USPSTF Reaffirms Rec Against Routine Screening for Genital Herpes

The U.S. Preventive Services Task Force (USPSTF) has reaffirmed a 2016 recommendation against routine serologic screening for genital herpes simplex virus (HSV) in asymptomatic adults and adolescents, including pregnant individuals.

Since 2016, there has not been any new evidence showing that the benefit of screening outweighs the risks, particularly the risk of false negatives, noted task force member Carol M. Mangione, MD, MSPH, of the University of California Los Angeles, and colleagues in the reaffirmation recommendation statement published in JAMA.

"The Task Force found that screening for genital herpes in people without signs and symptoms does not improve their overall health," said co-author James Stevermer, MD, MSPH, of the University of Missouri in Columbia, in a press release. "This is due in large part to the fact that the tests used to screen for genital herpes have limitations and a significant chance that the results will say a person has the infection when they do not."

"In fact," he added, "if current screening tests were used across all adolescents and adults, as many as half of the positive results could be wrong."

In the recommendation statement, the Task Force reported that previous studies have shown that serologic testing for HSV-2 infection ended in one false negative for every two diagnoses. In a 10,000-person population with a 15% prevalence of HSV-2, screening would result in approximately 1,585 true-positive and 1,445 false-positive results.

Moreover, "at the current U.S. estimated prevalence of 12%, true-positive results would likely further decrease and false-positive results would likely further increase," Mangione and colleagues wrote. "Additionally, the USPSTF concluded that there may be potential social and emotional harms associated with a false-positive diagnosis and potential harms of unnecessary treatment with preventive antiviral medications in persons with a false-positive diagnosis."

The report also noted that some populations are disproportionately affected. Data from the 2015-2016 National Health and Nutrition Examination Survey among people ages 14 to 49 showed that HSV-1 seroprevalence was 72% in Mexican Americans and 59% in non-Hispanic Blacks compared with 48% in the general U.S. population.

For asymptomatic HSV-2 infection, seroprevalence is difficult to determine, the Task Force added, as those estimates rely on serologic testing, but estimated seroprevalence in Black adolescents and adults is nearly three times that in the general population (35% vs 12%).

Newborns are also at risk, especially during vaginal delivery, resulting in potential morbidity and mortality, though the Task Force noted that transfer of neonatal herpes infection is uncommon.

"Pregnant persons with active genital lesions or prodromal symptoms can be managed with cesarean delivery to reduce the risk of neonatal transmission," Mangione and colleagues wrote.

Some experts do recommend targeted serotesting for populations at specific risk for adverse outcomes.

In an accompanying editorial, Mark D. Pearlman, MD, of the University of Michigan Health System in Ann Arbor, advised "counseling pregnant persons to undergo serologic screening for HSV-1 and HSV-2 when the nonpregnant partner is known to have genital or oral herpes and the pregnant person is uncertain of their infection status or serostatus."

"Because the highest risk for neonatal transmission occurs in persons who have a primary third-trimester infection, avoidance of sexual contact (genital contact if HSV-2-positive and genital/orogenital contact if HSV-1-positive) during the latter part of pregnancy in serodiscordant couples may reduce new-onset third-trimester infection and unwitting perinatal transmission," he wrote.

Pearlman agreed that routine testing could lead to incorrect identification. "Because there appear to be adverse effects on social, psychological, and relationships in many asymptomatic persons testing positive for HSV-2 antibody, incorrectly identifying persons as infected is a concern," he added.

Supporting the recommendation statement was an evidence report that reviewed 3,119 abstracts and 64 full-text articles.

"This systematic review yielded no new eligible studies published since the 2016 recommendation against screening for genital herpes in asymptomatic persons. Therefore, the overall conclusions of this review are unchanged from those of the previous review," wrote Gary N. Asher, MD, MPH, of the University of North Carolina at Chapel Hill, and colleagues.

The USPSTF noted that the recommendation statement is limited to asymptomatic adults and adolescents, and does not apply to people requesting a screening test from a healthcare provider when they have a history of infection, or signs and symptoms suggestive of genital herpes, or for people who are HIV-positive or have other immune system problems.

In a second editorial in JAMA Dermatology, Howa Yeung, MD, MSc, of Emory University School of Medicine in Atlanta, and colleagues endorsed the reaffirmation, noting that "serologic screening for genital herpes in asymptomatic persons should inspire patients, clinicians, and healthcare leaders to campaign against unnecessary testing in the spirit of 'do no harm.'"

However, they noted that there are important exceptions, such as people living with HIV.

"An ensuing informed risk-benefits discussion between patient and clinician could be considered on use of suppressive antiviral medications to prevent severe outbreaks, such as during the first 6 months after antiretroviral therapy initiation, particularly in individuals with CD4 less than 200 cells/mm³," they wrote.