual trauma of an HSV-2 diagnosis.
High rates of HSV serological testing acceptance29–31 suggest that patients desire greater access to HSV-2 testing. However, clinicians may avoid STD-related issues because of lack of comfort discussing sexuality37 38 and a perception that genital herpes counselling is burdensome and time consuming. Given that serological testing is available and that guidelines for counselling have been published,15 shared decision-making between the patient and clinician may be the more appropriate approach rather than assuming that HSV-2 serological testing will cause emotional harm, as is currently advocated for other health-related decisions.39
In the field of medical genetics, the availability of tests for inherited disorders has led to increased requests for testing by patients, even for diseases for which effective interventions are not available, such as Huntington's or Alzheimer's disease. Evidence suggests that people who are interested in knowing their genetic risk do not regret having been tested, and that the ‘pros’ outweigh the ‘cons’ after testing.40–43 Ethicists debate the balance between patient autonomy and the ‘right not to know’ and the potential harm to family members from such ‘genetic ignorance’.44 Such arguments can also be applied to HSV-2 infection, in which the rights of the infected partner not to know are balanced with the rights of susceptible partners to assess the risk of exposure. Finally, it is important to emphasise that preventive measures are available to reduce the risk of HSV-2 transmission and thus the patient is able to mitigate the ‘bad news’ partly by altering behaviour.
Limitations to this review include the lack of standardised scales across studies. All study populations were self-selected and outcomes were self-reported and thus subjective. Some study populations had low HSV-2 prevalence rates, which may have resulted in the study being underpowered to detect differences in psychosocial measures; however, the use of within-person comparisons increased power in many studies. In addition, while most studies noted that pre and post-test HSV counselling was performed, extensive counselling may not be feasible in a clinical setting and may influence psychosocial outcomes. The strengths of this review include the high quality of the studies and the variety of patient populations.
In summary, we found that serological diagnosis of HSV-2 does not result in lasting adverse psychosocial sequelae; these findings should be considered in developing future recommendations for HSV-2 serological testing. Broader testing would allow HSV-2-positive persons to receive appropriate treatment for undiagnosed HSV-2-related symptoms,5 45 and would allow both HSV-2-seropositive and seronegative persons to receive herpes counselling and education. Future studies should address whether higher rates of HSV-2 diagnosis can lead to a reduction in transmission through partner notification,46 antiviral suppressive medication47 and condom use.48
In a systematic review of studies conducted across a variety of clinical settings we found that serological testing for HSV-2 of persons without a recognised history of genital herpes:
Did not result in persistent mental health problems, including anxiety, depression, or distress, or persistent changes in sexual attitude.
Before testing most persons anticipate an HSV-2 diagnosis to be quite severe, but after receiving a positive diagnosis patients view it as less severe.
Most people are interested in HSV-2 testing and do not regret being tested.
Presented in part at the 19th International Society of STD Research Conference, Quebec City, Canada, 10–13 July 2011.
Funding This work was supported by the National Institutes of Health/NIAID grants P01-AI030731 (AW) and K24-AI071113 (AW), K23-AI079394 (CJ). CJ has received grant support from GlaxoSmithKline and is a research investigator for AiCuris. AW has received research funding from GlaxoSmithKline and is a consultant for AiCuris.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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