At what frequency of herpes simplex virus type 2 (HSV2) outbreaks is suppressive therapy typically considered?

Suppressive Therapy Threshold for HSV-2

Suppressive therapy for HSV-2 should be initiated when patients experience 6 or more recurrences per year. 1, 2

Primary Indication

• The CDC defines frequent recurrences as ≥6 episodes per year, which is the threshold for considering daily suppressive therapy. 1, 2
• This threshold is based on clinical trials demonstrating that patients with this recurrence frequency derive the greatest benefit from suppressive therapy. 3

Expected Benefits at This Threshold

• Daily suppressive therapy reduces recurrence frequency by ≥75% in patients with ≥6 recurrences per year. 1, 4
• Suppressive therapy reduces asymptomatic viral shedding, though it does not eliminate it completely, potentially decreasing transmission risk to sexual partners. 1
• Quality of life improves significantly by preventing the physical discomfort, psychological distress, and social impact of recurrent outbreaks. 1

Medication Options and Dosing

For patients with <10 recurrences per year:

• Valacyclovir 500 mg once daily is effective. 1
• Alternative: Acyclovir 400 mg twice daily. 2
• Alternative: Famciclovir 250 mg twice daily. 2

For patients with ≥10 recurrences per year:

• Valacyclovir 1,000 mg once daily provides better suppression. 1
• Valacyclovir 500 mg once daily appears less effective in this higher-frequency group. 4

Duration and Reassessment

• Long-term valacyclovir therapy has documented safety for 1 year of continuous use in immunocompetent patients. 1
• Acyclovir has documented safety for up to 6 years of continuous use. 1, 2
• After 1 year of continuous suppressive therapy, discontinuation should be discussed to assess the patient's current recurrence rate, as recurrence frequency often decreases over time. 1, 2, 4

Special Populations

HIV-infected patients:

• Require higher doses: valacyclovir 500 mg twice daily (not once daily). 1, 4
• Do not prescribe valacyclovir 500 mg once daily for HIV-infected patients—this is a common pitfall. 1

Critical Counseling Points

• Suppressive therapy does not eradicate the virus or completely prevent transmission—asymptomatic viral shedding can still occur. 1, 2
• Patients should be counseled to abstain from sexual activity when lesions or prodromal symptoms are present. 2
• Condoms should be used during all sexual exposures with new or uninfected partners. 2
• No laboratory monitoring is needed unless the patient has substantial renal impairment. 1

Common Pitfall to Avoid

• Do not wait for more than 6 recurrences per year before offering suppressive therapy—this is the established threshold, and delaying treatment unnecessarily prolongs patient suffering and increases transmission risk. 1, 2