Why HSV Testing Is Excluded from Routine Asymptomatic STI Screening
The U.S. Preventive Services Task Force explicitly recommends against routine serologic screening for HSV in asymptomatic individuals because there is no evidence that treating asymptomatic patients improves long-term health outcomes, and the harms of screening outweigh any potential benefits. 1
The Core Problem: No Clinical Benefit from Treating Asymptomatic Infection
- HSV screening can identify infected individuals, but treatment of asymptomatic patients does not improve morbidity, mortality, or quality of life outcomes. 1
- Unlike chlamydia or gonorrhea where asymptomatic infection leads to serious complications (PID, infertility) that can be prevented with treatment, HSV remains dormant in nerve ganglia and cannot be eradicated with current antivirals. 2
- Antiviral therapy only controls active symptoms and reduces viral shedding during treatment—it does not eliminate the virus or prevent future recurrences once discontinued. 3
Significant Harms That Outweigh Benefits
Psychosocial Harm
- A positive HSV diagnosis in an asymptomatic person can cause substantial psychological distress, anxiety, depression, and relationship problems without providing any medical benefit. 1
- There is considerable social stigma associated with HSV-2 infection specifically, even though HSV-1 can cause identical genital disease. 1
High False-Positive Rates
- Serologic tests with index values between 1.1-2.9 have only 39.8% specificity, meaning more than half of low-positive results are false positives. 4
- Even index values ≥3.0 have only 78.6% specificity, still producing substantial false positives in low-prevalence populations. 4
- The CDC recommends confirming any positive result with index <3.0 using a second assay to improve positive predictive value from 80.5% to 95.6%, adding complexity and cost. 4
No Impact on Transmission Prevention
- Approximately 20% of HSV-2 seropositive individuals never recognize symptoms, and asymptomatic viral shedding occurs unpredictably regardless of whether someone knows their status. 5, 3
- While suppressive therapy reduces transmission by 50% in serodiscordant couples, this benefit only applies when both partners know their status and the infected partner takes daily medication—a scenario that requires targeted, not population-based screening. 4, 5
When HSV Testing IS Appropriate
The CDC recommends type-specific HSV serologic testing only in specific clinical scenarios where the diagnosis would change management: 4
- Persons with genital symptoms or recurrent lesions consistent with herpes 1
- Sexual partners of persons known to have HSV-2 infection (to guide counseling and suppressive therapy decisions) 4
- HIV-infected persons (routine screening recommended due to more severe disease and higher transmission risk) 4, 5
- Pregnant women at risk of acquiring HSV near delivery (not routine screening, but risk-based) 4
- Persons told they have genital herpes without virologic confirmation 4
The Contrast with Other STIs
This differs fundamentally from chlamydia and gonorrhea screening because:
- Untreated asymptomatic chlamydia and gonorrhea cause pelvic inflammatory disease, ectopic pregnancy, and infertility—serious complications that are prevented by detecting and treating asymptomatic infection. 1
- HIV and syphilis screening prevents progression to life-threatening disease (AIDS, tertiary syphilis) and reduces transmission. 1, 6
- HSV cannot be cured, asymptomatic infection does not progress to worse disease, and knowing one's status without symptoms provides no medical benefit. 1, 2
Common Pitfall to Avoid
Do not order HSV serology as part of a "comprehensive STI panel" in asymptomatic patients. This creates more harm than benefit through false positives, psychological distress, and no improvement in clinical outcomes. 1 If a patient specifically requests HSV testing, counsel them first about the limitations and potential harms before proceeding. 4