Source: Seattle Times
By: Ferdinand M. de Leon
(SEATTLE, WA) — What if a quarter of the population caught an incurable and transmissible viral infection that, for some people, caused periodic bursts of pain? What if up to 90 percent of them didn’t know they had it, obliviously passing it on to others?
A health crisis, right? Public-service ads on billboards and buses and calls for more research funding would surely follow.
There is such an affliction: herpes. But the public and the medical community’s reaction to it remains decidedly low-key.
There are even new and highly accurate blood tests to detect the virus. But with herpes, the debate isn’t about how to control the illness; it’s whether it’s even worth diagnosing.
Rather than embracing the tests, the medical community is divided over this question: Is the knowledge offered by the new tests worth the widespread anxiety likely to follow?
"There’s always been the feeling, particularly among doctors, of let sleeping dogs lie," said Anna Wald, medical director of the University of Washington’s Virology Research Clinic. Since it’s rarely a life-threatening disease, they see herpes as a low-priority plague. "There’s a concern that diagnosing it only opens up a Pandora’s box."
Wald doesn’t buy into that philosophy.
She views the new tests as a crucial development in helping to halt the spread of herpes, and hopes to see more people taking the test. Those who know they have herpes can learn to take steps to make transmission less likely, such as avoiding sex during periodic outbreaks of genital lesions, and using condoms at all other times, she said.
"One can argue that perhaps pretty much anyone who is sexually active should be tested," Wald said. "Once people know, I think they’re less likely to transmit. Most people don’t purposely want to infect other people."
Yet the prospect of large numbers of people learning they have herpes raises some concerns about the appropriateness of widespread testing.
"Should clinicians be actively recommending a test? My answer is no, until we know more," said H. Hunter Handsfield, who directs the STD Control Program for Seattle/King County’s Public Health Department and has worked with the Centers for Disease Control on developing guidelines for a national herpes prevention program.
"Although it’s an extremely important disease, over 98 percent of the people who have it have mild symptoms," Handsfield said. "And yet there’s such tremendous hype and fear over having it. The pros and cons of uncovering infection in giant numbers of people should be studied."
Although the new tests have been highly accurate in trial runs, it hasn’t been proved that mass testing will work as well, Handsfield points out. And even if it does, he questions the usefulness of a positive diagnosis.
Someone diagnosed with herpes could in theory be more diligent about watching for symptoms, but in reality herpes can be transmitted even when there are no symptoms, Handsfield said. Advising people to wear condoms every time they have sex is simply unrealistic, he added.
Those factors need to be weighed against the "psychological weight of someone knowing that they have a red-letter disease," Handsfield said. Although increasingly effective treatments are available, a successful vaccine is still years away.
Until last year, testing was problematic. Most of the available tests could be performed only during an outbreak of herpes’ primary symptoms: lesions and sores in the genital area. The lesions were swabbed and the sample analyzed in the lab.
But most of those with herpes never experience outbreaks. For others, the flare-ups are gone by the time of their doctor’s appointment, making a swab sample impossible. Blood tests can detect herpes when no symptoms are present, but the old tests were often unreliable because they fail to distinguish between herpes simplex virus I, the relatively benign oral herpes that causes cold sores and fever blisters, and herpes simplex virus II, genital herpes. The Western Blot Test, developed at the University of Washington, is the only test that can accurately distinguish between the two, but it’s expensive and rarely used. The new blood tests (Meridian’s "Premiere" or Diagnology’s "POCkit," and a new test awaiting FDA approval) are cheaper and nearly as accurate. While they’re not yet widely in use, people can ask their doctors to obtain them.
Meanwhile, herpes has spread unchecked. While all other sexually transmitted diseases (STDs) have declined, the number of people with herpes only rises. A 1997 New England Journal of Medicine report concluded that the number of Americans with herpes had risen 30 percent since the late 1970s. The figure may be 60 million by today, Handsfield estimates.
While some question the impact of the test on the afflicted, others question whether the medical community is ready.
The health system is not prepared to give appropriate and compassionate care, said Leigh Jolley, manager of the herpes resource center at the American Social Health Association, the North Carolina-based agency that promotes education about STDs. According to an association survey, more people considered learning that they have herpes more traumatic than getting fired from a job, breaking up with a significant other or failing a course.
"I don’t think the medical community is ready for the onslaught of questions," Jolley said, "especially in the world of managed care, where time is limited."
Wald notes that at her clinic, it’s not unusual to spend an hour or two counseling the newly diagnosed. "They have so many questions. They’re in shock and in pain, and they want to know who gave it to them."
Already there’s agreement about some groups that clearly should take the new test: partners of people with herpes, those diagnosed with HIV infection, and pregnant women.
Women who contract herpes in their third trimester can transmit the virus to their babies, sometimes causing death. And genital ulcers associated with herpes and other STDs can facilitate the transmission of HIV, the virus linked to AIDS.
Recently, the Centers for Disease Control gave Wald one of two national grants to study the impact of more testing.
Over the course of the three-year study, Wald will approach 2,000 people at five different sites about testing for herpes. If they test positive, she will follow their progress for six months.
Among other things, the study will look at how those who learn they have herpes deal with that knowledge: Do they tell their partner? Do they change their sexual behavior? Are their partners also infected?
"I do think the new tests will have a lot of impact," Wald said. "And they’ll be important in getting herpes under control. No one likes to find out they have herpes. But my impression is that people deal with it quite well."
Resources:
Virology Research Clinic, 1001 Broadway, Suite 320, Seattle, 206-720-4340.
The STD Clinic at Harborview: 206-731-3590. National Herpes Hotline (open from 9 a.m. to 7 p.m. (EST) Monday through Friday: 877-411-HERPES (a toll-free call).
American Social Health Association: www.ashastd.org .
