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ORIGINAL ARTICLE

Herpes simplex virus type 2 serological testing andpsychosocial harm: a systematic review

Kaile Ross,1 Christine Johnston,1,2 Anna Wald1,2,3,4

ABSTRACTBackground Serological testing for herpes simplex virus(HSV) type 2 in persons without a history of genitalherpes is not recommended, partly because of concernsthat an HSV-2 diagnosis would lead to negativepsychosocial sequelae. This review aimed to examine theevidence regarding the psychosocial effects of HSV-2serological testing.Methods Eight electronic databases were searched forempirical studies indexed before March 2010. Abstractsfrom relevant conferences were reviewed and seniorauthors contacted to find unpublished materials. Eligible

studies examined participants without a history of genitalherpes who underwent HSV-2 serological testing andreported data from at least one quantitative or qualitativepsychosocial assessment conducted after receiving HSVresults.Results Of nine studies that satisfied the inclusioncriteria, seven reported that HSV-2 diagnosis byserological test did not have a persistent negative impacton 309 participants’ mental health or sexual attitude andsatisfaction. Two studies reported a negative impact oftesting; one found that five HSV-2-seropositive collegestudents had increased distress 3 months post-testingcompared with HSV-2-negative individuals, and the otherfound self-reports of sexual undesirability up to 1 year

after diagnosis in some people. The perceived severity ofa genital herpes diagnosis was moderately severe forparticipants before testing; however, post-testing, thereported severity of a herpes diagnosis was lower amongthose testing HSV-2 positive.Conclusions HSV-2 diagnosis by type-specificserological testing did not result in long-termpsychosocial harm in most persons without an identifiedhistory of genital herpes. Concerns about sustainedemotional impact should not deter clinicians fromoffering HSV-2 serological testing to appropriate patients.

Herpes simplex virus (HSV) type 2 is one of themost common sexually transmitted diseases (STD),with an estimated 536 million people infectedworldwide1 and 17% of the population aged15e49 years living with HSV-2 in the USA.2 Simi-larly, in western Europe the HSV-2 prevalence rate isapproximately 14% among women and 7% amongmen.1 HSV-2 is the main cause of recurrent genitalherpes and increases the risk of HIVacquisition twoto threefold.3 Most people infected with HSV-2have not been diagnosed with genital herpes and donot recognise genital symptoms that may be relatedto HSV.4 Even without recognised outbreaks, such

persons may transmit infection to sexualpartners orneonates during subclinical viral shedding.5 Most

transmission occurs from persons who are notsymptomatic or diagnosed with genital herpes.6

Sensitive and specific HSV serological testing hasbecome commercially available in the past decade.7

Many studies have found that patients, acrossa variety of settings,are interestedin receiving HSV-2testing.8e10 Despite patient interest, the appropriateapplication of HSV serological testing has beenmuchdebated.11e14 The Centers for Disease Control andPrevention and the USA Preventive Services TaskForcedo notrecommend herpesscreening among thegeneral public15 16 partly dueto concerns that HSV-2

diagnosis provides no benefit and could lead topsychosocial sequelae such as anxiety and sexualdissatisfaction. The distress that can result froma diagnosis of primary or recurrent genital herpeshasbeen well documented;17e19 however, patients wholack clinical symptoms and are diagnosed by a sero-logical test maynot have the same reaction to HSV-2diagnosis as would someone presenting with a firstclinical episode of genital herpes infection.

This systematic review examines studies thatmeasure the short and long-term psychosocialeffects resulting from serological diagnosis of HSV-2in persons without recognised symptoms of genitalherpes infection.

METHODSData sources and searchesElectronic databases were searched from theiroriginal start date to March 2010. The databasesincluded Pubmed/Medline, PsycINFO, Web of Science, EMBASE (Ovid), CINAHL Plus and theCochrane Library. Search terms used were: herpes

AND testing AND psychosocial, herpes ANDdiagnosis AND psychosocial, herpes AND screening

AND psychosocial, herpes simplex AND testing AND emotional, herpes simplex AND testing ANDimpact.

To identify unpublished studies, we searched theNational Research Register and clinical trials.gov,hand reviewed abstracts from relevant conferences,and searched for articles that cited or were citedby articles identified by the inclusion criteria. InMarch 2010, we contacted corresponding authorsand/or senior co-authors of the studies included inour systematic review, to determine if additionalunpublished data were available. This strategy did not yield additional data to include in oursystematic review.

