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My patient, who I’ll call Katie, came to my office in tears.
“I have herpes and I need a second opinion,” she said, wiping her eyes.
She brought it her lab results from another physician and it showed a positive herpes antibody test.
“Have you ever had any symptoms of herpes?” I asked.
“No, but the doctor said I have it and that I have to take medicine every day,” she replied.
This scenario is far more common than it should be. Patients often have their blood tested for herpes in the absence of symptoms, either as part of a “full STI screen” or because they request it. But it can cause a lot of confusion around a diagnosis that is misunderstood, especially because the stigma around herpes can be worse than herpes itself.
Take my patient Katie: She had been sexually active but said she never had any bumps or sores near her mouth or genitalia, and was tested for herpes by another medical provider. The blood test showed that she had the antibody to herpes virus type 2—a common strain of the herpes virus that is often associated with genital herpes. Because she’s never had herpes symptoms, but her blood test was positive for the herpes antibody, I can say that she’s probably been exposed to herpes at some point in her life, but I can’t say that she has a clinical diagnosis of herpes.
It used to be that physicians primarily saw the herpes virus type 1, or oral herpes, in patients with cold sores and herpes virus type 2 in patients with genital sores. It’s now, however, common to see both types of the herpes virus in both areas. So, if a patient has ever had a cold sore near the mouth, then the herpes blood test could be positive. The blood test could also be positive because of the one cold sore that person had or because of exposure to someone with herpes during childhood (i.e. from a kiss) or from a previous partner. There are also high rates of false-positive for herpes blood testing and, as a result, the U.S. Preventive Services Task Force recommends against routine screening for herpes antibody in the blood.
In other words, if a person doesn’t have, or has never had, symptoms of herpes, but has a positive antibody test in the blood, I wouldn’t necessarily diagnosis the patient with herpes. The only way to confirm a diagnosis is to swab the sore or the lesion itself and send it to the lab for testing, not by checking the blood. So, if you have a bump or sore and you’re not sure what it is, see your healthcare provider and have the area tested. It may be herpes, but it could also be a wart or syphilis. This test is done in a healthcare setting.
There is so much stigma around herpes; in large part, because few people speak openly about the STI. As a healthcare provider who talks to patients all day about sexual health, many of my patients have an actual diagnosis of herpes. Genital herpes isn’t uncommon; the Centers for Disease Control estimates that about one in six people between the ages 14 to 49 have genital herpes. It is perfectly normal to feel upset and scared on first hearing a diagnosis of herpes but those feelings will subside over time, gradually getting better. People who are living with herpes have long, healthy lives, with very few consequences.
Yes, the first outbreak can be painful, but people who get subsequent outbreaks become aware of symptoms (like tingling) that are associated with herpes before the outbreak. They can usually stay ahead of an outbreak and start treatment with an antiviral medication. Outbreaks can look like clusters of painful sores or even slightly tender tears in the skin. And folks who get frequent outbreaks can take a daily suppressive medication to prevent it from happening in the first place.
Any strain of herpes can be transmitted to someone who has ever kissed lip to lip or had sex—that’s a lot of people. It can also be transmitted through vaginal, anal, oral, or digital penetrative sex. It doesn’t carry the same risks as other STIs (for example, untreated chlamydia can lead to infertility and other complications), but if a pregnant person has an outbreak around the time of delivery, it can pose a risk to the baby. And rarely—and let me emphasize, very rarely—herpes can cause an infection in the brain. But most cases are easily manageable and do not significantly alter people’s lives, particularly their sex lives.
The most likely time to transmit the virus to a partner is during an outbreak. And in general, you’re more at risk of transmitting one STI if you have another (meaning, if you have an active outbreak of herpes and have sex, you may be at higher risk of getting HIV). And just because you’ve had one outbreak doesn’t mean you’ll have another and it doesn’t mean that the timing or the frequency of outbreaks can be predicted. We do know that stress can trigger outbreaks, so practicing mindfulness can help.
Talking to a partner about your herpes diagnosis can feel scary, but make sure to let your partner know that people with herpes have very normal sexual experiences and there are ways to prevent herpes from passing from person to person. Both internal and external condoms can minimize the risk of transmission but any surrounding exposed genitalia may be able to transmit the virus as well.
The bottom line is that there is no reason to get tested for the herpes antibody in your blood if you haven’t had an outbreak. And remember, people can have a normal sex life if they do receive a diagnosis of herpes.
Dr. Meera Shah, MD, MPH, MS is the Chief Medical Officer of Planned Parenthood Hudson Peconic in New York and a fellow with the Physicians for Reproductive Health. She is currently working on a book of essays about reproductive health access.