What is the management of Herpes Simplex Virus type 2 (HSV 2)?

Management of Herpes Simplex Virus Type 2 (HSV-2)

The management of HSV-2 should focus on both symptom control and transmission prevention through a combination of antiviral therapy (either episodic or suppressive), safer sex practices, and patient education. 1

Diagnosis

• Accurate diagnosis is essential before initiating treatment, using either viral detection methods for active lesions or type-specific serologic testing for those without active lesions 1
• PCR testing of lesions is the gold standard for diagnosis of active HSV-2 infection due to its higher sensitivity compared to viral culture 2
• Type-specific serologic testing should be performed in patients with genital symptoms consistent with herpes or those with high-risk exposures 1
• Serologic testing with HerpeSelect should ideally be confirmed with a second test when index values are <3.0 to improve specificity 1

Treatment Approaches

First Clinical Episode

• Oral antiviral therapy should be initiated promptly for first episodes of genital HSV-2 1
• Recommended regimens include:
  • Valacyclovir 1g orally twice daily for 7-10 days 3
  • Acyclovir 400mg orally three times daily for 7-10 days 1
  • Famciclovir is also an effective option 1
• Short-course therapy (1-3 days) should not be used in patients with HIV infection 1

Recurrent Episodes (Episodic Therapy)

• For recurrent episodes, treatment should be initiated at the earliest sign or symptom 4
• Recommended regimens include:
  • Valacyclovir 500mg orally twice daily for 5 days 3, 4
  • Treatment initiated more than 24 hours after onset of symptoms has limited efficacy 4

Suppressive Therapy

• All patients with symptomatic HSV-2 infection should be offered suppressive therapy to reduce recurrences and prevent transmission to partners 1
• Recommended regimens include:
  • Valacyclovir 500mg-1g orally once daily 3, 4
  • Acyclovir 400mg orally twice daily 1
• Suppressive therapy reduces HSV-2 transmission to susceptible heterosexual partners by approximately 50% 4, 5
• Suppressive therapy is not effective for reducing transmission in persons with HIV/HSV-2 coinfection 1

Special Populations

• For immunocompromised patients, including those with HIV:
  • Higher doses of antivirals are recommended 3
  • IV acyclovir is preferred for severe mucocutaneous lesions 1
  • Treatment should continue until lesions have completely healed 1
• For patients with acyclovir-resistant HSV-2:
  • Case reports suggest brincidofovir, imiquimod, and topical cidofovir may be useful 1
  • Helicase-primase inhibitors are under investigation in clinical trials 1

Prevention of Transmission

• Patients should be counseled on:
  • Avoiding sexual contact when lesions are present 4
  • Using condoms consistently, which reduces HSV-2 acquisition 1
  • Understanding that transmission can occur during asymptomatic viral shedding 4
• Partners should be encouraged to undergo type-specific serologic testing 1, 4
• Disclosure of HSV-2 status to partners has been associated with reduced transmission risk 1

Patient Education

• Patients should be informed that HSV-2 is a chronic infection without a cure 4
• Approximately 20% of HSV-2 seropositive individuals do not recognize symptoms 1
• Genital herpes is frequently transmitted during asymptomatic viral shedding 6
• Adequate hydration should be maintained during antiviral therapy 4
• Topical acyclovir is substantially less effective than oral therapy and is not recommended 3

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours of symptom onset significantly reduces effectiveness 3
• Treating based solely on positive serology without clinical symptoms is not recommended 3
• Failing to distinguish between HSV-1 and HSV-2 genital infections, which have different prognoses and counseling implications 1, 7
• Overlooking the increased risk of HIV acquisition in individuals with genital HSV-2 infection 8
• Discontinuing suppressive therapy prematurely in patients with frequent recurrences 4