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Are Black Women Now Wearing the Scarlett H?

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New Data on Black Women and HSV-2 Infection Raises Concern

The iconic 1982 Time magazine article “Herpes: Today’s Scarlet Letter” shed light on the stigmatizing nature of genital herpes infection. The recent announcement by the Centers for Disease Control and Prevention (CDC) that close to 50% of black women have genital herpes simplex virus type-2 infection has some wondering whether the Scarlet ‘H’ has now been branded upon them.

For Deborah Arrindell, ASHA Vice President of Health Policy, the new data are cause for concern in more ways than one. Beyond the issue of the high rate of infection lies the question of social stigma. "As an African-American woman,” Arrindell comments, “I find this data especially troubling. My first concern is that black women will be stigmatized.”

Arrindell is not alone in her concerns. The release of the data generated a significant critical outcry from the public at large. While many questioned how the data was gathered and the final figures calculated, some criticism even raised the specter of the Tuskegee Syphilis experiment, voicing concern over trusting data coming from a governmental agency and questioning the validity of the statistics themselves.

In response to the criticism, Dr. Kevin Fenton, Director National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention at the CDC, reflected on the significance of the data in a commentary published in NewsOne. While acknowledging that the report on genital herpes rates among black women was alarming and upsetting for many, he notes that, “Unfortunately, this latest news was not actually new. According to several CDC analyses of the National Health and Nutrition Examination Survey (NHANES)-the source of the data-the prevalence of genital herpes for black women has remained unacceptability high, at about 50 percent, for more than two decades.”Are black women wearing the Scarlett H?

Fenton explains some of the factors behind the disproportionate rate of infection among black women, highlighting social factors, not greater individual risk behaviors, that are likely responsible for the disparities seen with rates of HSV-2. African-Americans are more likely to seek partners within their own communities, for example, and the many ills affecting the underserved (including lack of access to health care) put these communities at much higher risks for all STIs to begin with.

All three racial/ethnic groups in the NHANES survey had increased HSV-2 seroprevalence as number of lifetime partners increased. However, it is interesting to note blacks reporting one partner had a higher percentage of HSV-2 infection when compared to Mexican Americans who had the second highest and whites who reported having one partner. Therefore, while STIs are common across the board in all groups, the double-whammy of poverty and being marginalized puts many communities of color at higher risk.

Yet while Dr. Fenton acknowledges that prevalence numbers in the African American community are high, he encourages the public health community “to look beyond the statistics” and instead focus on understanding the impact of this STI and others on communities most affected. Arrindell, for one, appreciates this approach. “I applaud Dr. Fenton for pointing out that there are factors other than behavior at work,” she comments. “This is challenging information to digest - but potentially life-saving."

Life-saving information not because genital herpes is a life-threatening condition, but in part because research demonstrates that people with genital herpes infection are two to three times more likely to acquire HIV, and that genital herpes can also make HIV-infected individuals more likely to transmit HIV to others. As Dr. Adaora Adimora, Professor of Medicine at the UNC-Chapel Hill School of Medicine, noted in an interview with National Public Radio on the topic, "Its important because of the illness it causes for people with it, and the fact that it can be transmitted from mother to child during childbirth, and the very important fact that it facilitates HIV infection," particularly given that HSV causes lifelong infection and may contribute to the high rates of HIV among the African American community in the U.S.

Avoiding the stigma
While there is no mistaking that these numbers offer a wake up call to the black community, the data suggest a need to better understand the effects of stigma in the public health community in order to avoid an undue burden on black women.

How should data of this nature be handled? Certainly the public health community and communities most affected need to know the information. But it is important to clearly convey the larger picture. For example, lost in the recent discussion of genital herpes rates among black women is the fact that rates among the population high overall are high at 17%, and higher still for women overall, at 21%.

As Dr. Fenton notes in his commentary, the focus should be on social and biological factors, rather than individual ones. As he states, “Women, in general, are more biologically susceptible to acquiring HSV-2 infection than men. Thus African American women are particularly vulnerable to HSV-2, due to both biological factors and the already high community prevalence of disease.” There is a greater likelihood of a male infected with HSV-2 to pass it to his female partner than an infected female to pass it her male partner. Anatomical differences between males and females are one of the biological factors that contribute to this.

But herpes-related stigma isn’t all about herpes—it’s also about sex. In his article “The Effects of Stigma on Genital Herpes Care-seeking Behaviours,” J. Dennis Fortenberry, MD, MS, suggests that, “Sex, not herpes itself, is a central aspect of herpes-related stigma – and the importance of sex in the stigma of herpes cannot be overstated.” Because sex is viewed as a choice, a voluntary behavior, so too is getting an STI. Therefore the person is viewed as responsible for getting the STI, and to blame for the consequences as a result of individual, voluntary behavior.

