Herpes simplex virus type 2 serological testing at a community court: Predictors of test acceptance and seropositivity among female defendants

Abstract

Despite the high prevalence of herpes simplex virus type 2 (HSV-2), testing for asymptomatic infections is uncommon. One population for whom targeted interventions may be prioritized include individuals involved with the correctional system. Here we describe the acceptability of a novel HSV-2 screening program, implemented in a court setting, as a possible intervention for corrections-involved women. Female defendants completed an interviewer administered survey assessing factors associated with uptake/refusal of free point-of-care HSV-2 serologic testing and HSV-2 seropositivity. Participants included 143 women, 18–62 years old (mean 32.85) with diverse ethnicities. The majority (65.7%) accepted testing and 62.4% tested HSV-2 seropositive. Factors independently associated with test acceptance included higher perceived susceptibility to genital herpes infection and not receiving a preventative health screen. Women who were seropositive tended to be older, Black, report having previous STI, and be arrested on a prostitution charge. Findings suggest point-of-care testing in a court setting is acceptable to women and can be implemented to improve case finding of STI.

Keywords

herpes simplex virus type 2 (HSV-2)genital herpes testing predictors seropositivity sexually transmitted infections community court

Key Messages

•

Court-based testing for herpes simplex virus 2 (HSV-2) is acceptable to female defendants and facilitates access to high-prevalence populations; 65.7% of participants accepted testing and 62.4% tested HSV-2 seropositive;

•

Factors associated with test acceptance included higher perceived susceptibility to genital herpes infection (adjusted odds ratio [AOR]= 1.19, 95% CI 1.07,1.33) and not receiving a preventative health screen within 36 months (AOR = 0.34, 95% CI 0.15, 0.99);

•

Women who were seropositive tended to be older (OR = 1.10, 95% CI 1.04, 1.16), be Black (AOR = 3.52, 95% CI 1.17, 10.56), report having previous STI (AOR = 4.55, 95% CI 1.14, 14.56), and arrested on a prostitution charge (AOR = 4.65, 95% CI 1.13, 19.11);

•

Court-based testing is a novel approach to improving case finding of sexually transmitted infections.

Background

Herpes simplex virus type-2 (HSV-2) affects approximately one in six Americans between the ages of 14 and 49 years of age.¹ Consequences of infection include painful, recurrent genital ulcers, neonatal herpes,² psychological distress linked to outbreak recurrence and disclosure of serostatus,³ and a two- to five-fold increased risk for HIV-1 acquisition.^4–6 Given that HIV rates are increasing fastest among women in the USA, this is a population that could benefit from HSV-2 control efforts. However, traditional medical interventions for prevention and control (e.g. curative therapy or vaccines) do not currently exist for HSV-2.⁷ Therefore, serological testing and behavioural strategies to limit transmission and promote women's sexual health are particularly relevant.

Serological testing of asymptomatic persons is a potential component of a herpes control effort. Most HSV-2 infections are asymptomatic and/or unrecognized.^8,9 In the absence of recognized symptoms, individuals have no cues to modify sexual behaviour or seek treatment but continue to shed virus from their genital tract.¹⁰ Asymptomatic persons can still transmit HSV-2 and are likely responsible for a significant proportion (up to 70%) of new infections.⁵ Type-specific antibody tests that distinguish strains of HSV are available and have good performance characteristics.^11,12

Despite the quality of HSV-2 tests available, there are challenges to implementing serological screening programmes, including concerns about the potential psychological risks (anxiety, anger, depression) of testing for asymptomatic HSV-2 infections and clinicians’ discomfort with communication of results. For these and other reasons, implementation of HSV-2 testing programmes has been inconsistent¹³ and interventions to increase HSV-2 testing have been understudied.^7,9,14 One population for whom targeted interventions may be prioritized include individuals involved with the correctional system.^15,16 Epidemiologic data demonstrate that these individuals are at particularly high risk for sexually transmitted infections (STIs).^17–19 However, many detainees never receive screening services either because testing for STIs is unavailable or because they are released within 48 hours.^18,19