Study selection

Studies were included based on the followingcriteria: participants underwent a HSV-2 serological

1Department of Medicine,University of Washington,Seattle, Washington, USA2Vaccine and Infectious DiseaseDivision, Fred HutchinsonCancer Research Center,Seattle, Washington, USA3Department of LaboratoryMedicine, University ofWashington, Seattle,Washington, USA4Department of Epidemiology,University of Washington,Seattle, Washington, USA

Correspondence toDr Christine Johnston,University of WashingtonVirology Research Clinic, Box359928, 325 Ninth Avenue,Seattle, WA 98104, USA;[email protected]

Presented in part at the 19thInternational Society of STDResearch Conference, QuebecCity, Canada, 10e13 July 2011.

Accepted 11 August 2011Published Online First8 September 2011

594 Sex Transm Infect 2011;87:594e600. doi:10.1136/sextrans-2011-050099

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test as part of study procedures or had undergone a HSV-2serological test in the past, and at least one psychosocialassessment of the participants was performed after serologicalresults were provided. Case studies, review articles and studiesthat only tested symptomatic or previously diagnosed partici-pants were excluded. Based on title and abstract, two authorsindependently reviewed identified references to determinewhether the study met the inclusion criteria. The articles

selected from this initial screening underwent full text review.

Data extraction and quality assessment We extracted standard data from each article, including study characteristics (year of publication, country, design, researchsetting), participant characteristics (number of subjects, age,gender, herpes history, co-morbidities), subject selection criteria,type of serological testing, testing acceptance, results of sero-logical testing, psychosocial methods and results (types andtiming of testing), study quality (limitations and bias) and study conclusion as summarised by study authors. Data extractionwas done by one author and verified for accuracy andcompleteness by a second author. Methodological study quality

was assessed utilising a modified Newcastle Ottawa quality assessment scale, which was specifically designed to assess thequality of non-randomised studies including caseecontrol andcohort studies.20

RESULTS We identified 173 articles using our search strategy (figure 1).The initial review process yielded 15 (9%) studies that metour predefined inclusion criteria and underwent a full textreview.19 21e34 Four articles were excluded because HSV testingwas not type-specific,1 9 2 1 2 4 3 4 and two articles were excludeddue to lack of post-testing psychosocial assessment.2 2 2 3 Theremaining nine articles were included in the systematic

review.25e33

Co-authors independently concurred on whichstudies met the inclusion criteria.

Study characteristicsDemographicsSix studies were conducted in the USA, two in the UK and onein Australia; all studies were conducted between 2000 and 2008(table 1). Of the 1355 participants included in the nine studies,793 (56%) were men; ages ranged from 16 to 67 years. Of the596 (44%) participants who were HSV-2 positive, 341 (57%)lacked a recognised previous history of genital herpes. Studies

had a median of 180 participants (range 24e

223).

SettingParticipants were recruited from primary care clinics (maternalinfant care, family medicine and adolescent care), speciality clinics (including an HIV clinic, STD clinics, genitourinary clinicand an academic STD research clinic), three hospitals, a healthmaintenance organisation (HMO) and two college campuses.

Study designThere were eight prospective cohort studies and one qualitativestudy. Seven of the eight prospective cohort studies assessedpsychosocial parameters at baseline and after type-specific HSVserological testing; one assessed testing regret after test resultswere delivered. Follow-up ranged from immediately afterparticipant received serological results to 6 months afterwards.

Comparison groupsSeven cohorts with baseline and follow-up measures usedwithin-person measurements to assess scores on psychosocialscales over time (table 2). Four studies also compared partici-pants who tested HSV-2 positive with participants who testedHSV-2 negative.2 5 2 8 3 1 3 2 Three studies compared responses inHSV-2-positive participants with and without a history of genital herpes.27 30 33

Measures

Several tools were employed to assess the psychosocial impact of HSV-2 testing. The qualitative study used a semistructuredinterview, including questions about sexual desire and reactionsto diagnosis. For one prospective cohort, the psychosocialassessment consisted of asking the participant if he/sheregretted having the test.29 The remaining seven prospectivecohorts used a range of two to six validated scales and ques-tionnaires. To analyse the results, the scales were grouped intosix categories.< Mental health: Center for Epidemiological Studies of Depres-

sion scale (CES-D), general health questionnaire (GHQ-30and GHQ-12), profile of mood states brief (POMS), Randmental health inventory (MHI-5), Coopersmith self-esteeminventory, brief symptom inventory (BSI) subscales, state

anxiety index, hospital anxiety and depression scale (HADS).< Coping and counselling: perceived social support subscale

from the multidimensional scale of perceived social support,relationship quality scale, ways of coping scale.

