Herpes simplex genitalis antiviral treatment of recurrent genital herpes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S.

Established HSV-2 Infection

• The majority of patients with symptomatic, first-episode genital HSV-2 infection subsequently experience recurrent episodes of genital lesions; recurrences are less frequent after initial genital HSV-1 infection.

• Intermittent asymptomatic shedding occurs in persons with genital HSV-2 infection, even in those with longstanding or clinically silent infection.

• Antiviral therapy for recurrent genital herpes can be administered either episodically to ameliorate or shorten the duration of lesions or continuously as suppressive therapy to reduce the frequency of recurrences. Majority patients, including those with mild or infrequent recurrent outbreaks, benefit from antiviral therapy.

• On the contrary, suppressive therapy has an additional advantage of decreasing the risk of genital HSV-2 transmission to susceptible partners.

Suppressive Therapy for Recurrent Genital Herpes

• Suppressive therapy reduces the frequency of genital herpes recurrences by 70%-80% in patients who have frequent recurrences (i.e., greater than 6 recurrences per year), and many patients report no symptomatic outbreaks. Treatment also is effective in patients with less frequent recurrences. Safety and efficacy have been documented among patients receiving daily therapy with acyclovir for as long as 6 years and with valacyclovir or famciclovir for 1 year. Quality of life frequently is improved in patients with frequent recurrences who receive suppressive, compared with episodic treatment.

• The frequency of recurrent genital herpes outbreaks diminishes over time in many patients, and the patient's psychological adjustment to the disease may change. Hence, periodically during suppressive treatment (e.g., once a year), the need to discontinue therapy may be discussed.

• Daily treatment with valacyclovir 500 mg daily decreases the rate of HSV-2 transmission in discordant, heterosexual couples in which the source partner has a history of genital HSV-2 infection. Such couples should be encouraged to consider suppressive antiviral therapy as part of a strategy to prevent transmission, in addition to consistent condom use and avoidance of sexual activity during recurrences. Suppressive antiviral therapy probably reduces transmission when used by persons who have multiple partners and by those who are HSV-2 seropositive without a history of genital herpes.

CDC Recommended Regimens

• Acyclovir 400 mg orally twice a day OR
• Famciclovir 250 mg orally twice a day OR
• Valacyclovir 500 mg orally once a day OR
• Valacyclovir 1.0 gram orally once a day

• Valacyclovir 500 mg once a day might be less effective than other valacyclovir or acyclovir dosing regimens in patients who have very frequent recurrences (i.e., more than 10 episodes per year). Several studies have compared valacyclovir or famciclovir with acyclovir. The results of these studies suggest that valacyclovir and famciclovir are comparable to acyclovir in clinical outcome. Ease of administration and cost also are important considerations for prolonged treatment.

Episodic Therapy for Recurrent Genital Herpes

• Effective episodic treatment of recurrent herpes requires initiation of therapy within 1 day of lesion onset or during the prodrome that precedes some outbreaks. The patient should be provided with a supply of drug or a prescription for the medication with instructions to initiate treatment immediately when symptoms begin.

CDC Recommended Regimens

• Acyclovir 400 mg orally three times a day for 5 days OR
• Acyclovir 800 mg orally twice a day for 5 days OR
• Acyclovir 800 mg orally three times a day for 2 days OR
• Famciclovir 125 mg orally twice daily for 5 days OR
• Famciclovir 1000 mg orally twice daily for 1 day OR
• Valacyclovir 500 mg orally twice a day for 3 days OR
• Valacyclovir 1.0 g orally once a day for 5 days