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Serological tests for herpes simplex virus (HSV) that can accurately distinguish between HSV-1 and HSV-2
are now commercially available. These tests detect antibodies to HSV glycoproteins G-1 and G-2, which evoke
a type-specific antibody response. Focus Technologies produces the HerpeSelect-1 and HerpeSelect-2 enzymelinked immunosorbent assay tests and the HSV-1 and HSV-2 HerpeSelect1/2 Immunoblot. Diagnology has
marketed POCkit-HSV-2, a point-of-care test for HSV-2 that allows blood from a finger stick to be tested in
a clinic. These tests can be used to confirm a genital herpes diagnosis, establish diagnosis of HSV infection
in patients with atypical complaints, identify asymptomatic carriers, and identify persons at risk for acquiring
HSV. Potential settings for use of these tests include sexually transmitted disease clinics, prenatal clinics, and
clinics that care for patients with human immunodeficiency virus. Patient interest in HSV serological tests
appears high.
Most people with herpes simplex virus (HSV)2 infection have unrecognized disease [1]. Despite the relatively mild course of their infection, these persons still
pose a risk of transmission to their sexual partners [2].
Pregnant women with unrecognized genital HSV infections pose a risk of transmission to their neonates
[3]. Even persons with clinical complaints relating to
HSV-2 infection often remain undiagnosed, because
their presentations are atypical and the confirmatory
laboratory tests that are in wide use have high rates of
false-negative results. The development of diagnostic
tools for genital herpes has lagged behind the development of diagnostic tools for other infections that are
characterized by a large proportion of asymptomatic
individuals, such as syphilis, chlamydia, and HIV. Molecular tests for Chlamydia trachomatis and sensitive
and specific antibody tests for HIV rapidly proceeded
from research laboratory use in clinical trials to commercial availability and application in clinical or public
health practice. In contrast, despite the development in
research laboratories of HSV typespecific serological
tests over a decade ago [4, 5], the adaptation of these
tests to a marketable format has been slow and their
clinical use limited. However, during the past 3 years
the Food and Drug Administration (FDA) has approved HSV typespecific serologies, and these are now
available commercially. Other tests are in development.
The next challenge will be to apply these tests to appropriate populations for clinical and public health
benefit. The present article reviews the basis for development of type-specific serologies for HSV-1 and
HSV-2, discusses the clinical interpretation of test results, and summarizes settings in which the use of such
tests may be of benefit.
regardless of whether an HSV-1 or HSV-2 infection has triggered the response [6, 7]. One structural protein, glycoprotein
G (gG-1 in HSV-1 and gG-2 in HSV-2), appears to elicit a
predominantly type-specific response. The immunodominant
human epitopes on HSV-1 are widely distributed through the
protein [8]. The most reactive epitopes on HSV-2 glycoprotein
G appear to reside within the homologous portions of the
protein [911] but, in tests with human sera, bind antibodies
only from patients with HSV-2 infections.
Several research or reference laboratories have developed
tests based on recognition of antibodies to gG-1 or gG-2. Western blot is one alternative that, when performed correctly, is
accurate for both HSV-1 and HSV-2 antibody detection [4, 12,
13]. Other formats depend on gG-1 and gG-2 that have been
affinity-purified from infected cell protein mixtures by use of
monoclonal antibodies [14, 15] or lectins such as Helix pomatia
[16]. Recombinant gG-1 and gG-2 constructs have been developed for these tests as well [17].
Commercial type-specific HSV tests. Tests based on glycoprotein G are now on the market in kit form from Focus
Technologies (formerly MRL Diagnostics) and from Diagnology (table 1). These kits have been approved by the FDA for
herpes serological diagnosis in adults and, in the case of the
Focus tests, for detection of HSV antibodies in pregnant women
as well. Focus tests include a pair of enzyme-linked immunosorbent assay (ELISA) kits called HerpeSelect-1 ELISA and
HerpeSelect-2 ELISA that detect antibodies to gG-1 and gG-2,
respectively. The tests are in standard 96-well plate format and
contain bacculovirus recombinant gG-1 (HSV-1) or gG-2
(HSV-2). Although 8-well strips can be snapped off for lowvolume testing, these tests are basically intended for highthroughput testing and can be run on an automated platform.
The second test is called the HerpeSelect1/2 Immunoblot and
consists of a single paper strip to which gG-1, gG-2, a typecommon antigen, and a control protein (for confirming that
serum has been added) have been applied. A single strip is used
for simultaneous testing for HSV-1 and HSV-2 antibodies (figure 1). This test is more expensive than ELISA but is well suited
to low-volume laboratory settings. Testing by HerpeSelect
ELISA or immunoblot can be ordered from Focus Technologies
reference laboratory, or the kits can be purchased by other
laboratories. Additional information about these tests can be
found at http://www.focusanswers.com or 800-445-0185.
