Journal of American College Health

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/vach20

Knowledge, attitudes, and testing preferences

for Herpes Simplex Virus infections among
undergraduate students at a large university in
Los Angeles, California

A.P. Tadanki, C. Hernandez-Tamayo, N. Saremi, C. Stafylis & J.D. Klausner

To cite this article: A.P. Tadanki, C. Hernandez-Tamayo, N. Saremi, C. Stafylis & J.D. Klausner
(2023): Knowledge, attitudes, and testing preferences for Herpes Simplex Virus infections
among undergraduate students at a large university in Los Angeles, California, Journal of
American College Health, DOI: 10.1080/07448481.2023.2194431

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Journal of American College Health
https://doi.org/10.1080/07448481.2023.2194431

MAJOR ARTICLE

Knowledge, attitudes, and testing preferences for Herpes Simplex Virus

infections among undergraduate students at a large university in Los
Angeles, California
A.P. Tadanki, BA, C. Hernandez-Tamayo, MPH, N. Saremi, BS, C. Stafylis, MD, MPH and J.D. Klausner, MD, MPH
Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles,
California, USA

ABSTRACT ARTICLE HISTORY

Objective:  Genital herpes is a common sexually transmitted disease among young adults in the Received 25 August 2022
United States. We conducted a cross-sectional survey to evaluate herpes simplex virus knowledge Revised 8 February 2023
among university students. Accepted 19 March 2023
Participants:  612 full-time undergraduate students. KEYWORDS
Methods: We gathered data on demographics, sexual activity, knowledge about the herpes simplex Herpes simplex virus; HSV;
virus, attitudes toward it, and preferences for testing and treatment. knowledge; sexually transmitted
Results:  Of 612 full-time undergraduate students, 71.4% (437/612) reported being sexually active. infections; students
Of them, 54.2% (237/437) reported ever being tested for a sexually transmitted infection. On a
standardized knowledge assessment of genital herpes, 22.7% (139/612) of participants scored
≥80% correct. Over half of participants, 57.2% (350/612), reported that they could not cope with
a genital herpes outbreak. Being sexually active and tested for sexually transmitted infections was
associated with higher scores on the genital herpes knowledge assessment.
Conclusion:  University students have low knowledge regarding genital herpes. Genital herpes
education is needed to improve sexual health and wellness.

Introduction Severe complications may also include mother to child trans-

Infection with the Herpes Simplex Viruses (HSV) type 1
and 2 is very common. While HSV-1 infections have tra-
ditionally been associated with oral lesions and HSV-2 infec-
tions with genital disease, both virus serotypes can infect
either location. In the United States, HSV-2 infection was
estimated to affect 12.1% of the population in 2016.1
However, the true prevalence of genital herpes remains
unknown because herpes is not a reportable condition. In
a 2003 retrospective analysis of genital HSV isolates collected
in a university student health service over a 9-year period,
HSV-1 was found to be the most common cause (78%) of
newly diagnosed genital herpes infections among college
students, reflecting a reversal of usual HSV-1/HSV-2 ratios.2
Clinical manifestations associated with HSV infections
may range from mild to severe and include meningitis. In
young sexually active women, the herpes simplex virus is
the leading cause of aseptic meningitis.3 Symptoms may also
be persistent in immunocompromised patients who experi-
ence frequent and severe recurrences of HSV-1 and HSV-2
lesions, some of which may become resistant to treatment.
mission resulting in newborn death or lifelong neurological
disability.4
The psychological complications of genital herpes include
stigma and shame. These can also be quite severe and dev-
astating, with many genital herpes patients suffering from
psychological and psychosexual problems that may be more
clinically significant and more common than the symptoms
themselves.5 Psychosocial responses may include fear of
informing sex partners, fear of transmission, feeling socially
isolated, and sex avoidance.5
From a prevention perspective, despite the numerous
complications and societal costs associated with genital her-
pes, the Centers for Disease Control and Prevention (CDC)
currently does not recommend genital herpes screening or
testing in asymptomatic individuals who have never expe-
rienced symptoms consistent with genital herpes.6,7 In the
absence of surveillance and reporting, the prevalence and
incidence of herpes infection is underreported, and its
impact underestimated.
College students belong to a highly sexually active pop-
ulation compared to other demographic groups and are at

