In an asymptomatic patient without risk factors, should routine testing for herpes simplex virus type 1 and type 2 be performed?

Routine HSV-1 and HSV-2 Testing in Asymptomatic Patients Without Risk Factors

Routine serologic screening for HSV-1 and HSV-2 should NOT be performed in asymptomatic patients without risk factors. 1, 2, 3

Primary Recommendation

The USPSTF explicitly recommends against routine serologic screening for HSV-2 infection among asymptomatic adolescents and adults with a Grade D recommendation, meaning the harms outweigh the benefits. 1, 2, 3 This recommendation is particularly applicable to asymptomatic individuals with low pretest probability of infection (few lifetime sexual partners, no known HSV-2 seropositive partners, no genital symptoms). 1

Screening of pregnant women without risk factors is also not recommended. 1

Why Screening Is Not Recommended

Test Performance Issues in Low-Risk Populations

• Commercially available serologic tests have significant limitations, particularly in low-prevalence populations where false positives become problematic. 1
• Index values of 1.1-2.9 have only 39.8% specificity, meaning 60% are false positives, while even index values ≥3.0 have 78.6% specificity, still resulting in 21% false positives. 2
• Patients with HSV-1 infection are more likely to have false-positive HSV-2 tests, especially with low index values. 1, 2
• HSV-1 serologic assays lack adequate sensitivity (only 70.2% in some studies), resulting in false-negative diagnoses. 2

Clinical Harms Outweigh Benefits

• The psychological burden of a positive diagnosis in an asymptomatic person without clear clinical benefit is substantial. 3
• Most HSV-infected individuals (approximately 91% of HSV-2 seropositive persons) remain unaware of their infection and never develop recognizable symptoms. 2
• There is no cure for HSV infection, and identifying asymptomatic infection does not clearly improve health outcomes in low-risk populations. 2, 3

Exceptions: When Testing SHOULD Be Considered

High-Risk Populations Where Screening May Be Beneficial

Testing should be considered in the following specific groups:

• HIV-infected persons who do not know their HSV-2 serostatus and wish to consider suppressive antiviral therapy to prevent HSV-2 transmission. 1, 2
• Men who have sex with men (MSM) at high risk for STDs and HIV infection who are motivated to reduce sexual risk behavior. 2, 4
• Sexual partners of individuals with known genital HSV-2 infection, as they have increased epidemiologic risk. 1, 2, 4
• Pregnant women at risk of acquiring HSV infection close to delivery (not routine screening of all pregnant women). 2
• Patients with genital symptoms (classic or atypical) that could be consistent with genital herpes should undergo HSV-2 serologic testing to establish diagnosis. 1
• Patients told they have genital herpes without virologic diagnosis have high pretest probability and should undergo HSV-2 serologic testing. 1

Critical Testing Pitfalls to Avoid

Common Errors in HSV Testing

• Never perform HSV molecular assays (PCR/NAAT) in the absence of genital ulcers—due to intermittent shedding, swabs obtained without lesions are insensitive and unreliable. 2, 5
• Do not use IgM testing for screening—approximately one-third of patients with recurrent genital herpes caused by HSV-2 have IgM responses, making it unreliable. 2
• Avoid testing during the "window period"—antibodies may take up to 12 weeks to develop after infection, and a negative result within this timeframe should be repeated after 12 weeks if recent acquisition is suspected. 2

Confirmatory Testing Requirements

• For low positive results (index value <3.0), confirmation with a second test using a different glycoprotein G antigen is recommended. 2
• Given that specificity improves substantially with higher index values, an index value ≥3.0 may be sufficient for diagnosis of HSV-2 infection without further confirmatory testing, though false positives have been described even at index values >3.5. 1
• Western blot is considered the gold standard for HSV serologic testing but has limited availability. 2

The Bottom Line

In asymptomatic patients without risk factors, the answer is clear: do not test. 1, 2, 3 The combination of poor test performance in low-prevalence populations, lack of clear clinical benefit, and potential psychological harm makes routine screening inappropriate. 3 Reserve testing for symptomatic patients or those in clearly defined high-risk groups where identification of infection can lead to meaningful interventions. 1, 2, 4