Court-based programmes could provide a bridge between individuals with pending criminal cases and STI control services including on-site STI testing and treatment, partner counselling and referral, and improved reporting of infectious diseases. Evidence in support of this type of programme comes from the literature regarding specialty courts, such as drug and mental health courts that attempt to reduce substance abuse or improve mental health as a mechanism to reduce recidivism.^20,21 The project described in this paper builds upon collaborative efforts between Indiana University researchers, the local public health department and a local community court with the goal of increasing access to testing for women at high risk for STI (Roth et al, 2012). Here we describe demographic, attitudinal and behavioural characteristics associated with HSV-2 rapid antibody test uptake and seropositivity among a sample of female defendants offered free point-of-care antibody testing in a court setting as one possible intervention for justice-involved women. Women were prioritized for this pilot project because of the types of criminal charges adjudicated at the Indianapolis Community Court which, among other non-violent offenses, include prostitution, possession of drug paraphernalia and public intoxication because defendants facing charges associated with sex work or substance abuse have heightened risk of acquiring STI, including HSV-2.

Methods

Study site

The Indianapolis Community Court is a free-standing, neighbourhood-based court handling misdemeanour criminal cases. The court's mission is to empower the residents to have a ‘voice in the criminal justice system and to improve the quality of life in the communities in which they live.’²² The court's focus on connecting defendants with needed health and social services offers a unique opportunity for public health intervention and research with high-risk individuals involved in the criminal justice system.

Procedure

A convenience sample of 152 female defendants was recruited from the Indianapolis Community Court. A female co-investigator (AMR) approached women in the waiting room outside of the public defender's office. Female defendants were taken to a private space and informed about the study purpose and procedures. Consenting participants completed an interviewer-administered questionnaire, were offered a no-cost test for HSV-2 with results available within 20 minutes and were compensated $20 for their time. HSV-2 testing was performed using the HerpeSelect Express assay (Focus Diagnostics, Cypress, CA, USA), which has sensitivity and specificity of 93.4% and 92.4%, respectively.²³ All participants received post-test counselling. Individuals testing HSV-2 antibody positive were offered a 90-day prescription of suppressive therapy at their own cost and were referred to their primary care provider for continued treatment. Additionally, participants were offered no-cost gonorrhoea, chlamydia and trichomonas screening using nucleic acid amplification testing. Participants electing to be tested completed a registration form for the health department STI clinic and provided a self-obtained vaginal swab. Participants testing positive were contacted by health department STI disease intervention services staff and offered no-cost treatment. Because these services were offered by the health department, and were not offered as a part of this project's protocol, the results of these tests are not reported as part of this manuscript. All procedures were approved by the IU/IU Health institutional review board.

Measures

Scales and items were developed based on health belief theories and prior empiric research on HSV-2 test acceptance.²⁴ Demographic data included age, ethnicity, race, and education level. Anxiety was measured using 6 items from the Brief Symptom Inventory (BSI) anxiety subscale.²⁵ These items measure nervousness or shaking inside, being suddenly scared for no reason, feeling fearful, feeling tense or keyed up, spells of terror or panic, and feeling so restless you could not sit still over the past week. Response choices assess the frequency of each symptom on a 5-point scale. Higher scores indicate greater anxiety.

Participants were asked to indicate if they had ever had any of nine STI or STI-related conditions, including chlamydia, gonorrhoea, syphilis, trichomonas, cervical dysplasia, genital warts, HIV/AIDS, pelvic inflammatory disease or genital herpes. For the purposes of data analysis, a response of ‘yes’ to one or more items was considered indicative of a history of STI. Women indicating (N = 8) they had a history of genital herpes were excluded from the analysis. Participants were also asked if they were currently experiencing genital symptoms (yes/no). Recent healthcare utilization was assessed by asking participants to identify what routine health screens they had received within the past 36 months.

Genital herpes knowledge was measured using 13 true-false items addressing a broad range of issues, including modes of HSV-2 transmission, symptoms, treatment and reoccurrence. Key constructs from the Health Belief Model (HBM) were also measured.²⁶ The HBM posits health behaviour is driven by an individual's perception of ‘threat’ of the condition (i.e. the likelihood of acquiring the condition and the perceived severity of the condition), and the balance of an individual's perceived ability to positively affect that condition through a new behaviour (in this case through testing and, if positive, taking suppressive therapy) with their perception of the negative consequences of that behaviour (e.g. costs, fears about disclosure of serostatus and hassles of medication taking). From the HBM, we measured perceived severity of a genital herpes infection (7 items), perceived susceptibility to infection (4 items), perceived benefits of being tested for genital herpes (2 items) and the perception that genital herpes would interfere with the establishment or maintenance of an intimate relationship (5 items). Responses were measured on a 5-point scale ranging from ‘Strongly Disagree’ to ‘Strongly Agree.’ We hypothesized that individuals with higher perceived susceptibility and higher perceived benefits of testing would be more likely to be tested. The outcome measures for this analysis were uptake of point-of-care genital herpes testing and HSV-2 seropositivity.

