Crosby, Richard A. PhD*; Head, Sara MPH†; DiClemente, Ralph J. PhD†; Meyerson, Beth PhD‡; Troutman, Adewale MD§
From the *Department of Health Behavior, University of Kentucky College of Public Health, Lexington, Kentucky; †Department of Behavioral Science and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia; ‡Policy Resource Group, LLC Indianapolis, Indiana; and §Louisville Metropolitan Health Department, Louisville, Kentucky
The authors gratefully acknowledge the assistance of the Clinic Director (Deborah Snow) and the clinic staff members.
Supported by Glaxo Smith-Kline (to R.A.C).
Correspondence: Richard Crosby, PhD, College of Public Health, 121 Washington Avenue, Lexington, KY 40506-0003. E-mail: firstname.lastname@example.org.
Received for publication October 10, 2007, and accepted March 16, 2008.
Objective: To test the hypothesis that individuals attending a sexually transmitted disease (STD) clinic would adopt sexual protective behaviors after receiving a positive test for herpes simplex virus 2 (HSV-2).
Methods: Recruitment (N = 360) occurred in a publicly funded STD clinic located in a metropolitan area of the southern United States. Participants were tested for HSV-2 using a rapid test manufactured by Biokit (Lexington, MA) and they completed a self-administered questionnaire before and 3 months after being tested for HSV-2. Follow-up questionnaires were completed by 256 participants (71.1%).
Results: Of those completing follow-up, 43.4% (n = 111) tested positive for HSV-2 at enrollment. Significant differences between participants testing positive and those testing negative (at baseline) for HSV-2 over the follow-up period were not observed for frequency of sex, frequency of condom use, avoiding sex, and number of sex partners. Controlling for statistically identified covariates did not alter the null findings for these between group analyses. When analyzing change (baseline to follow-up) among only those testing positive, significant differences were not found with the exception of reporting greater frequency of condom use with steady (P = 0.037) and nonsteady partners at follow-up (P = 0.017). However, repeated measures analyses yielded only 1 significant group × time interaction; this indicated a greater increase in condom use frequency with steady partners among persons testing negative compared with those testing positive.
Conclusions: Among STD clinic attendees, diagnosis of HSV-2 was unrelated to the adoption of sexual behaviors protective against further acquisition and transmission of STDs. In the absence of education beyond posttest counseling, becoming aware of HSV-2 positive serostatus may not be sufficient to motivate the adoption of safer sex behaviors among this population.
IN THE UNITED STATES, herpes simplex virus 2 (HSV-2) remains the primary cause of genital herpes and prevalence is estimated at 17%.1 HSV-2 is associated with neonatal herpes and transmission of human immunodeficiency virus (HIV).2,3 The advent of type-specific rapid testing for HSV-2 has led to research investigating psychosocial sequelae of testing positive, with results indicating only short-lived consequences.4–8 The next question is whether persons newly diagnosed with HSV-2 will adopt behaviors protective against further acquisition and transmission of sexually transmitted diseases (STDs). Literature investigating behavior change after HIV counseling and testing has led to variable and inconclusive results.9–12 The most recent review found reduced risky sexual behavior after HIV counseling and testing among persons newly diagnosed with HIV but not among persons testing negative for HIV.12 Although recent evidence suggests that people are less likely to acquire HSV-2 from partners who disclose their positive status,13 disclosure may not be normative in all populations. An important, but understudied, question is whether patients may engage in risk management after diagnosis with HSV-2 (meaning they adopt protective behaviors in response to the diagnosis). Accordingly, the purpose of this study was to determine whether protective behaviors follow the experience of testing positive for HSV-2.
Patients (≥18 years old) were recruited from an STD clinic located in the southern United States. Nurses referred potentially eligible patients to the research assistant. Eligibility requirements were 1) not previously diagnosed with HSV-2; 2) speaking English; 3) sexually active in the past 3 months; and 4) willingness to be tested for HSV-2. Of 381 patients referred, 360 (94.5%) were eligible, agreed to participate, and provided written informed consent. Of these, 256 (71.1%) completed follow-up assessments 3 months later. Procedures were approved by the Office of Research Integrity at the University of Kentucky.
Participants first completed a self-administered questionnaire using a 3-month recall period. Three months is a sufficient amount of time to fairly represent overall sexual behavior without being so long that recall bias becomes a strong possibility. Next, they were tested for HSV-2 using a rapid test manufactured by Biokit (Lexington, MA). The specimen for the assay is whole capillary blood. The assay detects IgG antibodies to glycoprotein G2. The test is 96% sensitive and 98% specific.14 Based on CDC guidelines,15 standardized posttest counseling messages were provided to all persons tested, with messages to those testing positive emphasizing the importance of preventing transmission to others and the protective value of condom use, periodic abstinence (based on suspected outbreaks), and suppressive therapy.
Three months later, participants returned to the clinic to complete a second self-administered questionnaire. Participants were provided with $30 as compensation for their time at each assessment period.
