Do you treat an asymptomatic patient with a confirmed Herpes Simplex Virus type 2 (HSV-2) infection?

Treatment of Asymptomatic HSV-2 Infection

Asymptomatic immunocompetent patients with HSV-2 do not require routine antiviral treatment unless they are at risk of transmitting infection to sexual partners or are HIV-positive. 1

Treatment Decision Framework

Immunocompetent Patients Without HIV

The CDC explicitly states that asymptomatic immunocompetent individuals have no indication for routine antiviral treatment unless transmission risk to partners exists. 1 This represents the standard approach for the majority of asymptomatic HSV-2 patients.

Key considerations for treatment:

• Transmission risk to partners: If the patient has a sexual partner who is HSV-2 seronegative, suppressive therapy should be offered to reduce transmission risk by approximately 48-50%. 1, 2
• Patient counseling is mandatory: All asymptomatic patients must be informed about the natural history of disease, potential for recurrent episodes, asymptomatic viral shedding (which occurs in 72% of seropositive individuals), and sexual transmission risk. 1, 3
• Asymptomatic shedding occurs frequently: Even without symptoms, HSV-2 seropositive persons shed virus in genital secretions approximately 3% of days, at rates similar to symptomatic patients. 3

HIV-Positive Patients

HIV-infected individuals with HSV-2 should receive treatment regardless of symptoms. 1 The CDC recommends routine type-specific serologic HSV-2 testing for all HIV-positive individuals due to significant interactions between HIV and HSV-2. 4

• HIV-positive patients may require intermittent or suppressive oral antiviral therapy due to more frequent, severe, and prolonged lesions. 1
• Increased dosing is beneficial for immunocompromised patients (e.g., acyclovir 400 mg orally 3-5 times daily). 1
• Management should consider frequency and severity of HSV recurrences, transmission risk to partners, and potential for HSV-2 to increase HIV viral load in plasma and genital secretions. 4

Suppressive Therapy Regimen for Transmission Prevention

When treatment is indicated for transmission prevention in immunocompetent patients:

• Valacyclovir 500 mg once daily is the evidence-based regimen that reduces HSV-2 transmission to susceptible heterosexual partners by 48-50%. 5, 1, 2
• This approach applies to heterosexual couples, MSM, women who have sex with women, and transgender persons, as the mechanism works through suppression of viral shedding. 4
• Important caveat: Suppressive therapy is NOT effective for decreasing transmission risk among persons with HIV/HSV-2 coinfection to their partners. 4

Essential Counseling Components

Even when treatment is not initiated, comprehensive counseling is required:

• Sexual transmission occurs during asymptomatic shedding periods, which is when most transmissions actually occur. 5, 2
• Partners should avoid sexual contact when visible genital or orolabial lesions are present, though this alone does not eliminate transmission risk. 5, 6
• Consistent latex condom use reduces HSV-2 acquisition and should be encouraged for all sexual exposures. 5, 6
• Transmission can occur even when using condoms AND suppressive therapy together—neither strategy provides complete protection. 5
• Sexual partners of infected persons should be advised they might be infected even without symptoms and should consider type-specific serologic testing. 6, 2

Special Populations

Pregnancy

• The safety of systemic acyclovir treatment during pregnancy is not fully established. 1
• Women of childbearing age should inform healthcare providers about HSV infection during pregnancy. 1

Partners of Asymptomatic Patients

• HSV-2 seronegative partners should request that the infected partner undergo type-specific serologic testing before initiating sexual activity. 6
• If confirmed HSV-2 positive, the infected partner should initiate suppressive valacyclovir 500 mg daily. 6
• Asymptomatic partners should be questioned about history of typical and atypical genital lesions and encouraged to self-examine for future lesions. 1

Common Pitfalls to Avoid

• Do not assume asymptomatic means non-infectious: 72% of HSV-2 seropositive individuals who report no history of genital herpes still shed virus genitally. 3
• Do not use short-course therapy (1-3 days) in HIV-infected patients if treatment becomes necessary for symptomatic episodes. 4
• Do not prescribe routine treatment for asymptomatic immunocompetent patients without documented transmission risk—this represents overtreatment. 1
• Do not rely solely on condoms or avoiding sex during lesions—most transmissions occur during asymptomatic periods through subclinical shedding. 5, 7