Treatment of HSV-2 in HIV-Infected Patients
For HIV-infected patients with HSV-2, the recommended treatment includes higher doses and longer duration of antiviral therapy, with valacyclovir 500 mg twice daily as the preferred suppressive regimen. 1, 2
First Episode Treatment
For first-episode genital herpes in HIV-infected patients, recommended regimens include:
Treatment may be extended if healing is incomplete after 10 days of therapy 2
For severe mucocutaneous HSV lesions requiring hospitalization, intravenous acyclovir is recommended as first-line therapy until lesions begin to regress, then transition to oral therapy 2, 1
Recurrent Episodes Treatment
For recurrent episodes in HIV-infected patients, recommended regimens include:
Short-course therapy (1-3 days) should not be used in patients with HIV infection 2, 3
Treatment should be initiated at the first sign of prodrome or genital lesions to maximize effectiveness 3
Suppressive Therapy
Suppressive therapy is recommended for HIV-infected patients who have frequent or severe recurrences 2, 1
The recommended suppressive regimen for HIV-infected patients is:
Daily suppressive therapy in HIV-infected persons results in a decrease in HIV concentration in plasma and anal and genital secretions 2, 5
High-dose valacyclovir (1000 mg twice daily) reduces plasma HIV-1 RNA levels more than standard-dose acyclovir in HIV-1/HSV-2-seropositive persons not receiving antiretroviral therapy 5
Management of Treatment Failure
Treatment failure related to resistance should be suspected if lesions do not begin to resolve within 7-10 days after initiation of therapy 2
Among immunocompromised patients with suspected acyclovir-resistant HSV, viral culture of the lesion should be obtained and, if virus is isolated, susceptibility testing performed to confirm drug resistance 2
The treatment of choice for acyclovir-resistant HSV is IV foscarnet 2, 6
Topical trifluridine, cidofovir, and imiquimod have been used successfully for lesions on external surfaces, although prolonged application for 21-28 days or longer might be required 2, 6
The rates of HSV-2 resistance among HIV patients are almost ten-fold those in immunocompetent individuals (6% vs 0.6%) 6
Monitoring and Adverse Events
No laboratory monitoring is needed in patients receiving episodic or suppressive therapy unless the patient has substantial renal impairment 2
For patients receiving high-dose IV acyclovir, monitoring of renal function and dose adjustment as necessary are recommended at initiation of treatment and once or twice weekly for the duration of treatment 2
Acyclovir, valacyclovir, and famciclovir are occasionally associated with nausea or headache 2
Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome has been reported among HIV-infected patients treated with high-dose (8 grams/day) valacyclovir but has not been reported at doses used for therapy of HSV infection 2
Special Considerations
HIV-infected patients receiving antiretroviral therapy who have immune reconstitution often experience improvement in the frequency and severity of their clinical episodes of genital herpes 2
However, immune reconstitution does not reduce the frequency of genital HSV shedding 2
Routine type-specific serologic testing for HSV-2 should be considered in persons who seek HIV care 2
Diagnosis of HSV-2 should be accompanied by counseling that discusses the risk for transmission of infection to sex partners 2
Consistent use of latex condoms should be encouraged for prevention of transmission of HSV-2 and other sexually transmitted pathogens 2, 3