Three-fourths of individuals who know that they have genital herpes either abstain from vaginal sex or always use condoms when they have symptoms, but only one-fifth do so when they are free of symptoms.1 In an international cross-sectional study of individuals with genital herpes who were in monogamous, heterosexual relationships, only about half knew that the infection could be transmitted between outbreaks. Participants' odds of having sex (vaginal, oral or anal) during symptomatic periods were elevated if they or their partner used an IUD, if they were Latin American or European (rather than North American) and if they had previously had an STD. Their odds also increased with the number of sex acts per month and with the number of outbreaks per year.
The study was conducted between 1998 and 2001 among clinic clients who were being screened for participation in an international trial of drug therapy to prevent transmission of genital herpes. In 17 countries in North America, Latin America and Europe, researchers gave questionnaires to individuals visiting clinics who were infected with herpes simplex virus type 2, reported having had symptoms and had partners who had never had symptomatic genital herpes. Participants provided information about their demographic characteristics and their sexual behavior (including whether they practiced abstinence and used condoms during symptomatic and asymptomatic periods), and answered questions testing their knowledge about genital herpes.
Analyses were based on 1,193 individuals, 88% of whom were white and 60% of whom were female. The median age was 36 among men and 33 among women. Six in 10 participants had attended college, and seven in 10 were employed. The median number of outbreaks of genital herpes each year was five. Some 87% of participants said that they could recognize early symptoms of an outbreak.
Participants had sex with their partner a median of 6–7 times per month. During periods when they had no symptoms of genital herpes, 98% of individuals had vaginal sex, 76% had oral sex and 25% had anal sex. In contrast, during periods when they had symptoms, 40% of individuals had vaginal sex, 29% had oral sex and 11% had anal sex.
For certain types of sex, regular condom use was more common during symptomatic periods than during asymptomatic ones. Specifically, 20% of individuals used condoms for every act of vaginal sex when they did not have symptoms, but 35% did so when they had symptoms. Similarly, 2% always used condoms when having oral sex during asymptomatic periods, whereas 7% did so during symptomatic periods. The level of regular use of condoms when having anal sex did not vary with the presence of symptoms.
An analysis of overall changes in behavior between asymptomatic and symptomatic periods showed that most participants (89%) engaged in some type of sex without always using condoms when they had no symptoms, and a substantial proportion of this group (38%) continued to do so when they were symptomatic. Nonetheless, the majority of individuals modified their behavior, either abstaining from sex or always using condoms, when symptoms were present. Whereas only one-fifth (21%) of participants abstained from or always used condoms during vaginal sex when they were free of symptoms, three-fourths (74%) did so when they had symptoms. The pattern was similar for oral sex (26% vs. 73%) and anal sex (78% vs. 91%).
Nearly all individuals (97%) knew that genital herpes is sexually transmitted, and two-thirds (66%) were aware that the disease is incurable. Most knew that medication can prevent outbreaks (91%) and can speed the healing of sores (96%), and that condoms can help prevent the spread of the disease between partners (92%). However, only 67% knew that a person can still transmit the virus after a sore has completely healed, and only 53% were aware that the virus can be transmitted between outbreaks.
In a multivariate analysis, individuals who currently used an IUD or whose partner did had higher odds of engaging in any kind of sexual activity during symptomatic periods than did nonusers (odds ratio, 3.0). The odds of having sex despite the presence of symptoms were higher among Latin American and European participants than among their North American counterparts (2.2 and 1.7, respectively), and higher among individuals who had previously had an STD than among those who had not (1.4). The odds also rose with each additional sexual act per month (1.1) and with each additional recurrence of symptoms per year (1.1).
A final, multinomial analysis examined factors associated with individuals' risk of transmitting genital herpes, as defined by their sexual behavior and condom use during asymptomatic and symptomatic intervals. The lowest risk (characterized by having vaginal sex only during asymptomatic periods and always using condoms) was associated with high levels of education and of knowledge about genital herpes. The highest risk (marked by frequent sexual activity with irregular condom use during both symptomatic and asymptomatic periods) was associated with being in a long-term relationship.
Study participants, the researchers acknowledge, were interested in preventing transmission of genital herpes and may not be representative of other populations. Nevertheless, although the majority of this group either abstained from sex or always used condoms when they had symptoms, their level of consistent condom use during asymptomatic periods was fairly low, suggesting that individuals with genital herpes may believe that they have little or no risk of infecting others at such times. "A focus of prevention must continue to highlight the importance of regular and consistent condom use during both symptomatic and asymptomatic periods," the researchers conclude. —S. London
1. Rana RK et al., Sexual behaviour and condom use among individuals with a history of symptomatic genital herpes, Sexually Transmitted Infections, 2006, 82(1): 69–74.