The Diagnology test (POCkit-HSV-2) uses lectin-purified
gG-2 and a lateral flow membrane format that allows capillary
blood from a finger stick to be tested in the clinic setting (figure
2). This point-of-care format is designed for direct patient testing of blood but can also be used on single sera in the laboratory. Diagnology is seeking FDA clearance of a Clinical Laboratory Improvement Amendmentswaived format for the test
that will allow wider use in clinics and offices that do not have
S174 CID 2002:35 (Suppl 2) Wald and Ashley-Morrow
Test name
Company
HerpeSelect2 ELISA
Focus
Sensitivity,
%
Specificity,
%
96100
97100
HerpeSelect immunoblot
Focus
97100
98
POCkit-HSV-2
Diagnology
93100
9497
Cobas-HSV-2
Roche
93
98
Captia Select-HSV-2
Trinity
9092
9199
NOTE.
Figure 1. Immunoblots are scored as reactive if a glycoprotein G-1 (gG-1) and/or gG-2 band and the herpes simplex virus (HSV) common
antigen band are observed. The antihuman serum band must be observed for the test to be valid.
Figure 2. Diagnologys point-of-care herpes simplex virus (HSV)2 serology. This test kit is about the size of a credit card and can be performed
in !10 min in the office, using capillary blood from a finger stick. The test membrane contains a dot with lectin-purified glycoprotein G-2 (gG-2)
on the right and an antihuman antibody reagent on the left. (Left) A positive test result with definitive red color change of both the gG2containing dot and the human serum control dots (arrow). (Right) A negative test result with only the control dot showing a red color change.
If neither dot turns color, the test is invalid and must be repeated with an additional capillary blood or serum sample.
Table 2. Tests based on crude antigen, which is not recommended for type-specific testing.
Test name
Company
Correct
diagnosis,
%
Diamedix
61
Diasorin
69
Sigma
62
Wampole
85
Zeus
79
Anonymous
questionnaire
Questionnaire
NOTE.
Attitudes to HSV-2
serotesting
Exposure/intervention
Acceptance of testing
Outcomes and
measures
Study population
type and setting
Cross-sectional
Study design
Reference
Table 3.
Reported findings
these data are promising, some experts caution against widespread use of acyclovir, because there is remaining concern
about the potential hematologic and renal toxicity of the drug
in the fetus.
Women are routinely tested for a variety of infections during
pregnancy; thus, it is likely that the routine use of HSV serological tests would be well accepted as has been the experience
with HIV antibody tests [7275]. One study in a London prenatal care clinic showed that 80% of women would consider
HSV antibody tests if they were available [76].
HSV serologies in STD clinics. Another setting in which
serological testing is likely to be useful is that of STD clinics.
Serological surveys in STD clinics have shown that the rates of
HSV-2 infection range from 25% to 80%, depending on the
sex and race of the population [77, 78]. As among the general
population, most patients with HSV-2 antibody who are seen
in STD clinics do not have a history of genital herpes [60]. It
is important to note that a significant proportion of patients25% in the Seattle STD clinicpresenting for care in
STD clinics request STD screen and do not have a specific
clinical complaint (M. Golden, personal communication).
These patients are usually evaluated for inflammation of the
genital tract, and serological tests for syphilis and HIV are
performed. However, the current standard of care is not to
perform HSV serology, thus avoiding diagnosing an infection
that is certainly more frequent in the United States than either
unsuspected syphilis or HIV infection.
Patients express considerable interest in obtaining serological
testing for HSV-2. For example, in a British STD clinic, 190%
of patients wanted to know their HSV-2 antibody status, and
a similar proportion were also interested in having their partners tested [79]. Of interest, 65% thought that type-specific
serological testing for HSV was included among the standard
tests offered.
The acceptance of HSV-2 testing depends partly on the cost
of the test. In the Seattle STD clinic, 52% of patients accepted
serological testing when it was offered free as part of a research
project, compared with 18% of patients who agreed when there
was a $15 charge for the test [20]. Other statistically significant
correlates of acceptance of HSV serological tests included older
age and white race. The largest difference in acceptance of the
free versus paid test was among blacks: 42% consented when
the test was free, compared with 4% when the test required
payment. Among whites, the rate of acceptance was 55% when
the test was free, compared with 24% when the test had a fee.
These data suggest that economic situation explains much of
the differential acceptance of the test among patients seeking
STD care. Programmatic budgetary issues have been raised as
barriers to the availability of HSV serological tests in STD clinic
settings. Although fiscal constraints may truly interfere with
offering this test without charge, as with other traditional tests
HSV-1 and HSV-2 Serologies CID 2002:35 (Suppl 2) S179
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