Figure 1

Test uptake and HSV-2 seropositivity. HSV = herpes simplex virus; RCT = randomized controlled trial

Statistical methods

Binary logistic regression was used to assess predictors of HSV-2 test acceptance and HSV-2 seropositivity. Univariate analyses first were conducted to determine demographic, attitudinal or behavioural predictors associated with HSV-2 test acceptance or a positive antibody test. A significance level of P < 0.15 was adopted as the criterion for a variable to enter the multivariable regression model. Forward stepwise procedures were then performed to determine which predictors remained in the final, reduced model (cut-off for inclusion P < 0.05). A backward step-wise approach was used to confirm the forward stepwise results. All analyses were performed using SPSS v19.0.²⁷

Results

Descriptive statistics

One hundred fifty-two women completed an interviewer administered survey. Eight women reported a previous HSV-2 diagnosis. Their data were removed prior to all analysis as were the data of one participant for whom no testing data were recorded (see Figure 1). A description of the sample, which included 144 participants, is provided in Table 1. The participants⁷ age ranged from 18 to 62 years (median 32.85; standard error 0.91). Reported race/ethnicity included Black (41.0%), White (52.1%) and other racial group (6.9%). The 10 respondents indicating ‘other⁷ as their racial group provided a qualitative response describing their race. These categories were collapsed into a binary race variable (Black and non-Black). Empirical support for this division comes from the recent US National Health and Nutrition Surveys (NHANES) which documents a disparity between racial groups with Black individuals experiencing the highest burden of HSV-2.¹

Table 1

Univariate predictors of HSV-2 test acceptance

Variable	Overall sample (n = 144)	HSV-2 test acceptors (n = 94)	HSV-2 test refusers (n = 50)	Univariate analysis Odds ratio (95% CI)
Age	32.85 (0.91)^†	33.05 (1.14)^†	32.45 (1.54)^†	1.0(0.97–1.04)
Ethnicity
Latino	5.0	5.4	4.1	1.35(0.25–7.23)
Race (%)
Non-Black^‡	55.6	57.5	52.8	0.75(0.38–1.51)
Black	44.4	42.3	47.2
Highest level of education
Less than high school^‡	7.1	8.7	4.2	0.45 (0.09–2.22)
High school or equivalent	77.9	76.1	81.3	0.50 (0.08–3.01)
College or beyond	15.0	15.2	14.6
Employment
Unemployed	73.9	74.2	73.5	1.04(0.47–2.28)
Arrested on prostitution charge (n = 34)	22.5	21.5	24.5	0.85(0.37–1.91)
BSI anxiety score (6–24)^§	13.62 (0.57)^†	14.46 (0.72)^†	11.97 (0.86)^†	1.06(1.00–1.12)^∗∗
Received preventive health screen within 36 months	74.6	69.6	83.7	0.45(0.19–1.09)^∗
No. of lifetime sex partners
1–5^‡	19.7	15.1	28.6	2.20 (0.77–6.30)
6–10	22.5	23.7	20.4	2.28 (0.95–5.48)^∗
Greater than 10	57.7	61.3	51.0
No. of sex partners within 90 days	3.24 (0.21)^†	3.25 (0.26)^†	3.22 (0.37)^†	1.00(0.88–1.15)
History of STI diagnosis	72.4	75.3	67.9	1.53(0.72–3.23)
Current genital symptoms	16.2	21.5	6.1	4.20(1.18–14.93)^∗∗
HSV-2 knowledge score (0–13)^§	9.91 (0.10)^†	9.91 (0.12)^†	9.90 (0.17)^†	1.01 (0.76–1.35)
HSV-2 health beliefs
Perceived susceptibility (4–20)^§	10.60 (0.31)^†	11.30 (0.39)^†	9.23 (0.47)^†	1.18(1.06–1.31)^∗∗
Perceived severity (7–35)^§	20.26 (0.50)^†	19.90 (0.62)^†	20.94 (0.87)^†	0.97(0.92–1.03)
Perceived benefits (2–10)^§	8.92 (0.08)^†	8.98 (0.10)^†	8.82 (0.13)^†	1.20(0.83–1.74)

