HSV type specific antibody tests: patients are ready, are clinicians?

Genital herpes infections continue to increase. In the United Kingdom, HSV-2 seroprevalence is 11%. In the United States, HSV-2 seroprevalence has risen from 16% in 1978 to 22% in 1990-a 31% increase. The greatest increase in incidence is in white people between 19 and 35 years of age. In Europe and the United States, 30% to 60% of clients attending STD clinics are HSV-2 seropositive In all populations studied, whether of high or low HSV-2 prevalence, the majority of genital HSV-2 infections are unrecognised by patients or clinicians.'-3 A number of studies also suggest that source partners in most transmission events (including mother to infant transmission) are unaware that they have genital herpes.4 Clearly, undiagnosed genital herpes infections are the major factor in fuelling the genital herpes epidemic. The most practical and common method for identifying silent virus carriers is testing for serum antibodies. Accurate, HSV type specific serology methods have been available in a number of research laboratories in Scandinavia,8 the United States,9 10 Australia," 12 and the United Kingdom'3 for a number of years and the technology for wide commercial distribution of these tests has existed for over a decade. Yet, in our opinion, companies have been reluctant to invest in type specific HSV test development because clinicians have shown little interest in diagnosing subclinical genital herpes. Why is this? Perhaps the medical and psychosocial consequences of genital herpes infections are not fully appreciated by most clinicians. Perhaps healthcare providers have been fearful of opening a "Pandora's box" of follow up concerns from patients who, in the absence of appropriate testing, would be otherwise unaware of their infections. The time involved in explaining to each of a potential 30-60% of STD clinic clients that he/she has a chronic, intermittently transmissible, infection is daunting. The personal aspects of answering questions such as "How did I acquire this infection?"; "What are my responsibilities regarding my present and future partners?"; or, even, "What do you mean these symptoms are not due to a treatable yeast infection?" are disconcerting. Unfortunately, medical and scientific information to easily answer such questions is not fully available. Thus, it is of interest that this issue of Genitourinary Medicine offers three articles related to the patient's viewpoint on genital herpes.'1'6 In particular, Drs Fairley and Monteiro have offered important insights on the opinions of patients regarding who should be tested and under what circumstances.'6 Their article, "Patient attitudes to type specific serological tests in the diagnosis of genital herpes' reveals that the majority of genitourinary medicine clinic attendees want to know their HSV serostatus. Further, a scaled response measure revealed that this desire to know was extremely strong in the following, perceived, "high risk" circumstances; having had sex with a partner known to have genital herpes, having symptoms suggestive of genital herpes, and having a partner with first episode genital herpes. The authors added an interesting twist to the study. Half of those who completed the questionnaires on test desirability did so after reading three pages of information which, as described, appears to have been well crafted to inform, in lay terms, of the risks of having genital herpes, the impact of subclinical infections on transmission, and the treatment options. Given this type of information, respondents were significantly more likely than those given no information to want to know if their partner had been infected with genital herpes (95% v 87%). Interestingly, about the same proportion of respondents (90% of "no information" and 95% of "information given") would "want to know" (via serology if by no other means) if they had been infected. Strength of desire for the test was very high in a variety of suggested circumstances for testing ranging from screening in pregnancy to having genital symptoms. This study strongly indicates that patients attending a genitourinary clinic desire testing for HSV-2 antibodies. A Early warning From 1998 the title of Genitourinary Medicine will become