What is the treatment for post-exposure prophylaxis (PEP) of genital herpes?

Post-Exposure Prophylaxis for Genital Herpes

There is no established post-exposure prophylaxis regimen for genital herpes, as antiviral medications have not been shown to prevent HSV acquisition after exposure. 1, 2

Why PEP Is Not Recommended

• The CDC explicitly states that prophylaxis of initial episodes of HSV disease is not recommended, as there are no data indicating that antiherpesvirus medications can be taken as PEP to prevent HSV-2 acquisition 2
• Current infectious disease guidelines do not support the use of antiviral medications for primary prevention in individuals without HSV infection due to lack of evidence 2
• Unlike HIV or bacterial STIs where post-exposure prophylaxis has demonstrated efficacy, no similar evidence exists for herpes simplex virus 3

What Should Be Done Instead After Potential Exposure

Immediate prevention strategies focus on barrier methods and behavioral counseling, not medication:

• Consistent and correct use of latex condoms during every act of sexual intercourse significantly reduces the risk of HSV transmission 2
• Avoid sexual contact when herpetic lesions are evident on either partner 1, 2
• Counsel patients that asymptomatic viral shedding is common and can lead to transmission even without visible lesions 1

Treatment If Infection Develops

If a patient develops symptoms of primary genital herpes after exposure, treatment should be initiated within 72 hours of symptom onset:

First Episode Treatment

• Valacyclovir 1 gram orally twice daily for 7-10 days 1, 4
• Alternative: Acyclovir 400 mg orally three times daily for 7-10 days 1
• Treatment is most effective when started during the prodromal period or within 1 day after onset of lesions 1

Important Clinical Caveats

• The efficacy of treatment initiated more than 72 hours after onset of signs and symptoms has not been established 4
• Systemic antiviral drugs control symptoms but do not eradicate latent virus or prevent all future recurrences 1
• Patients must understand that antivirals are not a cure for genital herpes 4

Special Population Considerations

HIV-infected individuals on PrEP may have some incidental protection:

• Daily tenofovir disoproxil fumarate (TDF) was associated with a 30% reduced risk of HSV-2 seroconversion in heterosexual discordant partnerships 2
• However, this is not an indication for prescribing HIV PrEP solely for HSV prevention 2

Patient Education After Potential Exposure

• Inform patients that many cases of genital herpes are acquired from persons who do not know they have genital HSV or who are asymptomatic at the time of sexual contact 1
• Advise patients to inform healthcare providers who care for them during pregnancy about any HSV exposure or infection 1
• Counsel that sex partners of infected persons should be advised that they might be infected even if they have no symptoms 4
• Type-specific serologic testing of asymptomatic partners can determine whether risk for HSV-2 acquisition exists 4

Common Pitfalls to Avoid

• Do not prescribe antivirals prophylactically after exposure - there is no evidence this prevents infection and it subjects patients to unnecessary medication risks 2
• Do not delay treatment if symptoms develop - waiting beyond 72 hours significantly reduces treatment effectiveness 4
• Do not reassure patients that condoms provide complete protection - they only provide partial protection as HSV can be transmitted from areas not covered by condoms 2