This suggests a larger social and cultural shift is needed—a shift in the perception of sexual health. A shift away from the blame game to one of empowerment regarding sexual health. One that encourages the public at large to seek testing, know their status and if infected share that information with partners as part of a large framework that uplifts sex as a natural part of life. As Fortenberry observes, “It is not entirely congruent to work against the stigma of herpes and other STIs while emphasizing the stigma of sex, all in the name of prevention.”

Addressing the disparity
While the intent of this article is to call attention to the possible stigmatization of black women, the fact remains something must be done to address the disparity in genital herpes prevalence. Lost in the media hype is the fact that rates among black men (29%) are also high when compared to other racial/ethnic groups. In respect to gender the gap between the sexes by race/ethnic group also shows similarities. For example, while white men HSV-2 seroprevalence was 8.7 percent, seroprevalence in white women was significantly higher (15.9 percent).

Nonetheless, it is troubling to know the high prevalence of HSV-2 among black women has remained steady, and the decline in prevalence among blacks in general has been low. So it is time to take up the following challenge issued by Dr. Fenton:

“So while this recent analysis may be alarming, it emphasizes that we cannot afford to be complacent about this infection or STIs in general. We each must do our part to educate and protect ourselves and our loved ones, and to face the harsh realities of this disease head on. The health of the men, women and children in our community demands nothing less.”


Male Circumcision for STI, HSV Prevention

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A review of recent studies finds more evidence of the value of male circumcision in reducing the risks for acquiring a number of viral sexually transmitted infections.

Circumcision, the surgical removal of the penis foreskin, is often done for religious or cultural reasons. The practice is not without controversy: Commonly done on infants, opponents point to discomfort (particularly if local anesthesia is not used) and questions about the impact on sexual enjoyment among reasons for not routinely performing the elective procedure.

Numerous studies do indicate that circumcision offers health benefits, especially in making a man less likely to contract HIV. Recently, evidence in this regard is mounting. The January 2010 issue of the Archives of Pediatric and Adolescent Medicine features a review of three randomized trials conducted in Africa since 2005 that looked at the impact of circumcision on STI acquisition. The review authors, Aaron Tobian, MD, PhD; Ronald Gray, MD, MS; Thomas Quinn, MD, MS, all of Johns Hopkins University, report that data from the trials shows circumcision greatly reduced heterosexual acquisition of several viral infections: HIV fell by 50-60%; HSV-2 (usually associated with genital herpes) by 28%-34%; and HPV by 32%-35%.

In the studies reviewed, the impact of circumcision on bacterial STIs (such as syphilis, chlamydia, and gonorrhea) in men was unclear, but female partners of circumcised men were much less likely to have bacterial vaginosis or trichomoniasis (a parasite associated with sexual transmission), among the most common STIs. Is there a study looking at the acquisition of HPV by women of men who are and are not circumsized?

The authors conclude, “This review evaluates the recent data that support revision of the AAP [American Academy of Pediatrics] policy to fully reflect the evidence of long-term health benefits of male circumcision.” The current position taken by AAP (and some other organizations) is that evidence is insufficient to recommend circumcision be done routinely with infants and boys. A story in the Washington Post (Stein, January 19, 2010) says both the AAP and Centers for Disease Control and Prevention (CDC) are evaluating whether or not to recommend routine circumcision for boys (and possibly men) as a result of these study results.

Dr. James Allen, a pediatrician, public health physician and former president of ASHA, praised these new developments but urged caution in developing policy recommendations based on them.

"I applaud the continuing studies that have been done to clarify the relationship between circumcision and risk of HIV and other sexually transmitted infections in both the man and his female partner. This is important information to consider in terms of formulating prevention recommendations. But there are several perspectives to consider, however.

"First, regardless of the significant reduction in risk of infection among men who are circumcised, responsible health personnel would still recommend that people use condoms and other proven prevention techniques at all times. Circumcision is not a substitute for other prevention methods.

"Second, the studies were done in countries in which the risk of HIV and other STIs may be quite different than in the United States, so the actual risk reduction and perceived benefits may be different in this country.

"Third, one would want to consider all the implications of developing policy recommendations for a particular area. For example, in an area of the world in which medical care is at a premium, where would this come as a priority and what would be the implications of devoting precious resources to providing circumcisions for newborns as opposed to all of the other important health care needs?

"And finally, it is essential in formulating policy recommendations in this country to consider all of the relevant issues. Among these is the fact that circumcision is a surgical procedure that has financial costs associated with it. There are also certain risks and complications, even though they are infrequent and most of them are not severe. But there will rarely be a significant problem or complication associated with circumcision, and this has to be factored into the policy considerations."

The World Health Organization’s website has extensive publications on male circumcision available for download, including an overview of risks and benefits.

Aaron A. R. Tobian, Ronald H. Gray, Thomas C. Quinn. Male Circumcision for the Prevention of Acquisition and Transmission of Sexually Transmitted Infections. Archives of Pediatric and Adolescent Medicine, 2010. 164(1): 78-84.
Michael T. Brady. Newborn Circumcision. Routine or Not Routine, That Is the Question. Archives of Pediatric and Adolescent Medicine, 2010. 164(1): 94-96.


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