HSV = herpes simplex virus; STI = sexually transmitted infection; BSI = Brief Symptom Inventory

†

Mean and standard error

‡

Designated reference level for categorical variables

Numbers in parentheses indicate the range of possible scores for each item; all scales are constructed such that higher numbers indicate a greater effect (or perceived effect)

∗

P <0.15;

∗∗

P < 0.05

Predictors of accepting an HSV-2 serological test

Nearly two-thirds of the sample (65.3%) accepted a rapid HSV 2 antibody test. Results of the univariate logistic regression analyses indicated that compared with women who refused the rapid HSV-2 serological screen, test acceptors experienced higher anxiety (P < 0.03), were more likely to be experiencing genital symptoms (P < 0.03) and reported a higher perceived susceptibility to genital herpes infection (P < 0.01). Variables not statistically significant but meeting the criterion for entry into the model as potential covariates included not having received a preventive health screen in the past 36 months (P < 0.08) and greater than five lifetime sexual partners (P < 0.15). Variables not significantly associated with test acceptance and not meeting the criterion for consideration as potential covariates for the multiple logistic regression were age, ethnicity, race, education level, employment status, having been arrested for prostitution, number of sexual partners within the previous 90 days, lifetime self-reported history of STI, HSV-2 knowledge, perceived severity of HSV-2 and perceived benefits of being tested for genital herpes.

In the multivariable model (see Table 1), perceived susceptibility was significantly associated with testing behaviour (P < 0.02). Each one-point increase on the scale measuring perceived susceptibility was associated with a 1.19 greater odds of test acceptance (95% CI 1.07, 1.33). Not having received a preventive health screen was inversely associated with test acceptance (P < 0.05) such that women who had not previously received a preventive health screen had a greater odds of getting tested (adjusted odds ratio [AOR]= 0.34, 95% CI 0.15, 0.99).

Predictors of HSV-2 antibody positivity

The HSV-2 test result for one participant was inconclusive. Her data were removed prior to calculation of the models where seropositivity was the outcome measure. The rate of HSV-2 antibody positivity among the 93 women for whom test results were available was 62.4%. Table 2 displays the participant characteristics significantly associated with a positive antibody test result.

Table 2

Univariate predictors of HSV-2 antibody positivity^†

Variable	HSV-2 positive (n = 58)	HSV-2 negative (n = 35)	Univariate analysis Odds ratio (95% CI)
Age	36.22 (1.26)^‡	27.63 (1.89)^‡	1.09(1.04–1.15)^∗∗
Ethnicity
Latino	3.5	8.6	0.39 (0.06–2.45)
Race (%)
Non-black^§	50.0	71.4	2.50(1.02–6.12)^∗∗
Black	50.0	28.6
Arrested on prostitution charge (n = 34)	27.6	11.4	2.95 (0.09–9.70)^∗
No. of lifetime sex partners
1–5^§	6.9	28.6	3.33(0.79–14.16)^∗
6–10	20.7	25.7	6.56(1.80–23.95)^∗∗
>10	72.4	45.7
No. of sex partners within 90 days	3.62 (0.39)^‡	2.71 (0.24)^‡	1.20(0.96–1.50)^∗
History of STI diagnosis	84.5	57.1	4.08(1.53–10.84)^∗∗
Current genital symptoms	22.4	22.9	0.98 (0.36–2.66)

STI = sexually transmitted infection

†

HSV-2 test result for one participant was inconclusive; their data are not included in this analysis

‡

Mean and standard error

Designated reference level for categorical variables

∗

P < 0.15;

∗∗

P < 0.05

Compared with women testing antibody negative for HSV-2, seropositive women were older (P < 0.01), and more likely to report Black race (P < 0.05), have a history of STI (P < 0.01) and having 10 or more lifetime sexual partners (P < 0.01). Variables not statistically significant but meeting the criterion for entry into the model as potential covariates included being arrested on a prostitution charge (P < 0.08) and a greater number of sexual partners over the last 90 days (P < 0.11). Variables not significantly associated with seropositivity and not meeting the criterion for consideration as potential covariates for the multiple logistic regression were ethnicity and current genital symptoms.