Using a 3-month recall period, 4 behaviors were assessed in relation to “steady sex partners” and the same 4 were assessed in relation to “nonsteady sex partners.” First, as a proxy measure of abstinence from sex stemming from having herpes, frequency of sex was assessed. Sex was defined to participants as “putting the penis or tongue in the vagina or rectum (butt) of a partner or putting the penis in the mouth of a partner.” Second, to simplify recall, frequency of condom use was assessed by the use of a 7-point response scale ranging from 1 (“always”) to 7 (“never”). Next, participants were asked, “in the past 3 months, have you ever avoided sex with a steady partner because you had a concern about an STD?” For those indicating “yes” a follow-up question assessed how many time this occurred. A subsequent question was identical except the term “steady partner” was replaced with “nonsteady partner.” Finally, using the same definition of sex, the number of steady and the nonsteady partners participants had sex within the past 3 months was assessed.
First, differences at follow-up between those testing positive and those testing negative for HSV-2 were assessed by independent groups t tests. Next, a series of linear regression models was used to control for baseline demographic differences between groups and to control for the baseline measure of the 3-month outcome variable being tested. Subsequently, paired samples t tests were used to investigate change only among those testing positive. This was followed by the use of McNemar testing for the same purpose but using dichotomized versions of the outcome measure. Finally, we used the repeated measures function in the general linear model to test for group × time interactions across each of the assessed behaviors.
Characteristics of the Sample
Average age was 31.7 years (SD = 11.6). Nearly one-half (48%) were women. The majority was black (64.1%) with 30.9% of them identifying as white. Most (73.1%) were single. At the baseline assessment, more than 1 of every 4 (26.6%) reported they were currently experiencing symptoms they believed indicated genital herpes. Of these participants, 72.1% tested positive for HSV-2. Of the 256 followed, 43.4% tested positive for HSV-2. For descriptive purposes, Table 1 displays a baseline values for the outcomes measures, stratified by whether they tested positive for HSV-2.
Between Group Differences
Table 2 displays unadjusted comparisons between those testing HSV-2 positive and those testing HSV-2 negative for each of 8 behaviors. As shown, no significant differences were observed between those testing positive and those testing negative for HSV-2.
Four key covariates were entered into the linear regression models to control their potentially confounding influence on the study outcomes. Baseline demographic comparisons showed that persons testing positive were: 1) more likely to be women (52.3% vs. 36.8%, P = 0.02), 2) more likely to report having symptoms (76.8% vs. 33.5%, P = 0.001), and 3) more likely to identify as black (50.0% vs. 33.8%, P = 0.02). Thus, gender, symptom status, and whether participants identified as black were 3 of these 4 covariates. Prevalence among single persons was 47.2% compared with 35.6% among nonsingles; this difference was not significant (P = 0.12) but was nonetheless included as a covariate in the regression models. Age differences were not observed (P = 0.33) and were therefore not included in the models. Findings from the regression models supported the unadjusted findings. None of the 8 behaviors showed even a trend association (P <0.25) with participants’ serostatus.
Differences Over Time
Table 3 displays results from paired samples t tests conducted for persons testing positive for HSV-2. As shown, significant change in the 3-month period was observed relative to frequency of condom use with steady as well as with nonsteady partners (with condom use being more likely after testing positive for HSV-2). None of the other behaviors yielded significant differences over the 3-month follow-up period.
To further explore the apparent increase in condom use among those testing positive for HSV-2, we dichotomized the condom use variables to reflect consistent versus less than consistent use. We then conducted a McNemar test to detect significant change over time. Among persons with steady partners (n = 88) a favorable change was observed (P = 0.02), with 23 people (26.1%) shifting from inconsistent condom use with steady partners to consistent (always) use with steady partners. Only 6 people (6.8%) shifted from consistent use to inconsistent use. However, among HSV-2 positive persons who reported sex with nonsteady partners (n = 32) change in condom use over the observation period was not significant (P = 0.51), with only 18.7% shifting from inconsistent to consistent condom use.
In testing for group × time interactions, with 1 exception, none of the interaction terms approached significance. The exception was frequency of condom use with steady partners (F = 6.29; P = 0.013). In this case, the increase in frequency of condom use (represented by decline in the mean score of the ordinal measure) was actually greater among those testing negative (mean of 4.70–3.01) as compared with those testing positive (mean of 4.09–3.42).
In this study of STD clinic attendees not previously diagnosed with HSV-2, we found that testing positive for HSV-2 did not alter protective behaviors. For those testing positive, an increase in condom use with steady partners was observed. However, this increase cannot be attributed to the experience of testing positive because frequency of condom use with steady partners actually increased significantly more so for persons testing negative. The increase in both groups may therefore be attributable to the experience of simply attending the STD clinic, being assessed for STDs, or the experience of specifically being assessed for HSV-2. The experience of testing positive for HSV-2 does not seem to foster sexual protective behaviors. Thus, the experience of testing positive for HSV-2 does not seem to be sufficient to motivate STD clinic attendees to reduce frequency of sex, increase frequency of condom use, avoid sex based on concerns about STDs, or reduce the number of subsequent sex partners. Study findings based on a between-groups analysis indicated that persons testing positive did not demonstrate an increase in condom use relative to those testing negative. Moreover, the between groups analysis did not support significant differences relative to the other protective behaviors assessed.
