Ethics of screening for asymptomatic herpes virus type 2 infection
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7466.618 (Published 09 September 2004) Cite this as: BMJ 2004;329:618
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Editor – The recent article on the ethics of screening for herpes
simplex virus type 2 (HSV 2) infection raised many issues which we would
like to discuss further. [1] In their paper, Krantz et al argue that it
is not ethically justifiable to screen asymptomatic patients for HSV 2,
when no cure is available and false positives may occur.
Their conclusion is entirely dependent on the ethical calculus they
chose to apply. Hard autonomists would put the individual’s right not to
know, above the rights of those who may become infected, or above the
rights of public health bodies who attempt to control transmission and
undertake surveillance. A utilitarian approach on the other hand, would
support such screening, even at the expense of false positives because it
would be for the far greater good of the public. We do not see how
screening costs for HSV 2 serological testing feature in their decision,
unless the authors are arguing that if costs continue to decrease over
time, they would finally reach a point where they would change their view
on the ethics of screening.
Whilst the authors limit their analysis to HSV, it must be noted that
asymptomatic individuals are offered screening for incurable conditions,
by tests which are not 100% specific or sensitive, such as HIV and
Hepatitis B and C, all of which have far worse clinical outcomes than
genital HSV 2 infection.
The article suggests that the only practical way of identifying
individuals with asymptomatic HSV infection is using serological tests.
However, PCR techniques have been developed and although not yet
commercially available, are employed for research methodology. This could
prove to be a useful adjunct to serological diagnosis and for identifying
the anatomical localization of infection.
We do agree with the authors’ observation that a common reason for
not testing opportunistically, is because of adverse psychological
outcomes in those who discover they have the infection. Nevertheless,
there is evidence that being diagnosed with asymptomatic infection
increases the awareness among individuals of symptomatic recurrences which
were previously unnoticed. [2]
A further benefit, not explored in this paper is that screening
asymptomatic patients would determine if they are eligible to participate
in the current studies investigating prophylactic HSV2 vaccines. Clearly,
the potential benefit for the individual who is seronegative and for the
public health may be much enhanced if an effective vaccine was available.
Whilst we disagree with the authors’ conclusion that screening for
HSV 2 is not ethically justified, we do agree that the issue is complex
and that individual health care providers need to evaluate the usefulness
and cost effectiveness of this test. In our directorate we currently offer
HSV serological type specific testing to asymptomatic partners of patients
with diagnosed genital HSV infection. We counsel patients about the
limitations of the test and its potential implications. In special
circumstances, such as a pregnant partner of a patient with known genital
HSV 2 infection, the benefits of additional measures to reduce the risk of
infection are emphasised.
Ultimately, we believe that Krantz et al, have raised an important
debate about the availability of HSV 2 screening but we feel that testing
asymptomatic individuals can be ethically justified, providing it is
appropriately offered to informed individuals with adequate discussion and
subsequent management. In the end it is the patients’ choice, not ours,
as to whether they take the test.
C E Cohen, Specialist Registrar,
S E Barton, Consultant
Chelsea & Westminster Healthcare NHS Trust, Dept of Genitourinary
Medicine, London
A Lawson, Senior Clinical Fellow
Medical Ethics Unit, Imperial College School of Medicine, London
[1] Krantz I, Gun-Britt L, Ahlberg B M, Nilstun T. Ethics of
screening for asymptomatic herpes type 2 infection. BMJ, 2004; 329: 618-
621 (11 Sept)
[2] Corey L. The current trend in genital herpes. Progress in
prevention. Sex Transm Dis 1994; 21 (S38-44)
Competing interests:
None declared
Competing interests: No competing interests
Is Screening the Panacea?
I read with interest an article from Krantz et. al. concerning the
controversy underlying the employment of screening for asymptomatic herpes
virus type 2 (HSV-2) infection1.
Whilst the plausibility of routine screening for HSV-2 in the general
public will be limited by the low positive predictive value in low
prevalence populations, the lack of treatment options and the possible
psychosocial and psychosexual distress resulting from a positive result,
its acceptance at antenatal clinics may seem more cost-beneficial owing to
the severe morbidity and mortality resulting from maternal-fetal
transmission in neonates2. It was shown that the positive predictive value
of screening test was relatively low in the setting of a low prevalence
population and thus there was only limited benefit in detecting large
numbers of HSV-2 positive patients who was previously unrecognized2. In
addition, the uptake of such screening test was also population dependent,
varying from only 40% quoted in their study to over 90% in some others2.
Based on a cohort study done over a 25-year period of time, Fisman
et. al. argued that in spite of an expected reduction in the incidence of
HSV-2 infection in both adults and newborns, there is likely an increase
in the healthcare cost, at the expense of US$8000-$9000 per infection
prevented3. Despite the fact that this is a considerable burden on
clinical resources, the knowledge of HSV-2 status may prove useful for the
prevention of primary HSV-2 infections in pregnancy, especially late in
the third trimester when the association with the rate of neonatal
transmission is extremely high4. Interestingly, it was found that there
was an abstinence from sexual intercourse or a decrease in unprotected sex
among those disconcordant couples after the acknowledgement of their
serologic status5. Moreover, there was a tendency of delay in the
recognition and initiation of antiviral therapy in neonates, and this had
contributed to a high mortality and morbidity with neurological sequelae4.
Therefore, detection of maternal serological status may ensure prompt
treatment for HSV-2 infected neonates. Moreover, by identifying maternal
HSV-2 status, the option of caesarean delivery, which is recommended for
HSV-2 infected individuals to reduce the rate of transmission, can be
provided, although it is controversial that this procedure is often
associated with higher maternal morbidity and mortality compared to
vaginal delivery6.
There is currently no effective treatment for eliminating latent
herpes infection, and it may seem that psychological distress associated
with the knowledge of one’s HSV-2 positive status is inevitable.
Therefore, it is important to quantify the impact of HSV-2 infection for
health related quality of life before introducing this screening test into
practice.
Wai Kei Chio
4th year medical student (UNSW)
Macarthur Ambulatory Care Service
Reference:
Competing interests:
None declared
Competing interests: No competing interests