CONTACT N. Saremi nsaremi@usc.edu Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California,
Los Angeles, CA, USA.
Supplemental data for this article can be accessed online at https://doi.org/10.1080/07448481.2023.2194431
© 2023 The Author(s). Published with license by Taylor & Francis Group, LLC.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in
any way. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.
2 A.P. TADANKI ET AL.
high-risk for STIs,8 which makes them a priority population
for sexual health education programs. There is a limited
number of studies evaluating knowledge regarding HSV
among college students. A 1999 study among psychology
students in Ohio showed adequate levels of knowledge.9
Even though the study records gaps of knowledge that war-
rant improvement, the STI epidemic was different, and soci-
etal and behavioral changes make its results outdated. A
recent study conducted in 2017 evaluating local sexual health
education policies in Virginia showed adequate knowledge
levels but identified gaps regarding transmission and treat-
ment.7 However, this single study reflects the situation in a
specific area and specific policies. National data from dif-
ferent Universities and areas to understand gaps in knowl-
edge and policies are needed.
Herpes cure, prevention, and treatment efforts are begin-
ning to coalesce as herpes is becoming a public health issue.
Congress recently prioritized federal action for HSV direct-
ing the National Institutes of Health (NIH) to address the
apparent gaps and prioritize clinical research to improve
patient outcomes.10 Therefore, to inform new efforts at her-
pes prevention, we conducted an online survey to assess
the knowledge, attitudes, and testing and treatment prefer-
ences of undergraduate students at a large university in Los
Angeles, California.
Materials and methods
Study population and data collection
We aimed to conduct a representative survey of undergrad-
uate students at the University of Southern California (USC).
We randomly selected 5,000 undergraduate students out of
the 19,606 total undergraduate students enrolled at USC to
participate in the survey. Those surveyed were eligible to
participate if they were enrolled as full-time undergraduate
students attending USC in Spring 2022. In March 2022, the
survey was distributed via email and administered online
through Qualtrics. We incentivized participation through a
lottery, in which interested participants could enter to win
an electronic gift card or a pair of AirPods.
Measures
Participants were asked to provide demographic information,
history of sexual activity, and sexually transmitted infection
testing history. Participant knowledge of genital herpes was
assessed through a series of survey questions based on the
Herpes Knowledge Scale.11 Of the 54 true-false questions
on the Herpes Knowledge Scale, 16 were selected in this
survey based on relevance. Participants could select “True,”
“False,” or “I don’t know”. Participant attitudes toward genital
herpes were assessed through a series of survey questions
based on the Herpes Attitudes Scale.11 Of the 40 items on
the Herpes Attitudes Scale, 5 were selected for this survey.
A 5-point Likert scale, ranging from “strongly disagree” (1)
to “strongly agree” (5), was used to record participant
responses. Participants were also asked to rate their
willingness to test for genital herpes given certain scenarios
and to rate their willingness to treat herpes and receive a
future HSV vaccine using a 5-point Likert scale (“highly
unlikely” (1) to “highly likely” (5)).
Statistical analysis
Categorical variables (heritage, year in university, and history
of sexual activity) were summarized as percentages, and
continuous variables (age in years) were presented as means
and standard deviations. We used Pearson’s chi-square tests
to test for an association between sexually active status and
the knowledge statements from the Herpes Knowledge Scale
about genital herpes (true or false). Responses selected as
“I don’t know” were classified as ‘incorrect’ for the analysis.
In addition, we explored the association between a high
score on the Herpes Knowledge Scale (score ≥80%) and
participant characteristics.
SAS Software Version 9.4 (Cary NC, USA) was utilized
to perform the data analysis. Tableau Software (Seattle WA,
USA) produced the data visualizations for this study.
Ethical consideration
The University of Southern California’s Institutional Review
Board (IRB) approved this study under application UP-21-
00997. Informed consent was obtained from all participants
at the start of the online survey.
Results
Basic demographic characteristics
From an initial pool of 5,000 randomly selected students,
612 (12.2%) full-time undergraduate students with an average
of 20.3 years (SD= ±1.8) who met all eligibility criteria par-
ticipated in the survey. Demographic information, health
seeking behavior, sexual activity, and prior testing history
for participants are summarized in Table 1. Among the par-
ticipants, the majority reported being sexually active, and
nearly half of the sexually active participants (54.2%, 237/437)
reported ever being tested for a sexually transmitted infec-
tion. Of those that responded that they had ever tested,
49.8% (118/237) had tested for genital herpes (Table 2).
Knowledge about genital herpes
Upon evaluating correct responses to questions from the
Herpes Knowledge Scale, the average score of correct
responses was 60.5%, with 22.7% (139/612) of participants
scoring over 80%. We explored the association between par-
ticipant characteristics and the high score on the Herpes
Knowledge Scale Questionnaire (Table 3). No association was
found between sex and high score of genital herpes knowl-
edge. Sexually active students were 2.82 times (95% CI:
1.67–4.75) more likely to score high on the Herpes Knowledge
Scale compared to those who were not sexually active.
 Journal of American College Health 3