In the multivariable model (see Table 3), each year increase in age was associated with a 1.10 greater odds of testing antibody positive (P < 0.01). Women of Black race had 3.52 increased odds of testing positive (P < 0.03) as did women reporting a history of STI (AOR=4.55, P < 0.01) and women arrested on a prostitution charge (AOR=4.65, P < 0.03).

Table 3

Results of the multivariable analysis for seropositive subjects: reduced model (N = 58)

Predictors	Adjusted odds ratio	95% confidence interval	P value
Age	1.10	1.04–1.16	<0.001
Race^∗
Black	3.52	1.17–10.56	0.03
History of STD diagnosis	4.55	1.14–14.56	0.04
Prostitution	4.65	1.13–19.11	0.03

STI = sexually transmitted infection

∗

Comparison is between dichotomized variables Black and Non-Black

Discussion

Serological testing is an important component of any HSV-2 control effort. The current project builds upon collaborative projects between university researchers, the local public health department and the Indianapolis Community Court that aim to increase access to testing for justice-involved individuals. Little is known about the health of arrestee populations. However, this study suggests that non-incarcerated, court-involved individuals are at disproportionate risk for STIs and their rates of disease may be akin to prevalence estimates among incarcerated individuals.^16,19

Court-based programmes could provide a critical bridge between individuals with pending criminal cases and health services including STI testing, treatment and disease intervention services. Nearly 65% of participants tested positive for HSV-2 which underscores the potential of court-located projects to improve infectious disease surveillance and control. Further, this rate of disease was unexpectedly high. Proportionately, the rate of infection was three-fold the national prevalence rate (20.9%) and double the rates documented among other high-risk populations including women accepting optional HSV-2 testing in our local public health STI clinic (37.4%) which indicated this is indeed a population that warrants outreach efforts.^1,28

These results highlight how this non-traditional partnership with the justice system provided an opportunity to intervene with high-risk individuals. Problem-solving courts, such as the Indianapolis Community Court, have become more prominent over the past two decades and offer a promising vehicle for public health intervention. Community courts, in particular, offer unique opportunities to interact with high-risk individuals because of their focus on connecting defendants to local health and social services.^22,29 This court-based testing initiative was easily implemented as part of a research study; additional challenges may exist for a sustained herpes control programme. Logistical concerns including the need for additional resources to cover the cost of staff, office space, testing supplies and the HSV-2 test itself. In this sample, HSV-2 testing, when offered for free, was highly acceptable. However, in an earlier sample, when we offered the same test for a cost of $10 the rate of uptake was significantly lower, with only one of 49 women accepting testing.³⁰ While few women cited cost as a reason for not being tested, the difference in testing uptake between the low-cost and no-cost groups suggests that cost was a substantial, nearly insurmountable, barrier. Participant unwillingness to pay for screening services would require the allocation of public health resources to encourage this and other high-risk populations to be screened for HSV-2. Finally, the HerpeSelect Express rapid test used in this study is no longer available for use. Although another rapid test (BioKit) is available, it is Clinical Laboratory Improvement Amendments (CLIA)-classified as a moderately complex test, making it difficult to use outside of a clinical setting.

There is a paucity of information regarding collaboration between health systems and courts. In this paper we describe how a herpes screening programme was implemented within a court setting and demographic and attitudinal factors associated with test acceptance and seropositivity. The unexpected prevalence of disease found among this sample of court-involved women has prompted public health officials to initiate a court-based STI screening programme.²¹ Uptake of the services offered at the court testing site has been slow thus far. Information on the development of the court-based testing centre is described elsewhere.³¹ However, these findings demonstrate how novel methods, including point-of-care testing in a court setting, can be implemented to improve case finding of STIs.

Ethics approval: This study was conducted with the approval of the Indiana University Institutional Review Board.

Footnotes

Acknowledgements

This study would be impossible without the invaluable support of the Indianapolis Community Court. Research was supported by the Indiana University School of Health, Physical Education and Recreation Faculty Research Support Program (Bloomington, Indiana) and Indiana University School of Health, Physical Education and Recreation Student Research Grant (Bloomington, Indiana).

Competing interests: None.

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