< Sexual satisfaction: the multidimensional sexual self conceptquestionnaire and a subset of the BSI were used to measuresexual optimism, sexual attitudes and perceived quality of sex. The sexual attitudes scale was also used.

< Herpes-related quality of life: herpes-related quality of lifescale (HRQoL).35

< Perceived severity of HSV-2 and STD stigma: health belief model subscales (perceived severity of and susceptibility togenital herpes), perception of genital herpes instrument from

the American Social Health Association, STD-related stigma.< Acceptance and acceptability of testing.

Records idenƟfied through

database searching

(n=423)

Records idenƟfied through other

searching methods

(n=2)

Records aŌer duplicates removed

(n=173)

Records screened

(n=173)

Records excluded

(n=158)

Full-text arƟcles assessed

for eligibility

(n=15)

Full-text arƟcles excluded

(n=6)

Non-serologic specific: 4

No psychosocial

assessment following

HSV serologic tesƟng: 2

Studies included in

systemaƟc review

(n=9)

Figure 1 Study selection flow diagram. Psychosocial impact of herpessimplex virus serological testing.

Sex Transm Infect 2011;87:594e600. doi:10.1136/sextrans-2011-050099 595

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T a b

l e 1

C o n t i n u e d

S t u d y

P a r t i c i p a n t s

S i z e

F e m a l e %

M e d i a n a g e

( r a n g e )

* m e a n

S e r o l o g

i c a l t e s t

H S V - 2 t e s t

r e s u l t s

P s y c h o s o c i a l

a s s e s s

m e n t

F o l l o w - u p

S u m m a

r y r e s u l t s

R i c h

a r d s 3

0

( U S A , 2 0 0 7 )

U r b a n H M O e n r o l l e e s

r e c r u i t e d v i a m a i l a n d

p h o n e

2 0

1

6 0

4 6 ( 1 9 e 6 7 )

H S V w e s t e r n b l o t

2 6 % ( 8 7 o f 3 4 4 )

t e s t e d p o s i t i v e , 4 4

w i t h o u t p r e v i o u s

d i a g n o s i s o f H S V - 2 , 8 7

p o s i t i v e s a n d 1 1 4

n e g a t i v e s w e r e e n r o l l e d

i n t h e f o l l o w - u p s t u d y

P e r c e i v

e d s u s c e p t i b i l i t y

a n d s e v e r i t y m o o d s t a t e s

G e n i t a l h e r p e s H R Q o L

S e x u a l

o p t i m i s m

S e x u a l

s a t i s f a c t i o n

W a y s o f c o p i n g

2 w e e k s ,

3 m o n t h s ,

6 m o n t h s

6 % [ o n m o o d d i s t u r b a n c e f o r

n e w l y d

i a g n o s e d s u b j e c t s r e l a t i v e

t o b a s e l i n e ( p ¼ 0 . 0 0 3 ) , n o

s i g n i fi c a

n t d i f f e r e n c e w h e n

c o m p a r i n g b e t w e e n g r o u p s e x c e p t

w i t h i n H

S V - s p e c i fi c m o o d

d i s t u r b a

n c e . A t 2 w e e k s , n e w l y

d i a g n o s e d c o p e d b y w i s h i n g

s i t u a t i o n w o u l d d i s a p p e a r ( 0 . 0 3 8

p o i n t s h

i g h e r , p ¼ 0 . 0 1 4 ) r e l a t i v e t o

p r e v i o u s l y d i a g n o s e d a n d o t h e r t i m e

p o i n t s ( 0 . 3 7 , p < 0 . 0 0 1 ) .