Table 1.  Participant demographic characteristics in a university undergraduate Table 3. Frequency of high knowledge score by participant demographic
study evaluating knowledge, attitudes, and testing preferences regarding HSV characteristics, testing and sexual behavior in a university undergraduate study
(N = 612). evaluating knowledge, attitudes, and testing preferences regarding HSV.
Characteristic Frequency % Characteristic High Knowledge (Score ≥ 80%) Percent p-value
Age, years (Mean + SD) 20.3 + 1.8 Sex
Sex  Female 95/401 23.7 0.40
 Female 401 65.5  Male 43/208 20.7
 Male 208 34.0 Heritage <0.01
 Other/Prefer Not to Say 3 0.5  Black 6/39 15.4
Heritage  Asian 39/184 21.2
 Latinx 129 21.1  Latinx 11/80 13.8
  White or Caucasian 189 30.9  Other 2/23 8.7
  Black of African American 39 6.4  White 61/189 32.3
 Asian or Asian American 184 30.1  Mixed 19/92 20.7
 American Indian, Alaska Native, Native Hawaiian 1 0.2 Year in University <0.01
or other Pacific Islander  1st Year 17/152 11.2
 Mixed 194 31.7  2nd Year 39/164 23.8
  Decline to answer 5 0.8  3rd Year 33/134 24.6
Year in University  4th Year 41/140 29.3
 1st 152 24.8   5+ Years 9/22 40.9
 2nd 164 26.8 Tested for Sexually 83/244 34.0 <0.01
 3rd 134 21.9 Transmitted
 4th 140 22.9 Infections
 5+ 22 3.6 Tested Positive for 20/43 46.5 <0.01
Sexually Transmitted
Infections
Table 2.  Participant sexual history and sexually transmitted infection testing Sexually Active 119/437 27.2 <0.01
in a university undergraduate study evaluating knowledge, attitudes, and
testing preferences regarding HSV (N = 612).
Characteristic Frequency %
80% on the Herpes Knowledge Scale as compared to those
Have you ever been sexually active with a partner?
  Yes 437 71.4
who reported a negative STI test result. However, the num-
  No 162 26.5 ber of lifetime sex partners was not statistically significantly
  Prefer not to answer 13 2.1 associated with higher herpes knowledge (OR: 0.99, 95%
Number of Lifetime Sex Partners (Mean + SD) 6.0 + 8.7
n = 437
CI: 0.97–1.01, p = .44). Results of the multiple logistic regres-
Have you ever tested for STIs and how often? sion suggested that for every increase in year of age, the
  Yes 237 38.7 odds of receiving a high score on the Herpes Knowledge
How often do you test? (n = 237)
  Only when I think I might have something 64 27.0
Scale increased. For every year increase in age, there was a
  At least every year 86 36.3 2% absolute increase in the predicted Herpes Knowledge
  About every 6 months 20 8.4 Scale score. We found slight differences in Herpes Knowledge
  About every 3 months 21 8.9
  After every partner 46 19.4
Scale scores by year in school. As shown in Table 3, the
Never tested for STI 368 60.1 proportion of students scoring high in the knowledge scale
I don’t know 7 1.1 increased by the year in school (p = .001).
Tested positive for STI (n = 237)
  Yes 43 18.1
Table 4 shows the frequency of correct responses to a
  No 193 81.4 select number of knowledge questions regarding HSV infec-
  I don’t know 1 0.4 tion (Table 4). A low proportion of participants replied
If tested positive for STI, which one? (n = 43)
  Human Papilloma Virus 4 9.3
correctly to the statements regarding the causative agent of
  Chlamydia 24 55.8 HSV infection (statements 1 and 2), transmission of infec-
  Gonorrhea 11 25.6 tion (statements 5 and 6), and the impact of the infection
  Syphilis 3 7.0
  Genital Herpes 8 18.6
in personal health (statements 9, 11, 12, 14).
  Human Immunodeficiency Virus 0 0
  Other 3 7.0
  Prefer not to answer 1 2.3 Attitudes about genital herpes
Recent STI Testing Location (multiple selections apply) (n = 237)
  My family doctor 84 35.4 Among participants, 57.2% felt unequipped to cope with a
  Community Clinic (ie Planned Parenthood) 30 12.7
  USC Health Center 107 45.1 potential genital herpes outbreak. Conversely, stigma toward
  Ordered a home test kit from the Internet 4 1.7 genital herpes was relatively low, as most participants either
  Other 12 5.1 felt neutral or agreed to the Likert scale question regarding
Ever tested for Genital Herpes (n = 237) 118 49.8
Tested positive for Genital Herpes (n = 118) 6 5.1 openness to dating someone who has history of herpes
(Figure 1). We recorded high acceptability (90.2%, 552/612)
of a hypothetical herpes vaccine (Figure 2).
Participants who had been tested for STIs were 2.87 times
(95% CI: 1.94–4.24) more likely to score over 80% on the
Discussion
herpes knowledge test as compared to those who had never
tested for an STI. Those who tested positive for STIs were We surveyed undergraduate students at a large university,
3.26 times (95% CI: 1.73–6.14) more likely to score over and assessed knowledge, attitudes, testing, and treatment
4 A.P. TADANKI ET AL.