Given the current research pertaining to programs that successfully foster improved safer sex practices among persons at risk of STD acquisition and transmission,16 it should not be surprising that routine delivery of posttest counseling messages may be an inadequate strategy to achieve lasting behavior change. Clearly, persons testing positive for HSV-2 are at risk of transmitting their infection to others and at risk of acquiring other STDs, including HIV. The existence of evidence-based interventions provides clinicians with an important repertoire of options that could be applied to these patients.16 Working with health educators, clinicians can adopt one or more of many programs for use by their clients. Their role then becomes one of referral and follow-up to assure that patients have the opportunity to benefit from the programs that are adopted.
Findings are limited by the use of a convenience sample. Further, the validity of findings is dependent on the accuracy and truthfulness of the self-reported measures used in the analyses. An important limitation of the between group findings is the lack of control for the possibility that the experience of being tested (alone) may have influenced behavior change for both groups. Further research investigating the adoption of sexual protective behavior after HSV-2 diagnosis is needed.
Among STD clinic attendees, diagnosis of HSV-2 was largely unrelated to the adoption of sexual behaviors protective against further transmission, with the important exception of increased condom use with both steady and nonsteady partners. In the absence of education beyond posttest counseling, becoming aware of HSV-2 positive serostatus may not be sufficient grounds for the adoption of other safer sex behaviors among this population.
1. Xu F, Sternberg MR, Kottiri BJ, et al. Trends in herpes simplex virus type 1 and type 2 seroprevalence in the United States. JAMA 2006; 296:964–973.
2. Brown ZA, Gardella C, Wald A, et al. Genital herpes complicating pregnancy. Obstet Gynecol 2005; 106:845–856.
3. Blower S, Li M. Calculating the contribution of herpes simplex virus type 2 epidemics to increasing HIV incidence: treatment implications. Clin Infect Dis 2004; 39:S240–S247.
4. Melville J, Sniffen S, Crosby RA, et al. Psychosocial impact of serological diagnosis of herpes simplex virus type 2: a qualitative assessment. Sex Transm Infect 2003; 79:280–285.
5. Meyer JL, Crosby RA, Whittington W, et al. The psychosocial impact of serological herpes simplex type 2 testing in an urban HIV clinic. Sex Transm Infect 2005; 81:309–315.
6. Miyai T, Turner KR, Kent CK, et al. The psychosocial impact of testing individuals with no history of genital herpes for herpes simplex virus type 2. Sex Transm Dis 2004; 31:517–521.
7. Rosenthal SL, Zimet GD, Leichliter JS, et al. The psychosocial impact of serological diagnosis of asymptomatic herpes simplex virus type 2 infection. Sex Transm Infect 2006; 82:154–157.
8. Richards J, Scholes D, Caka S, et al. HSV-2 Serologic Testing in an HMO population: uptake and psychosocial sequelae. Sex Transm Dis 2007; 34:718–725.
9. Higgins DL, Galavotti C, O’Reilly KR, et al. Evidence for the effects of HIV antibody counseling and testing on risk behaviors. JAMA 1991; 266:2419–2429.
10. Holtgrave DR, Qualls NL, Curran JW, et al. An overview of the effectiveness and efficiency of HIV prevention programs. Public Health Reports 1995; 110:134–146.
11. Wolitski RJ, MacGowan RJ, Higgins DL, et al. The effects of HIVcounseling and testing on risk-related practices and help-seeking behavior. AIDS Educ Prev 1997; 9(suppl B):52–67.
12. Weinhardt LS, Carey MP, Johnson BT, et al. Effects of HIV counseling and testing on sexual risk behavior: A meta-analytic review of published research, 1985–1997. Am J Public Health 1999; 89:1397–1405.
13. Wald A, Krantz E, Selke S, et al. Knowledge of partners’ genital herpes protects against herpes simplex virus type 2 acquisition. J Infect Dis 2006; 194:42–52.
14. Ashley RL, Wald A, Eagleton M. Premarket evaluation of the POCkit HSV-2 type-specific serologic test in culture-documented cases of genital herpes simplex virus type 2. Sex Transm Dis 2000; 27:266–271.
15. Centers for Disease Control and Prevention. STD Treatment Guidelines, 2002. MMWR Morb Mortal Wkly Rep 2002; 51:1–60.
16. Centers for Disease Control and Prevention (2001). Compendium of HIV prevention interventions with evidence of effectiveness. Department of Health and Human Services. Division of HIV/AIDS Prevention, Atlanta, GA.