R o s e n t h a l

3 1

( U S A , 2 0 0 6 )

<

S t u d e n t s f r o m a n u r b a n

u n i v e r s i t y s e t t i n g ,

a t t e n d e e s f r o m a n S T D

c l i n i c , p r i m a r y c a r e c l i n i c

a n d a d o l e s c e n t c l i n i c s

– N o p r e v i o u s h i s t o r y o f

g e n i t a l H S V

– 7 % o f p o s i t i v e s w e r e

a d o l e s c e n t s

9

3

8 7

2 2 . 7 * ( c r i t e r i a :

1 4 e 3 0 y e a r s )

H S V - 2 a

n t i b o d y t e s t

1 8 % ( 1 4 9 o f 8 2 0 )

t e s t e d p o s i t i v e , 3 3

p o s i t i v e s a n d 6 0

n e g a t i v e s w e r e

e n r o l l e d i n t h e

f o l l o w - u p s t u d y

P e r c e i v

e d s o c i a l s u p p o r t

R e l a t i o n s h i p q u a l i t y

S T D - r e l a t e d s t i g m a

P e r c e i v

e d q u a l i t y o f s e x

G e n i t a l h e r p e s H R Q o L

3 m o n t h s

N o s i g n i fi c a n t d i f f e r e n c e b e t w e e n

p o s i t i v e

a n d n e g a t i v e s u b j e c t s o n

d e p r e s s i o n , a n x i e t y , p a r a n o i a ,

h o s t i l i t y

, i n t e r p e r s o n a l s e n s i t i v i t y ,

S T D s t i g m a , r e l a t i o n s h i p q u a l i t y ,

o r q u a l i t y o f s e x . N o e f f e c t f o r t i m e .

S m i t h 3 2

( A U , 2 0 0 0 )

<

S e x u a l h e a l t h c e n t r e

a t t e n d e e s

– N o s y m p t o m s o r h i s t o r y

o f g e n i t a l H S V

– P r e s e n t i n g f o r g e n i t a l

a n d s e r o l o g i c a l s c r e e n i n g

t e s t s

1 8

0

4 6

N o o f s u b j e c t s b y

a g e g r o u p

1 8 e 3 0 y e a r s : 1 2 7

3 1 e 4 0 y e a r s : 3 2

> 4 0 y e a r s : 2 1

H S V - 2 e

n z y m e

i m m u n o a s s a y a n d

H S V - 1 w

e s t e r n b l o t

2 1 ( 1 1 . 7 % ) t e s t e d

p o s i t i v e

G e n e r a

l h e a l t h

q u e s t i o

n n a i r e ( G H Q - 1 2 )

S t a t e a

n x i e t y i n d e x

S e l f - e s t e e m i n v e n t o r y

S e x u a l

a t t i t u d e s s c a l e

3 m o n t h s ,

6 m o n t h s

N o c h a n g e i n G H Q - 1 2 o r o t h e r s c a l e s

f o r H S V - 2 - p o s i t i v e o r n e g a t i v e

p a r t i c i p a n t s o v e r t i m e .

W i l k

i n s o n 3

3

( U K ,

2 0 0 0 )

l e t t e

r t o t h e

e d i t o r

<

A t t e n d e e s f r o m t h r e e

h o s p i t a l s ( o u t p a t i e n t )

– S u b j e c t s e n r o l l e d i n

s t u d y c o m p a r i n g P O C K i t t o

s t a n d a r d H S V s e r o l o g y

– 3 5 / 9 0 w i t h h i s t o r y o f

g e n i t a l h e r p e s

9

0

5 0

N o t s p e c i fi e d

P O C K i t H S V - 2

5 1 ( 5 7 % ) t e s t e d

p o s i t i v e , 2 5 w i t h o u t

p r e v i o u s H S V - 2

d i a g n o s i s

H o s p i t a l a n x i e t y a n d

d e p r e s s i o n q u e s t i o n n a i r e

( H A D )

3 m o n t h s ,

6 m o n t h s

N o s i g n i fi c a n t d i f f e r e n c e i n t h e n u m b e r

o f c a s e s o f a n x i e t y o r d e p r e s s i o n i n

t h o s e w

h o t e s t e d p o s i t i v e w i t h o r

w i t h o u t

a p r e v i o u s h i s t o r y o f H S V - 2 .

* M

e a n a g e .

E I A

, e n z y m e i m m u n o a s s a y ; E L I S A , e n z y m e - l i n k e d i m m u n o

s o r b e n t a s s a y ; H M O , h e a l t h m a i n t e n a n c e o r g a n i s a t i o n ;

H S V , h e r p e s s i m p l e x v i r u s ; S T D , s e x u a l l y t r a n s m i t t e d d i s e a s e .


