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Genital Ulcers

Feb 2, 2003

Dear Dr. Wohl,

I like your answers to questions. You are straight with many of the questions. I maybe in the wrong forum but please excuse this transgression.

I was wondering about genital ulcers. I have read that genital ulcers are a factor in the transmission of hiv. Could you expand this? I am talking about three things in particular.

Let's take herpes which 1 out of 5 have, including many who are hiv+. If you had herpes and used a condom, what is your risk? This is considering that it is in the surrounding skin and not on the penis.

Secondly, If the female had herpes and you did not see ulcers, but used a condom, how would you know that you were protected? Many people get herpes even with condom use. Is this a risk for the transmission of hiv. Do they co-infect at the same time.

Third, herpes need small openings in the skin, just as hiv needs an opening. Sex is messy especially when multiple posiitions are explored. How does vaginal fluids that get everywhere play into that risk. Couldn't hiv virsus find that same cut that herpes could find in the external genitalia?

I guess that these questions enter my mind with that study about recruits in thailand that "used" condoms but still showed about the same risk as those who did not. Seems to go against the conventional wisdom.

Thank you so much for you answer.

Response from Dr. Wohl

Thanks for your comments.

Herpes simplex virus (HSV) and other ulcerative sexually transmitted diseases (STDs) facilitate HIV transmission by creating ulcers that bypasses the usual body surface barriers to HIV infection. When there is a sore on the penis or vagina, blood and cells containing HIV can be present on the surface, increasing the amount of HIV present. As in all infections, you need a sufficient inoculum to have transmission. Increase the amount of HIV in genital secretions and you increase the inoculum and risk of transmission.

Interestingly, even non-ulcerative STDs like chlamydia and gonorrhea, can increase HIV transmission during sex as they also recruit immune cells that are infected with HIV to the genital tract that can then find their way to semen and vaginal fluids.

In addition to inoculum, the infectiousness of a germ plays a role in transmission. HSV is relatively more transmittable than HIV. HSV can enter the body through the lining of the mouth, vagina and rectum - not just through breaks in the skin. People with HSV can shed the virus widely from all of these orifices, even when no ulcers are present, creating a field of HSV that can infect others even when a condom is used.

HIV is more confined to the genital secretions. Therefore, given the differences in at least the transmissibility and transmission routes of these viruses condoms are much more effective at HIV transmission prevention than they are for HSV.

Co-transmission (sort of piggybacking of one of these viruses on another) does not happen.

I am unsure what study you are referring to regarding Thai military recruits. According to what I have read and the World Health Organization website, STD and HIV rates have dropped among these men. Check out

There may be more recent info that you have and I have not seen. If so, let us know. DW

RE: Just wondering
Time to start meds?

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