Infectious Diseases in Obstetrics and Gynecology Table 3: HSV seroprevalence. Data are expressed as number (%) of participants. HSV-1 positive HSV-2 positive HSV-1 positive and HSV-2 positive HSV-1 positive and HSV-2 negative HSV-1 negative and HSV-2 positive HSV-1 negative and HSV-2 negative HSV-1/HSV-2 combinations N = 134 81 (60) 15 (19) 15 (11) 66 (49) 12 (9) 41 (31) concern about what will be done with the results (60%). As only 71 or 72 (depending on the reason) of 115 participants who changed from willing to unwilling provided reasons for being unwilling, these data may be unrepresentative and should be interpreted cautiously. Whether aspects of the study protocol aﬀected willingness to provide a blood sample is not known. Participants had to go to another location to get their blood drawn, and it was not part of their routine prenatal blood workup. The latter factors may have inﬂuenced willingness to provide a blood sample. In addition, the questionnaire included several items on presence of baseline genitourinary signs and symptoms such as genital itching or redness, burning or tingling around genitals, thighs, or buttocks, pain with urination, discharge with urination, and vaginal discharge. Most participants reported absence of these symptoms. Possibly, the absence of these symptoms contributed to participants’ perception of not being at risk from genital herpes and suggested to them that they would not beneﬁt from serologic testing. In addition, participants had to go to another location to get their blood drawn, and it was not part of their routine prenatal blood workup. These factors may also have aﬀected willingness to be tested. Although participants generally showed good under- standing and retention of the information imparted during counseling, being counseled about genital herpes and neona- tal herpes appears not to have been eﬀective in motivating participants who were initially unwilling to be tested to change their minds: only 2 of those initially unwilling to be tested decided to have their blood tested after the brief counseling session. The counseling did not aﬀect the reasons for being unwilling to be tested: the frequency of citing reasons for being unwilling to be tested did not diﬀer as a function of whether or not participants had received counsel- ing. The counseling may have been ineﬀective because it did not address some of the most common reasons for not being willing to be tested: being tested is too personal and concern about what will be done with the results. The counseling information was speciﬁc to genital herpes and its potential eﬀects on the neonate; it did not include information on conﬁdentiality or other aspects of disposition of the test results. Perhaps inclusion of such information would be useful in reducing unwillingness to be tested, a possibility that warrants further study. 7 HSV-2 seroprevalence in this sample from a single obstetrics/gynecology ambulatory unit was 20%, a result consistent with the prevalence of HSV-2 in US women generally and with US population-based data showing HSV- 2 seroprevalence of 22% among pregnant women [1–3]. Likewise, the HSV-1 seropositivity rate of 60% in this study is consistent with the US population rate of 63% [3]. None of the women who tested positive for HSV-2 were aware of their HSV-2 serostatus prior to enrollment in the study. (Awareness of prior HSV-1 serostatus was not assessed in this study.) This ﬁnding, which corroborates the previous ﬁnding that the majority of HSV-2 infections remain undiagnosed [1, 2], highlights the importance of improving awareness and recognition of genital herpes among pregnant women. That all women who tested positive for HSV-2 agreed that it is important to use medicine to treat herpes during pregnancy and were willing to take a medicine during the last 4 weeks of pregnancy to treat herpes suggests that women aware of their seropositive status will implement measures to reduce the risk of transferring the virus to their infants. Importantly, 31% of population was seronegative for both HSV-1 and HSV-2 and therefore susceptible to getting primary genital herpes during pregnancy. The majority of neonatal HSV infections occur among infants born to women experiencing primary HSV infections. The risk of neonatal infection is particularly high when the mother con- tracts a primary or nonprimary ﬁrst episode of genital herpes late in gestation [23]. These considerations underscore the importance of education of women and their partners about the prevention of acquisition of HSV during pregnancy. 5. Conclusions Results of this study corroborate previous ﬁndings on the high prevalence of HSV seropositivity among pregnant women and support the feasibility of HSV serologic testing and counseling in this population. Further research is needed on methods of counseling patients about HSV and neonatal herpes and on speciﬁc information that should be included in counseling materials. Appendix Counseling Script for Visit 1 What Is Genital Herpes? (i) Genital herpes is a virus that is spread through intimate, skin-to-skin contact, including vaginal, oral, or anal sex. (ii) The genital herpes virus can be active on the surface of the skin with symptoms and a visible outbreak or without any visible signs or symptoms. (iii) There are many symptoms that can be associated with the virus such as itching, redness, bumps, tingling, and cuts in the genital area/boxer short area.