Table 4.  Proportion of participants with correct responses on the Herpes Knowledge Scale Questionnaire regarding genital herpes by sexually active status in
a university undergraduate study evaluating knowledge, attitudes, and testing preferences.
T = TrueaF = Falseb Overall (n = 599) Sexually Active (n = 437) Not Sexually Active (n = 162)
ID Knowledge Question N (%) N (%) N (%) p-value
1. Genital herpes is caused by a virus (T) 420 (70.1%) 317 (72.5%) 103 (63.6%) 0.03
2. Oral herpes is caused by a virus (T) 425 (71.0%) 319 (73%) 106 (65.4%) 0.07
3. Genital herpes makes people infertile/sterile (F) 398 (66.4%) 296 (67.7%) 102 (63.0%) 0.27
4. A person who gets cold sores on the mouth is immune 531 (88.7%) 391 (89.5%) 140 (86.4%) 0.30
to genital herpes (F)
5. If a person has sexual intercourse with someone who 331 (55.3%) 265 (60.6%) 66 (40.7%) <0.01
has genital herpes, they will definitely be infected
with genital herpes too (F)
6. Several hundred people are expected to catch genital 295 (49.3%) 229 (52.4%) 66 (40.7%) 0.01
herpes from toilet seats this year (F)
7. Genital herpes leads to death (F) 500 (83.5%) 379 (86.7%) 121 (74.7%) <0.01
8. There is a cure for genital herpes (F) 322 (53.8%) 244 (55.8%) 78 (48.2%) 0.09
9. A person who has genital herpes often has more 313 (52.3%) 138 (31.6%) 39 (24.1%) 0.07
psychological complications than physical
complications (T)
10. Condoms offer 100% protection from being infected 469 (76.6%) 340 (77.8%) 129 (79.6%) 0.63
with genital herpes (F)
11. A genital herpes infection usually leads to syphilis (F) 251 (41%) 206 (47.1%) 45 (27.8%) <0.01
12. A person who had genital herpes must have a Cesarean 186 (30.3%) 148 (33.9%) 38 (23.5%) 0.01
section if they give birth to a baby (F)
13. Most people have been exposed to oral herpes at one 367 (58.9%) 291 (66.6%) 76 (46.9%) <0.01
time or another (T)
14. If both parents have genital herpes, their children will 302 (49.3%) 220 (50.3%) 82 (50.6%) 0.95
be born with herpes (F)
15. Genital herpes is not common on college campuses (F) 463 (75.6%) 347 (79.4%) 116 (71.6%) 0.04
16. Oral Herpes cannot be transferred to the genitals during 392 (64%) 301 (68.9%) 91 (56.2%) <0.01
oral-genital sex (F)
a
Proportion of participants who correctly answered “True”.
b
Proportion of participants who correctly answered “False”.

