Why Herpes Diagnoses Are More Complicated Than You Think

Photographed by Nicholas Bloise.
Considering it's such a common virus (about one out of every six Americans has some form of herpes), getting diagnosed with herpes turns out to be way more complicated than you might think. For starters, if it's so common, then why isn't a herpes test included in your average yearly STD panel? "Most providers want to make that diagnosis just because of the implication for [the patient's] partners," and also because it's possible to spread it from one part of your body to another, explains Cheryl Iglesia, MD, associate professor at Georgetown University School of Medicine.

But there are a lot of other competing factors to consider before a doctor decides to give you a herpes test. Here's everything you need to know about the wild world of herpes diagnoses.

Before we get going, let's take it back to Herpes 101 for a sec. The herpes simplex virus (HSV) is a sexually transmitted infection that affects your nerves, though its more visible (and infamous) effects are the skin sores it can cause. It also comes in two types: In general, the more common HSV-1 causes lesions on your mouth, while HSV-2 affects the genital area. However, as we've written before, it's totally possible to get either kind in either location. So you can't really diagnose your type based solely on where you're infected.

The vast majority of people who have herpes have zero symptoms, so it's entirely possible to have it without knowing. If you do have symptoms, there are medications that can help suppress the virus, tame outbreaks, and allow you to go back to living your (mostly) normal life. "You may just have one episode your whole life and forget about it," adds Dr. Igleisa. "But this is not a curable disease. You have it forever."

To make an accurate diagnosis, your doctor will need to take all things into account. That includes looking at any signs of a current outbreak (usually this is the thing that brings people in to ask for a test, for obvious reasons), your risk factors (e.g. how much unprotected sex you're having), and whether or not you have other symptoms (such as a burning or tingling sensation before the sores appeared).

In some cases, your doctor will recommend a laboratory test to confirm the diagnosis or rule out others, but it's only recommended in specific cases. For instance, if your symptoms keep coming back, if you had sex with someone who has genital herpes, or if you're pregnant, your doctor may suggest getting tested. If you don't have symptoms, routine testing isn't recommended the way it is for other STIs, such as chlamydia.

And this is where it gets really complicated.

There are two basic ways to test for herpes: a blood test, or a swab of one of the sores, if you're in the middle of an outbreak, Dr. Iglesia says.

According to the U.S. Centers for Disease Control and Prevention (CDC), blood tests aren't always reliable, because you may test positive even if you don't have herpes. Although that's a risk you run for pretty much any test for anything, the false-positive rate here is high enough that the agency recommends against routinely screening everyone for herpes via blood test. That's because the rate of false-positives like these is too high, and there's no evidence to suggest that people actually have safer sex after a positive diagnosis. So, the CDC concludes that a false positive may be "a greater concern than the benefits of an actual diagnosis."

Aside from screening, however, the blood tests (yes, there is more than one type) can be helpful in those more specific circumstances mentioned previously. The first one, which tests your blood for the IgM antibody, turns out to be pretty unreliable. An IgM response may not be detectable immediately because your body just hasn't produced enough of those antibodies. And once it has actually peaked, the response fades away rather quickly. So it should never be used on its own to diagnose herpes, but that doesn't stop some experts from offering it anyways. If you're offered a blood test, you can ask your doctor to make sure it's not the IgM one.

Then there's the test for the other antibody response, the IgG. This is the most reliable type of test. It's especially useful because it can actually differentiate between HSV-1 and HSV-2. However, your body can take up to six months after you initially got the infection to develop a sufficient IgG response. So it's not particularly useful if you're wondering about a potential infection stemming from, say, some unprotected sex a few weeks ago.

The bottom line: "The initial peak can be positive for IgM, but it goes away. It's the long-term IgG response that shows you've developed antibodies," Dr. Iglesia says. "When we're testing, we're testing for IgG."

The other reliable option looks at the swab test of herpes sores. That means you have to actually have symptoms at the time of testing. Rather than looking at antibodies, the swab test seeks out the actual virus. To do so, your tissue sample will either be tested with a viral culture, (in which the lab waits to see if the herpes virus grows from the sample), or with the more sensitive polymerase chain reaction (PCR). Through the PCR process, copies of the viral DNA are made so that it's present in a level that's actually detectable. There are other kinds of herpes DNA tests out there, but PCR is the most widely used.

Thanks to all of this confusion, unfortunately, rare misdiagnoses of herpes do happen. What looks to be herpes isn't always herpes: Our own Shannon Coffey explained in an episode of Report Card on RIOT that she initially received a visual diagnosis of herpes. But when her test came back a week later, it was negative. So if you think you may have herpes (or any STI, actually) check in with your doctor to get it cleared up, and know that you might need to be patient to get to the bottom of it.

If, after all of that, you do test positive for herpes, remember that it's very common. "It’s better to just get over the initial shock and stigma, put on your big-boy and big-girl panties, and tell the people that you’re sleeping with — and any new doctors — that you have it," says Dr. Iglesia. "The good news is we have a lot of treatment options out there. Even if you're someone who is getting frequent outbreaks, you don’t have to live like that."
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