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Individual study resultsQualitative studyMelville et al

26 conducted semistructured interviews with 24participants, 1 month to 1 year following serological diagnosis of HSV-2 infection. Emotional responses ranged from surprise(50%) and denial (37%), to relief at knowing (20%). Ongoingthemes at 1 year following diagnosis were acceptance (58%),

concerns about telling partners (50%) and transmission (46%),and feeling sexually undesirable (42%).

Prospective cohort studies Mental health Among the six studies that assessed mental health impact, fourreported no mental health impact from HSV serological testingon 203 participants.27 28 32 33 There were no changes in mentalhealth scores, depression, anxiety or mood scores whencompared with baseline,28 32 when compared with HSV-2-seronegative participants28 32 or when compared with HSV-2-seropositive individuals with a previous diagnosis of genitalherpes.33 Similarly, Meyer et al

27 tested patients in an urban HIV

clinic and found no significant changes in mood disturbance forpatients who tested positive compared with pre-test baseline orwhen compared with those with a previous history of HSV-2.

Two studies reported a negative impact following an HSV-2diagnosis.25 30 Three months after HSV serological testing, Mark et al

25 found that five HSV-2-seropositive college studentsreported significantly higher levels of distress than 23 studentswho tested HSV-2 negative, but found no differences in depres-sion. Similarly, among HMO enrollees, HSV-2-positive personsreported higher levels of mood disturbance at multiple timepoints compared with baseline (p¼0.003), yet these mood scoreswere not significantly different from HSV-2-negative persons.30

Coping and counselling

Three studies measured changes in coping and relationshipquality. Meyer et al

27 found that newly diagnosed participantshad a decrease over time in seeking social support, as measuredby the ways of coping scale (p¼0.018). Richards et al

30 foundthat newly diagnosed patients were temporarily more likely toengage in avoidant coping at the 2-week follow-up comparedwith negative or previously diagnosed patients; however, thisdifference resolved by 3 months. In contrast, Rosenthal et al

31

found that social support and relationship quality did not vary among newly diagnosed participants over time or in comparisonto participants who tested negative for HSV-2.

Three studies noted that some participants required furthercounselling or information after receiving a HSV-2 diagnosis.

Market al

25

found that six (75%) of eight HSV-2-positive collegestudents contacted study staff for additional counselling. In the

other two studies, few participants requested additionalcounselling (one (4%) of 2533 and four (2%) of 223).29

Sexual satisfactionFive studies measured the impact of HSV-2 diagnosis on sexualhealth and attitudes.27 28 30e32 Miyai et al

28 found a temporary decrease in multidimensional sexual self-concept questionnaireassessed sexual attitude scores for HSV-2-positive subjectscompared with seronegative subjects at 1 week (p¼0.01), whichresolved by 3 months (p¼0.74). The other four studies found nosignificant decline for 214 newly diagnosed participants in sexualsatisfaction or sexual optimism for HSV-2-positive participantscompared with baseline or seronegative participants.27 30e32

Herpes-related quality of lifeThree studies assessed herpes-related quality of life.27 30 31

Rosenthal et al31 reported that at 3 months post-HSV-2 diagnosis,

most participants endorsed that ‘it is dif ficult to forget that I haveherpes’ (63%). The least endorsed item was ‘Herpes is making my life miserable’ (4%). Rosenthal et al

31 further noted that greaterbaseline interpersonal sensitivity (p<0.05), lower sexual satisfac-

tion (p<0.01) and lower social support (p<0.05) were associatedwith lower herpes-related quality of life scores at 3 months. Theauthors concluded that ‘individuals who are already vulnerablewith regard to their sexual and interpersonal experiences appearto be most impacted by an HSV diagnosis’. Two studies foundthat the herpes-related quality of life scores remained consistentthroughout the 6-month follow-up for persons who tested HSV-2positive and found no difference in scores between newly diag-nosed and previously diagnosed participants.27 30

HSV-2 perception and stigmaIn examining perceptions about the severity of having HSV-2,Meyer et al

27 and Richards et al30 reported that participants found

a genital herpes diagnosis as traumatic as being diagnosed withhigh blood pressure or being involved in a car crash withouthospitalisation. HSV-2 diagnoses were rated less severe amongHMO enrollees who reported a previous HSV-2 diagnosiscompared with newly diagnosed participants (p<0.001), suggestingthat persons who have lived with HSV-2 perceive the infection asless of a burden.30 Similarly, Miyai et al