Figure 1. Attitudes toward genital herpes in a university undergraduate study Figure 2.  Willingness to test and treat for genital herpes in a university under-
evaluating knowledge, attitudes, and testing preferences. graduate study evaluating knowledge, attitudes, and testing preferences.

preferences for genital herpes. While 5,000 undergraduate
students were randomly invited to participate, only 612
responded. The low response rate limits the generalizability
of our findings. Overall, knowledge regarding genital herpes
was low. Higher knowledge about genital herpes, however,
was associated with older age, sexually active status, and prior
history of STI testing. The overall low awareness and knowl-
edge about genital herpes underscores the need to ensure
that genital herpes education is included in comprehensive
sexual health educational programs for undergraduate stu-
dents in existing sexual health services. It is crucial to educate
on topics such as herpes transmission, contagiousness, health
consequences, and the absence of a cure, as participants
demonstrated limited knowledge on these subjects.
Only a small number of studies have evaluated the knowl-
edge of college students on genital herpes. In a study among
235 undergraduate students in Virginia in 2017, 92.8% of
participants knew about the transmission of herpes and
70.6% knew about treatment options.7 A study conducted
in 1999 focusing on HSV-2 knowledge among psychology
undergraduate students (n = 518) at an urban university in
Cincinnati9 recorded high levels of general knowledge and
transmission without identifying differences between males
and females. In 1984, Hillard et  al12 identified similar pat-
terns of knowledge in a study of 351 university students in
Virginia. Our findings demonstrated inadequate knowledge
about genital herpes among students in a large urban uni-
versity, as well as no statistically significant difference

