people. Although few adolescents could name an STD other than HIV/AIDS, they were more likely than adults to answer correctly that some STDs (in addition to HIV/AIDS) are incurable and that some STDs are asymptomatic.

STDs are far more common than is generally perceived by the general population or health care professionals. For example, while there is widespread awareness of genital herpes infections, there also are many misperceptions about them. Perhaps the single largest misperception concerns the prevalence of herpes infection. In a recent national survey of sexual behavior (Laumann, Gagnon, et al., 1994), 2 percent of survey respondents age 18-59 reported having had genital herpes. In contrast, population-based studies suggest that the prevalence of antibodies to herpes simplex virus type 2, which causes about 85 percent of initial episodes of genital herpes, was 21.7 percent in 1990 (Johnson et al., 1993). The reason for the substantial differences between the low prevalence of self-reported genital herpes infections and the far higher true prevalence of the disease may be misperceptions regarding the clinical manifestations of genital herpes infections. Herpes is most often described as an episodic illness, typically presenting as a painful genital eruption and recurring with similarly painful lesions of shorter duration. In fact, a quite different clinical spectrum of infection exists. Herpes infection may manifest as mild initial episodes and asymptomatic shedding of the virus (Koutsky et al., 1992). Other studies indicate that most genital herpes infections are spread by asymptomatic individuals who often are unaware of their infections (Mertz et al., 1992).

Conclusions

Biological and social factors contribute to the hidden nature of the STD epidemic. Biological factors, including the lack of signs and symptoms in infected persons, the long lag time from initial infection until signs of severe complications, and the propensity for STDs to more easily infect women than men, contribute to the general lack of awareness of STDs among health professionals and the public. A number of social factors contribute to the risk of STDs and place a disproportionate burden on certain populations in the United States. Poverty and inadequate access to health care, substance use, and sexual abuse all increase an individual's risk for STDs. Lack of health insurance is particularly acute among the age and ethnic groups at greatest risk of STDs. Even for the insured, access to comprehensive STD-related services may be difficult. Sex workers, persons in detention facilities, the homeless, migrant workers, and other disenfranchised persons represent "core" transmitters of STDs in the population. Efforts to prevent STDs in the entire community are not likely to be successful unless these groups receive appropriate STD-related services.

Many Americans are reluctant or unwilling to discuss sexuality and STD-related issues openly or refuse to have the issue appear in the public arena. Such reluctance has devastating consequences for STD prevention efforts. Open and



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