What is the recommended prophylactic treatment for genital herpes?

Prophylactic Treatment for Genital Herpes

Recommended Daily Suppressive Therapy

For patients with frequent recurrent genital herpes (≥6 episodes per year), daily suppressive therapy with valacyclovir 1 gram once daily or valacyclovir 500 mg once daily is the recommended prophylactic treatment. 1, 2

First-Line Suppressive Regimens

The CDC recommends the following daily suppressive therapy options for immunocompetent patients: 3, 1

• Valacyclovir 1 gram orally once daily - most effective option, particularly for patients with ≥10 recurrences per year 3, 4
• Valacyclovir 500 mg orally once daily - appropriate for patients with <10 recurrences per year 1, 4
• Acyclovir 400 mg orally twice daily - alternative option with documented safety up to 6 years 3, 1
• Famciclovir 250 mg orally twice daily - alternative option with documented safety up to 1 year 3, 1

Note: Valacyclovir 500 mg once daily is less effective in patients with very frequent recurrences (≥10 episodes per year), and higher doses should be used in this population. 3

Clinical Benefits of Suppressive Therapy

Daily suppressive therapy provides substantial clinical benefits: 1, 2

• Reduces recurrence frequency by ≥75% 1, 2
• Reduces asymptomatic viral shedding (though does not eliminate it completely) 3, 1
• May reduce transmission risk when combined with safer sex practices 1

Duration and Reassessment

• Safety and efficacy documented: Acyclovir for up to 6 years; valacyclovir and famciclovir for up to 1 year 3, 2
• After 1 year of continuous suppressive therapy, consider discontinuation to reassess recurrence frequency 1, 2
• The frequency of recurrences naturally decreases over time in many patients, making periodic reassessment important 3

Special Population: HIV-Infected Patients

For HIV-infected patients with CD4+ count ≥100 cells/mm³, the recommended suppressive dose is valacyclovir 500 mg twice daily. 3, 5

• HIV-infected patients may require higher doses due to increased viral replication 2
• Famciclovir 500 mg twice daily has been shown effective in decreasing both recurrence rates and subclinical shedding in HIV-infected patients 3

Transmission Reduction Strategy

For reduction of transmission to uninfected partners in discordant couples, valacyclovir 500 mg once daily is recommended for the source partner with a history of ≤9 recurrences per year. 5

• This indication is specifically for heterosexual, monogamous, immunocompetent couples discordant for HSV-2 infection 5
• Must be combined with counseling about safer sex practices, including condom use and abstinence during prodromal symptoms or active lesions 1, 2

Critical Pitfalls to Avoid

• Do not use topical acyclovir - it is substantially less effective than oral therapy and is not recommended 1, 2
• Avoid valacyclovir 8 grams per day in immunocompromised patients - associated with hemolytic uremic syndrome/thrombotic thrombocytopenic purpura 1, 6
• Monitor for treatment failure: If lesions do not begin to resolve within 7-10 days of appropriate therapy, suspect acyclovir resistance and consider IV foscarnet 40 mg/kg every 8 hours 1, 7

Patient Counseling Requirements

Patients on suppressive therapy must understand: 1, 2

• Antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences 1
• Asymptomatic viral shedding can still occur, potentially leading to transmission 1
• Abstain from sexual activity when lesions or prodromal symptoms are present 1, 2
• Inform sex partners about having genital herpes 1, 2
• Use condoms during all sexual exposures with new or uninfected partners 1, 2

Pregnancy Considerations

• Routine suppressive therapy is not recommended during pregnancy for recurrent genital herpes 1
• The safety of systemic acyclovir and valacyclovir in pregnancy has not been definitively established 1
• Pregnant women with genital herpes should inform their healthcare providers about the HSV infection 2