between males and females. Direct comparisons between
studies are not feasible due to differences in study methods,
time the study was conducted, and study populations. Thus,
we can’t make direct comparisons regarding the trend of
knowledge levels regarding HSV. However, the
above-mentioned studies underline the need for ongoing
education programs to address gaps in knowledge.
Continuous population-based sexual health knowledge sur-
veys would be useful in monitoring knowledge among dif-
ferent populations to inform the need for updates in sexual
education programs.
Studies evaluating knowledge of other STIs among college
students have also shown gaps in specific areas of STI knowl-
edge.13,14 In a recent study among female undergraduate stu-
dents, overall knowledge about bacterial STIs was low, even
though participants knew more about chlamydia and gon-
orrhea, which are among the most common sexually trans-
mitted diseases.13 This low overall knowledge suggests
increasing sexually transmitted disease information is neces-
sary. Medical providers are a trusted and acceptable source
of information for students,15 and our findings showed that
students use their primary care providers and the student
health clinic. For that reason, university student health pro-
grams could play an important role in educating students as
well as offering screening to students at increased risk of
infection.
Undergraduate students seem to view treatment and vac-
cination for prevention of herpes favorably, which is encour-
aging despite efforts to developing a vaccine against HSV
still being underway.16 A modeling study by Ayoub et  al.17
showed the potential impact of a herpes vaccination pro-
gram. Utilizing a hypothetical scenario of an HSV-2 vacci-
nation with a 50% vaccine efficacy, they showed that by
2050, the annual number of new infections reduced by 58%
and avert as many as 350,000 infections, yearly. Given the
potential impact of a vaccination campaign, adolescents and
young adults should be high-priority populations.
There are a few limitations that should be considered
when interpreting our findings. We achieved a response rate
of 12.2%; thus, nonresponse bias may have limited the rep-
resentativeness of our study. Our survey also offered respon-
dents the option of not answering specific questions by
selecting, “prefer not to answer/say,” which may have resulted
in a potential bias in the results as not all survey items
were answered. Also, our survey did not provide a clear
definition of sexual activity, which may have affected our
findings since there are potential varying interpretations of
what constitutes sexual activity. In addition, women were
overrepresented in this study (65.5% of survey participants
vs. 52.0% of total USC population) compared to the men
(34.0% of survey vs. 48.0% of total USC population).
Future directions
Knowledge of genital herpes was low among undergraduate
students, as many students possessed incorrect assumptions
about causation, transmission, frequency, and implications
of infection. Sexually active status, prior history of STI test-
ing, and prior history of a positive STI test all appeared to
Journal of American College Health 5
be contributors to differences in knowledge levels. Ultimately,
while the CDC does not recommend routine testing for
HSV infections in asymptomatic individuals who have never
experienced symptoms consistent with genital herpes, our
findings reveal both the need to improve knowledge about
genital herpes among undergraduate students and the impor-
tance of offering comprehensive support services to indi-
viduals infected with herpes. Increasing knowledge
surrounding genital herpes is important because it is a
common STI with substantial morbidity. Addressing knowl-
edge gaps can help individuals understand risks and make
informed decisions to decrease transmission. This is espe-
cially valuable among university students, as they may be
at higher risk for STIs due to engagement in riskier sexual
behaviors. Herpes is generally assumed to be benign and
rare, and increased awareness and knowledge can increase
individuals perceived severity and susceptibility, ultimately
influencing their health behaviors. Furthermore, herpes is
often stigmatized, and increasing knowledge and sharing
accurate information regarding herpes can help prevent
stigma.18 In light of the increasing rates of STIs, as well as
the evolving sexual practices among adolescents and young
adults, studies evaluating STI knowledge and behavioral
attitudes should be performed frequently to identify knowl-
edge gaps and inform student prevention programs.
Acknowledgments
The authors would like to thank Andrew Zaw, MPH Program Analyst,
from the Department of Population and Public Health Sciences IT
team for his support during this project.
Conflict of interest disclosure
The authors have no conflicts of interest to report. The authors confirm
that the research presented in this article met the ethical guidelines,
including adherence to the legal requirements of the United States and
received approval from the Institutional Review Board of University
of Southern California.
Funding
No funding was used to support this research and/or the preparation
of the manuscript.
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