herpes demographics

[irritatedscrotum]

Thank you Dr. Hansfield for taking the time and providing us answers to our questions and your service in the Seattle area.

First I have a question about my health.  Would a sore from masturbation and herpes look different?  Last night I masturbated harder than normal (and I've been doing so more frequently this week). Today there is what I think is simply a raw spot from friction on the shaft of my penis near where my index finger usually resides when masturbating.  I've had this happen a couple of times before, but usually along the vein on the underside of my penis.  The sore is not on top of the skin, but rather looks like I rubbed part of the skin off.  How embarrassing.  There isn't any puss and it already appears to be healing.  Its been 8 weeks since I last had sex. Should I not worry - after much reading, I don't think I should?  Also, I'm pretty sure that over the summer I had a genital wart, but was unaware of its cause and simply snipped it off with nail clippers (even more embarrassing).  I guess I'm an idiot, but I thought warts were caused by "germs." I now know what the wart is all about and will see a doctor soon.  Will he have me tested for herpes by default?

My other questions are:
1. Where does the 25% statistic of herpes infection come from?  Who was studied? Is the 25% an extrapolation from a studied subset who were unhealthy to begin with?  
2. Is regular herpes blood testing recommended?  Due to its asymptomatic nature I'm afraid to get tested.  I've had 10 partners in my life and am very worried.  I'm a 28 year-old student (at UW - maybe I'll see you around some time..hopefully not, though.)  Mostly I used a condom, except with 3 girlfriends and one not-quite-a-girlfriend.  I'm stressed.
3. Who has herpes? Are there any demographic breakdowns? My partners have all been heterosexual female college students under the age of 25.  
4. Are there any measurements of # of herpes infections at the UW or Seattle area?
5. Switching to HPV (I'm definitely getting my $10 worth! :). How many other researchers share your view that contagiousness is significantly reduced after 6 months to a year? How effective is a condom when it covers the are where the wart was?
6. I heard a story from a woman whose husband recently died.  They had warts about 20 years ago, but no symptoms afterward until near his death. I presume his immune system was shot. His warts reappeared. was he contagious again?  Or was his body unable to fight off even the small amount of virus left on the skin.
7. How much does it cost to get an HPV-type test to see if my wart is really a wart and to see if its a type that will soon be covered by the upcoming vaccine? Is it worth it? My current gf is still a virgin and I know now that an ex-gf had a high-risk HPV strain.  Since due to the wart anyways, we probably can't have sex until the summer. And that's only a few months away froom the vaccine, right?
8. Will "boosting" my immune system help with the HPV?

Thanks

[gracefromHHP]

I thought I'd include this easy to read link about the 25% infection rate since you seem interested.  It's nicknamed the "but I don't see herpes in my practice" study ;)  http://www.gsk.com/press_archive/press2003/press_07282003.htm  I'm not sure if you've ever heard of lewisburg, PA ( home of bucknell unniversity - they made the news last year at the college basketball playoffs! ) but it's a fairly small town surrounded by other fairly small towns ( ~ 6000 residents ).  A doctor there last year , who's employed part time with GSK, repeated this same test to see what the rate of infection was here in small town usa - the results were the same! About a 25% rate of infection with hsv2 ( I don't believe the hsv1 infection rate was mentioned ) was found and like most other studies the vast majority of folks had no idea they were infected before tested.  It really is that common almost everywhere! Most folks who have it assume that they'd know in a heartbeat if they had any std - the reality is that the most common symptom of all std's is a relative lack of symptoms so if you don't get tested in between partners or on a regular basis you might never know what you have and would assume you were std negative when asked.  Also unless you specifically request herpes blood testing it often isn't performed so when you hear that you are std negative you just assume that herpes was included when it probably wasn't.

I think everyone should have herpes blood testing on a regular basis - better to pay the money and know what you have than to try to deal with the guilt/pain of unknowingly infecting someone.  Just knowing you have hsv2 has been shown to reduce transmission ( you are more likely to avoid sex during any questionable symptoms down yonder ).  I transmitted the virus to 2 partners before I knew I had it - it was not easy to deal with.  If I had known I had it I don't think I would've sowed as many oats as I did during my college years and might've avoided transmitting it like I did.

The hpv blood test isn't of much use to you from what I know about it.  Should you have a return of genital symptoms you can have it removed and tested for hpv then but otherwise there isn't any real helpful commercially available test.  Should your gf notice any obvious genital warts she should see a doctor and have them removed.  

Both you and your gf should consider type specific herpes blood testing. You are near one of the best clinic's in the US for herpes - take advantage of it!! If your penis lesion is 48 hours old or less go to the clinic asap for a lesion culture and typing.

