What is the recommended treatment and counseling approach for patients with genital Herpes Simplex Virus (HSV) 1 or HSV 2 infection?

Treatment and Counseling for Genital HSV-1 vs HSV-2 Infection

For patients with genital herpes, valacyclovir 500 mg orally twice daily for 5 days is the recommended first-line treatment for recurrent episodes, with treatment being most effective when started during the prodromal period or within 1 day after onset of lesions. 1, 2

Treatment Approaches Based on Clinical Presentation

First Clinical Episode

• Valacyclovir 1 g orally twice daily for 7-10 days is recommended for first episodes of genital herpes 1, 3
• Alternative regimens include acyclovir 400 mg orally three times daily for 7-10 days or famciclovir 250 mg orally three times daily for 7-10 days 3
• Treatment may be extended if healing is incomplete after 10 days of therapy 3

Recurrent Episodes

• Valacyclovir 500 mg orally twice daily for 5 days is the preferred treatment for recurrent genital herpes 1, 2
• Alternative regimens include acyclovir 400 mg orally three times daily for 5 days, acyclovir 800 mg orally twice daily for 5 days, and famciclovir 125 mg orally twice daily for 5 days 1, 2
• Patients should be provided with medication or a prescription to initiate treatment at the first sign of prodrome or genital lesions 2
• Treatment is significantly less effective if started more than 24 hours after onset of symptoms 1

Suppressive Therapy

• Daily suppressive therapy is recommended for patients with frequent recurrences (≥6 episodes per year) 1, 3
• Valacyclovir 1 g orally once daily or 500 mg orally once daily is recommended for suppressive therapy 2, 3
• Alternative options include acyclovir 400 mg orally twice daily or famciclovir 250 mg orally twice daily 3
• Suppressive therapy can reduce recurrence frequency by ≥75% and reduce asymptomatic viral shedding 1, 3
• After 1 year of suppressive therapy, consider discontinuation to assess recurrence frequency 3

Counseling Approach for HSV-1 vs HSV-2

Key Differences Between HSV-1 and HSV-2 Genital Infections

• HSV-1 causes 5-30% of first-episode cases of genital herpes, with clinical recurrences being much less frequent than with HSV-2 3
• Identification of the infecting strain (HSV-1 vs HSV-2) has important prognostic implications and should be used for counseling 3
• Asymptomatic viral shedding occurs more frequently in patients with HSV-2 infection than HSV-1 infection and in patients who have had genital herpes for less than 12 months 3

Essential Counseling Points for All Patients

• Inform patients that genital herpes is a recurrent, incurable viral disease 2
• Explain that antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences 2, 4
• Advise patients to abstain from sexual activity when lesions or prodromal symptoms are present 2, 3
• Counsel patients to inform sex partners about having genital herpes 2, 4
• Recommend condom use during all sexual exposures with new or uninfected partners 2, 3
• Explain the risk of asymptomatic viral shedding and potential for transmission even without visible lesions 2, 4
• Discuss the risk of neonatal infection, especially for women of childbearing age 3

Transmission Reduction Counseling

• Valacyclovir has been shown to reduce the risk of HSV-2 transmission to uninfected partners by 48% overall when combined with safer sex practices 4
• Counsel patients that herpes is frequently transmitted in the absence of symptoms through asymptomatic viral shedding 4
• Advise patients that suppressive therapy combined with safer sex practices provides the best protection against transmission 4

Special Considerations

Immunocompromised Patients

• Higher doses or longer courses of antivirals may be needed for immunocompromised patients 1
• For HIV-infected patients, consider acyclovir 400 mg orally three to five times daily until clinical resolution 1
• Antiviral resistance is rare in immunocompetent patients but more common in immunocompromised individuals 3

Severe Disease

• For severe disease or complications requiring hospitalization, acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution is recommended 5, 1

Pregnancy

• Pregnant women with genital herpes should inform their healthcare providers about the HSV infection 3
• The safety of systemic acyclovir therapy during pregnancy should be discussed with patients 5

Clinical Pearls and Pitfalls

• Topical acyclovir is substantially less effective than oral therapy and is not recommended 2, 3
• Valacyclovir offers more convenient dosing than acyclovir (fewer daily doses), which may improve patient adherence 6, 7
• Treatment is most effective when started during the prodromal period or within 1 day after onset of lesions 1, 2
• Patients with a history of <10 recurrences per year can be effectively managed with valacyclovir 500 mg once daily for suppression, while those with ≥10 recurrences per year may benefit from valacyclovir 1 g once daily 8