28 found that HSV-2-positive participants perceived genital herpes to be less traumaticthan did participants who were seronegative (p<0.001). Nodifferences in perception of stigma were found for HSV-2-positiveparticipants compared with baseline or HSV-2-negative persons.31

Acceptance and acceptability of testingIn the studies that measured testing acceptability, the majority of eligible individuals accepted testing.29e31 Narouz et a l

29

found that only three out of 223 (1%) genitourinary clinic

Table 2 Comparison groups

ReferenceWithin groups(newly diagnosed)

Between groups

Newly diagnosedto negative

Newly diagnosed topreviously diagnosed

Mark25 (USA, 2008) Yes Yes NA

Melville26 (USA, 2003) Yes NA NA

Meyer27 (USA, 2005) Yes Yes Yes

Miyai28 (USA, 2004) Yes Yes NA

Narouz29 (UK, 2003) NA NA NARichards30 (USA, 2007) Yes Yes Yes

Rosenthal31 (USA, 2006) No Yes NA

Smith32 (AU, 2000) Yes Yes NA

Wilkinson33 (UK, 2000) No No Yes

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attendees regretted having HSV-2 serological testingperformed.

Methodological quality The nine studies were ranked on the Newcastle Ottawa Scale,which assesses quality based on the selection of the comparisongroups, study comparability and outcomes.20 The methodologicalquality of the studies was moderate to high, with a median score

of seven out of nine stars and a range of fi

ve to eight (table 3).

DISCUSSIONThis systematic review thoroughly examined the findings andquality of the literature reporting the psychosocial impact of HSV-2 diagnosis by serological testing. We found that mostpersons without a recognised history of genital herpes whotested positive for HSV-2 did not experience longstandingmental health problems, have persistent sexual attitude prob-lems, or regret being tested. Of the nine studies included in thisreview, two reported a negative impact of testing. One reportedhigher levels of distress but not depression in a small number of college students who tested positive for HSV-2 3 months earlier,and a qualitative study found self-reports of sexual undesir-ability in some people up to 1 year after diagnosis. Mostparticipants anticipated the trauma of a genital herpes diagnosisto be moderately severe; however, this did not translate intomeasurable mental health or psychosexual sequelae post-diag-nosis. As such, the published literature indicates that HSV-2diagnosis by serological testing does not cause adverse long-termpsychosocial effects.25e33 36

Our findings contrast with literature describing heightenedrates of anxiety, distress and sexual dissatisfaction after a clinicaldiagnosis of primary and recurrent genital herpes,17e19

suggesting that it is not the experience of being diagnosed withHSV-2 infection that causes psychosocial harm, but perhaps theexperience of painful lesions and the uncertainty of frequent

recurrences that accompany a clinical HSV-2 diagnosis. Wefound HSV-2 diagnosis appeared to have less psychosocialimpact when the diagnosis was made at a STD clinic, perhapsbecause people already perceive themselves to be at higher risk of sexually transmitted infections. Conversely, college studentsmay have an increased risk of negative sequelae, as a populationwith heightened interpersonal sensitivity and vulnerability.31

Current STD treatment guidelines do not recommend routinetesting for genital herpes among asymptomatic persons.1 5 1 6

One reason is the perceived risk of psychosocial harm.16 Ourfindings suggest that the potential risk of psychological harm isnot a valid reason to withhold serological HSV-2 testing from

patients without a reported history of herpes symptoms. Infact, one study found that once diagnosed, HSV-2-positiveparticipants perceived genital herpes to be less traumatic thanHSV-2-negative participants,28 suggesting that the preconceiveddistress of a hypothetical HSV-2 diagnosis is overinflated whencompared with the actual trauma of an HSV-2 diagnosis.

High rates of HSV serological testing acceptance29e31

suggest that patients desire greater access to HSV-2 testing.