So why doesn't everybody have hsv2?  It's really not THAT contagious. Just avoiding sex during obvious symptoms goes a long way in decreasing transmission.  If you know you have genital herpes that alone causes a decrease in transmission rates. It's almost as much about bad luck as anything when you think about it - wrong place at the wrong time.  As for your std education at least you got some - many schools won't even talk about std's and just preach nothing before marriage and leave their students completely in the dark!  If you feel you need to know more about std's www.ashastd.org has a terrific list of them, symptoms, how to test for them and how to lower transmission of them.

grace

[irritatedscrotum]

In regards to testing.  I was informed by a urologist at UW that an HPV-type blood test could be administered.  Was he misinformed?  He said that its usually done only for research purposes and could be expensive.  He even offered to order the test when I was in his office.  By the way, the reason I was there was due to "pelvic pain", as he diagnosed it, after having dull aches in my testicles and epididymal area for about a month.  It's still there, though less frequently.  I mentioned HPV from my ex-girlfriend (but not the wart because I was stupid and scared) and he said it wasn't an issue.  The skin trauma on my penis shaft is very recent.. and hopefully not associated.  It has never happened before on this spot and by now its almost completely healed.  Though now my worry for herpes increases.  I guess that I should just bite the bullet and get tested.  I'm mostly just worried about having a continued relationship with my girlfriend... its the most amazing love/friendship I've ever had.  Hopefully she'll be understanding.

I feel so angry at our society for not being more aware/worried of these things.  Everyone is, justifiably, so worried about life-threatening HIV, but not about more probable severly life-altering STDs. 25% herpes rate!  I couldn't believe it.  33% in sweden! Its just seems like such a non-issue, yet it affects millions of American's lives.  Or was I just unlucky and received a bad education about STDs?  Maybe I wasn't paying attention... :( I only ever worried about HIV and didn't even know that a wart was caused by a virus!  Hopefully the HPV vaccine will only make people more aware of herpes and such.  (Which could be a good argument to the conservative groups that don't want the HPV vaccine.  They could use it to increase awareness of other things, perhaps.)

Thanks again for all your comments.

[irritatedscrotum]

Sorry - one more question that you probably can't really answer without writing a thesis.  Given the predominantly asymptomatic behavior, why isn't the herpes infection rate higher - like in HPV?  Simply because it is at least somewhat symptomatic, right?  Or is HPV more contagious per sexual encounter?  Let's go with both... i won't be upset if you don't answer this one if you don't know and your fingers are bleeding from answering my other questions.

Thanks again.

[H. Hunter Handsfield, M.D.]

Your penile lesion may be entirely traumatic.  However, friction/trauma often just unmasks a milder lesion that the patient might not have noticed otherwise, and herpes is a common explantion for lesions that seem to be due to injury.  It is particularly important to consider herpes if someone has had similar lesions before, even if they also seemed to follow trauma or friction.  Testing for herpes will be up to your health care provider, but it might be a good idea.

There is no way to know whether the lesion you snipped was a wart.  Skin tags and other non-wart lesions are hard for non-professionals (and often for very experienced STD experts) to tell from one another.  Most persons with genital warts have more than one lesion; if there was only one, warts are somewhat less likely.

To your questions:

1) The 25% statistic comes from testing several thousand randomly chosen, outwardly healthy persons in the United States.  It is considered a highly reliable figure.

2) There is an ongoing debate among STD experts about whether all sexually active persons, or those at risk for STD, should have routine HSV blood tests.  Most believe not, and that is my view.  However, testing is recommended for anybody with clinical suspicion of herpes (such as uneplained genital sores, like you), and for people know to be exposed--that is, with sex partners known to have genital herpes.

3) Genital herpes is somewhat less common under age 25, and is more common in African Americans than in whites or persons of Asian background; Hispanics are in the middle.  Among college students age 20-25, on average probably 10-15% are infected.

4) Seattle and King County (where I am from) has average herpes statistics; i.e., the national data probably apply.  The health care providers at Hall Health Center (for other readers, that's the student health service at UW) know herpes well; that's because UW and Seattle are the world's center of expertise on genital herpes.  You can also get excellent care at the Public Health clinic at Harborview; or, if you have a positive test for HSV-2, at the UW Viral Disease Research Clinic (also at Harborview) or it's non-research arm, called the Remington Clinic.  The STD Clinic can provide more information (206-731-3590).

5) All STD and HPV experts agree that most infections resolve and infectiousness declines with time.  There is no sharp cut-off; sometimes 3 months, 6 mo, 9 mo, a year, or longer.  In my view 6 mo. is a pretty good estimate for most people, but there are no definitive data and equally qualified experts differ in their opinions.  Recent research (also done at UW in Seattle) proves that 100% condom use is around 90% protective against HPV; the exceptions occur because the condom does not prevent all skin-to-skin genital contact.  And even occasional failure to use condoms almost entirely negates all protection.

6) Warts often reappear when a person's immune system fails due to aging, chronic illness, cancer, AIDS, etc.  Such persons are contagious.  It sounds like your friend's husband's case was typical.

7) There is no test for HPV in men, except to visually inspect for warts. The available lab tests for HPV are designed for women, for use in conjunction with pap smear, and are not considered reliable in men and are not recommended.  But even if the lesion you snipped was not a wart, you can assume you have (or have had) HPV; almost everybody acquires it within their first 3-4 lifetime sex partners.  Getting genital HPV is a normal event; it happens to almost everyone.  The new HPV vaccine is probably a year or so from FDA approval and marketing.  It won't provide instantaneous protection, which will require 3 doses over a 6-month period.

8) There is no such thing as "boosting" the immune system in healthy adults.  You can take all the vitamins you want, eat healthy, sleep well, get plenty of exercise, and control stress; none of it will make any difference in how well a person's immune system prevents or control HPV or any other infection.

9) Your question below:  There is no easy or certain explanation for the difference in epidemiology between HPV and HSV-2.  In general, HPV probably is more transmissible.

Best wishes--  HHH, MD