What is the recommended treatment for asymptomatic herpes simplex virus (HSV) infection?

Treatment for Asymptomatic HSV Infection

For asymptomatic HSV-2 infection, suppressive antiviral therapy should be offered to reduce transmission risk to sexual partners, while asymptomatic HSV-1 infection typically does not require treatment unless the patient has a known HSV-2 seropositive partner or desires transmission risk reduction. 1

HSV-2: Asymptomatic Infection Management

When to Offer Suppressive Therapy

Approximately 20% of HSV-2 seropositive persons do not recognize genital symptoms, yet they can still transmit the virus through asymptomatic viral shedding. 1

Suppressive therapy is recommended for asymptomatic HSV-2 infection when:

• The patient has a sexual partner who is HSV-2 seronegative and wishes to reduce transmission risk 1
• The patient desires to reduce asymptomatic viral shedding 1
• The patient is in a heterosexual serodiscordant relationship (suppressive therapy reduces transmission by approximately 50% in this population) 1

Recommended Suppressive Regimens for Asymptomatic HSV-2

First-line options include:

• Valacyclovir 500 mg orally once daily 2, 3
• Valacyclovir 1 g orally once daily 4, 3
• Acyclovir 400 mg orally twice daily 4, 3
• Famciclovir 250 mg orally twice daily 4, 3

Important Caveats for Suppressive Therapy

Suppressive therapy does not completely eliminate transmission risk. Patients must understand that asymptomatic viral shedding can still occur despite daily medication, and consistent condom use should be encouraged during all sexual exposures. 1, 3

Suppressive therapy is NOT effective for preventing transmission in HIV/HSV-2 coinfected persons. 1 This is a critical distinction, as the mechanism of viral suppression differs in immunocompromised hosts.

For men who have sex with men, women who have sex with women, and transgender persons: Suppressive therapy can be considered to prevent transmission, as the mechanism works through suppression of viral shedding regardless of sexual orientation or gender identity. 1

HSV-1: Asymptomatic Infection Management

General Approach

Asymptomatic HSV-1 infection typically does not require treatment. 2 HSV-1 causes less frequent asymptomatic viral shedding compared to HSV-2, and the transmission risk during asymptomatic periods is substantially lower. 2

Consider suppressive therapy for asymptomatic HSV-1 only when:

• The patient has a sexual partner with known HSV-2 infection and desires additional protection 1
• The patient specifically requests treatment to reduce already-low transmission risk 2

If suppressive therapy is chosen for HSV-1, use the same regimens as for HSV-2 (valacyclovir 500 mg to 1 g daily, acyclovir 400 mg twice daily, or famciclovir 250 mg twice daily). 2

Counseling Requirements for Asymptomatic Patients

All asymptomatic HSV-infected persons must receive comprehensive counseling:

• Explain that asymptomatic viral shedding occurs and transmission can happen without visible lesions 1, 3
• Emphasize that HSV-2 sheds asymptomatically more frequently than HSV-1 1, 2
• Discuss the chronic, incurable nature of HSV infection 4, 3
• Recommend consistent condom use with all sexual partners, particularly new or uninfected partners 1
• Advise patients to inform sexual partners about their HSV status 1, 4
• Explain the risk of neonatal infection to all patients, including men 1

When NOT to Screen or Treat

The U.S. Preventive Services Task Force recommends against screening for HSV-2 in asymptomatic persons with low pretest probability (few lifetime sexual partners, no known HSV-2 seropositive partners, no genital symptoms). 1 This means that incidentally discovered asymptomatic HSV-2 infection in low-risk individuals may not warrant treatment unless transmission prevention is specifically desired.

Screening of pregnant women for asymptomatic HSV is not recommended. 1 However, if a pregnant woman is known to be HSV-2 seropositive, different management considerations apply during pregnancy.

Common Pitfalls to Avoid

• Never use topical acyclovir for any HSV management—it is substantially less effective than oral therapy. 2, 4, 3
• Do not assume suppressive therapy eliminates all transmission risk—patients must continue safer sex practices. 1
• Do not prescribe suppressive therapy to HIV/HSV-2 coinfected persons for transmission prevention—it has been proven ineffective in this population. 1
• After 1 year of continuous suppressive therapy, reassess the need for continuation to evaluate the patient's psychological adjustment and ongoing transmission risk. 1, 4