However, clinicians may avoid STD-related issues because of lack of comfort discussing sexuality 37 38 and a perception thatgenital herpes counselling is burdensome and time consuming.Given that serological testing is available and that guidelines forcounselling have been published,15 shared decision-makingbetween the patient and clinician may be the more appropriateapproach rather than assuming that HSV-2 serological testingwill cause emotional harm, as is currently advocated for otherhealth-related decisions.39

In the field of medical genetics, the availability of tests forinherited disorders has led to increased requests for testing by patients, even for diseases for which effective interventions arenot available, such as Huntington’s or Alzheimer’s disease.Evidence suggests that people who are interested in knowingtheir genetic risk do not regret having been tested, and that the‘pros’ outweigh the ‘cons’ after testing.40e43 Ethicists debate thebalance between patient autonomy and the ‘right not to know’

and the potential harm to family members from such ‘geneticignorance’.44 Such arguments can also be applied to HSV-2infection, in which the rights of the infected partner not toknow are balanced with the rights of susceptible partners toassess the risk of exposure. Finally, it is important to emphasisethat preventive measures are available to reduce the risk of HSV-2 transmission and thus the patient is able to mitigate the ‘badnews’ partly by altering behaviour.

Limitations to this review include the lack of standardisedscales across studies. All study populations were self-selected

and outcomes were self-reported and thus subjective. Somestudy populations had low HSV-2 prevalence rates, which may have resulted in the study being underpowered to detectdifferences in psychosocial measures; however, the use of within-person comparisons increased power in many studies. Inaddition, while most studies noted that pre and post-test HSVcounselling was performed, extensive counselling may not befeasible in a clinical setting and may influence psychosocialoutcomes. The strengths of this review include the high quality of the studies and the variety of patient populations.

In summary, we found that serological diagnosis of HSV-2does not result in lasting adverse psychosocial sequelae; these

Table 3 Newcastle Ottawa scale methodological assessment

Reference

Selection Comparability Outcome

Total criteria out of 91 2 3 4 1 2 1 2 3

Mark25 (USA, 2008) C C C C C C C 7

Melville26 (USA, 2003) C C C C C 5

Meyer27 (USA, 2005) C C C C C C C C 8

Miyai28 (USA, 2004) C C C C C C C 7

Narouz29 (UK, 2003) C C C C C C 6

Richards30 (USA, 2007) C C C C C C C C 8

Rosenthal31 (USA, 2006) C C C C C C C 7

Smith32 (AU, 2000) C C C C C C 6

Wilkinson33 (UK, 2000) C C C C C 5

Selection: 1, representativeness of the HSV-2-positive cohort; 2, selection of HSV-2-negative cohort; 3, ascertainment of serostatus; 4, demonstration that outcome of interest was not presentat start of study.Comparability: 1, study controls for previous HSV-2 diagnosis; 2, study controls for age or gender.

Outcome: 1, method for assessment of outcome; 2, sufficient follow-up; 3, sufficient participant retention in follow-up.HSV, herpes simplex virus.


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findings should be considered in developing future recommen-dations for HSV-2 serological testing. Broader testing wouldallow HSV-2-positive persons to receive appropriate treatmentfor undiagnosed HSV-2-related symptoms,5 45 and would allowboth HSV-2-seropositive and seronegative persons to receiveherpes counselling and education. Future studies should address

whether higher rates of HSV-2 diagnosis can lead to a reductionin transmission through partner notification,46 antiviralsuppressive medication47 and condom use.48

Funding This work was supported by the National Institutes of Health/NIAID grantsP01-AI030731 (AW) and K24-AI071113 (AW), K23-AI079394 (CJ). CJ has receivedgrant support from GlaxoSmithKline and is a research investigator for AiCuris. AW hasreceived research funding from GlaxoSmithKline and is a consultant for AiCuris.

Competing interests None.

Contributors AW conceived the study. KR, CJ and AW designed the review. KR andCJ performed literature searches and collected and analysed data. KR drafted thepaper, which was revised by all authors. All authors have read and approved the finalversion of the paper.

Provenance and peer review Not commissioned; externally peer reviewed.

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40.

Key messages

In a systematic review of studies conducted across a variety ofclinical settings we found that serological testing for HSV-2 ofpersons without a recognised history of genital herpes:< Did not result in persistent mental health problems, including

anxiety, depression, or distress, or persistent changes in

sexual attitude.< Before testing most persons anticipate an HSV-2 diagnosis to

be quite severe, but after receiving a positive diagnosispatients view it as less severe.

< Most people are interested in HSV-2 testing and do not regretbeing tested.

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doi: 10.1136/sextrans-2011-050099September 8, 2011

2011 87: 594-600 originally published onlineSex Transm Infect

Kaile Ross, Christine Johnston and Anna Waldsystematic reviewtesting and psychosocial harm: aHerpes simplex virus type 2 serological

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