Low acceptance of HSV-2 testing among high-risk women

Introduction

Herpes simplex virus type 2 (HSV-2), a highly prevalent sexually transmitted infection (STI), is the principal cause of genital herpes. ¹ The prevalence of HSV-2 is even higher among certain racial/ethnic groups and among women. Consequences of infection include a two- to five-fold increased risk for HIV-1 acquisition.^2,3 Therefore, implementing HSV-2 serological testing as a part of STI control programmes could be an important step towards slowing HIV transmission. However, HSV-2 testing is not common clinical practice. Furthermore, infected individuals often do not recognize symptoms of infection, but nonetheless shed virus from the genital tract.^1,4 These individuals may contribute to a large proportion of new HSV-2 infections because they are not aware that they are contagious. ⁵ There are important health disparities associated with testing HSV-2 seropositive. A recent study demonstrated that adult women of colour had the highest prevalence of HSV-2 but were least likely to access testing. ⁶ Among young adults who were tested for HSV-2 antibodies, increasing age, non-white race and having had a STI were predictors of a positive test. ⁷ In the present study, we offered point of care HSV-2 antibody testing to recently arrested women at high behavioural risk for infection and evaluated characteristics associated with HSV-2 rapid antibody test uptake/refusal.

Methods

Participants were recruited from the County Community Court of Indianapolis (Indiana, USA), which handles lower-level, non-violent misdemeanour criminal cases. English-speaking adult women who had a court case pending were invited to enrol. Consenting participants completed an interviewer-administered questionnaire assessing knowledge and attitudes about HSV-2 and intention to get tested for HSV-2 using items derived from the Health Belief Model (HBM) (see Table l). ⁸ Knowledge of genital herpes was measured with 13 true-false items and 13 additional items measured attitudes about HSV-2, including: perceived likelihood of infection, herpes stigma and expected impact of diagnosis on romantic relationships. ⁹ Intention to be screened for HSV-2 was assessed with one item describing a testing scenario identical to the one that participants were subsequently offered: ‘how likely is it that you would get tested for genital herpes today if the test involved a finger prick and you would receive your results today, within 20 minutes?’ The first 50 women were told that the test would cost US$10, and subsequent participants were told that the test would be free. Participants responded on a scale ranging from 0 (I would never get this test) to 100 (I would definitely get this test) in 10–point increments.

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Table 1

Application of the Health Belief Model to survey items

Construct	Illustrative items
Perceived severity	Having genital herpes is as bad as having cancer
	Genital herpes is a dirty disease
	No one will want me if I have genital herpes
Perceived susceptibility	There are things I've done that could have led to me being infected with genital herpes
	I worry about the possibility that I'm infected with genital herpes
Perceived benefits	Finding out whether or not I have genital herpes would be helpful to me
	Getting a test for genital herpes would be an important part of taking care of my health

In order to protect their privacy in the court setting, we did not ask for details about each participant's arrest. After completing the interviewer-administered survey, participants were immediately compensated US$20 (two US$10 bills). In the initial phase of the study, we offered point of care HSV-2 testing for US$10. Only one of the first 50 women agreed to pay for testing and so we adjusted the offer to free testing for the next 50 women.

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. ¹⁰ Participants testing HSV-2–positive received post-test counselling, were offered a prescription for low-cost suppressive therapy (acyclovir) and were referred to their primary care physicians for continued treatment. All procedures were approved by the Indiana University/ Clarian Hospitals Institutional Review Board.

Results

The 100 women enrolled in the study were 18–62 years of age (median = 34) and identified as white (55%), black (40%) and other (5%), which included biracial and Latina women. The majority (57%) had more than 10 lifetime sexual partners. The number of sexual partners within the last 90 days ranged from 1 to greater than 10 (mean = 3.69) and 53% reported never using condoms during penetrative intercourse. Participants reported histories of several STIs in their lifetime including chlamydia (40%), gonorrhoea (29%), Trichomonas vaginalis (42%), syphilis (4%) and pelvic inflammatory disease (14%). No one reported HIV infection.

Participants were knowledgeable about HSV-2 with a mean score of 11.8 out of a possible 13 (SD = 1.24). Nonetheless, 67% did not believe that they were at-risk for infection. Further, many women expressed negative attitudes towards HSV-2, with 46% believing it would ruin their sex life; 50% reporting that herpes was a ‘dirty disease’ and 27% indicating that no one would want them if they had HSV-2. However, 97% believed that getting tested for HSV-2 would be an important part of taking care of their health and 98% reported that finding out if they had HSV-2 would be helpful. Demographic, knowledge, attitudes about HSV-2 and preferences for future HSV-2 testing did not differ between the low-cost and no-cost groups. Testing intention differed by group, however, with 70% of the low-cost group indicating no intention of getting tested compared with 22% in the no-cost group (P < 0.001). We examined the relationship between test uptake and number of sexual partners (lifetime and past 30 days) and condom use over the past 30 days but did not find a significant relationship. Only one participant elected to be tested when the cost was US$10 while 36/50 were willing to be tested for free (P < 0.001). The rate of positivity among those tested was 59.4% (22/37) and 18/22 (81%) women testing positive accepted a prescription for acyclovir. Participants’ rationale for not getting tested included recently being tested (33.9%), no perceived risk for infection (19.4%), time constraints (17.7%) or cost of the test (17.7%).

Conclusions

We assessed factors related to HSV-2 testing intentions and uptake among women at high behavioural risk for infection using a general framework informed by the constructs of the HBM. This theoretical framework proved beneficial for understanding the factors related to screening and treatment of HSV-2. To that end, the HBM may also offer a valuable model for interventions to increase screening and treatment among this particular population.

Despite reporting high-risk sexual behaviours and being knowledgeable about genital herpes, many participants did not believe they were at-risk of infection. This misconception may be due to misunderstandings about the types of STI screening services provided at annual female wellness exams or visits to STI-specific services. In this sample, 33% believed they had recently been tested for HSV-2, which is unlikely given that testing is uncommon. It is clear that many women do not understand the tests performed when a Pap smear is done. ¹¹

We identified discrepancies among knowledge, health beliefs and behaviours that need to be addressed to increase uptake of HSV-2 testing especially given that participants believed that knowing their HSV-2 status is beneficial. Further, we identified a gap between reported rationale in case of not testing and actual behaviours. 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 is a substantial barrier. This is particularly notable given the fact that the women had two US$10 bills in hand as compensation for research participation.

Rates of HSV-2 in our sample were high, exceeding rates seen among the US adult population and higher-risk individuals screened for HSV-2 in the local public health STI clinic.^1,6,10 The widespread misconceptions about the likelihood of being HSV-2 seropositive and the public health concerns regarding undiagnosed individuals shedding virus in the absence of recognized symptoms argue for the development of strategies to encourage testing.

Women in this sample who tested positive were interested in suppressive therapy and the majority accepted a prescription for acyclovir. We do not know whether these prescriptions were filled but willingness to accept the prescriptions in the wake of an unexpected HSV-2 diagnosis is an important first step to preventing outbreaks and curbing transmission.

Finally, to capitalize on previously missed opportunities to reach high-risk women we developed a judicial – public health partnership. The data shown here expand current collaborative efforts between the local public health system and the judicial system and aim to better understand women's attitudes towards HSV-2 and how these attitudes affect their behaviour. Our findings indicate that this population would benefit from community-based sexual health services and that they may be willing to access them in a judicial setting.

Key Messages

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No cost community-based HSV-2 screening with point of care testing is acceptable to recently arrested women;