What are the consequences for a patient with genital herpes if they opt not to take acyclovir (antiviral medication)?

Consequences of Not Taking Acyclovir for Genital Herpes

If you opt not to take acyclovir for genital herpes, you will experience longer duration of symptoms, prolonged viral shedding with increased transmission risk to partners, delayed healing of lesions, and potentially more severe disease—particularly during first episodes.

Natural Course Without Treatment

First Episode (Initial Infection)

Without acyclovir treatment, patients with first-episode genital herpes experience significantly prolonged disease:

• Viral shedding continues for a median of 8 days (versus 1 day with treatment) 1, 2
• Pain and symptoms persist for approximately 4.5 days (versus 3.5 days with treatment) 2
• Time to crusting extends to 9 days (versus 3.5 days with treatment) 2
• Complete healing takes 11 days (versus 5.5 days with treatment) 2
• New lesion formation continues throughout the untreated episode 1, 2

The first clinical episode may manifest as extensive disease requiring hospitalization in some cases 3.

Recurrent Episodes

For recurrent genital herpes without treatment:

• Viral shedding lasts a median of 2.5 days (versus 0.5 days with treatment) 2
• Complete healing requires 7 days (versus 5 days with treatment) 2
• Recurrence frequency remains unchanged at baseline rates, typically averaging 1.1 episodes per 28 days in patients with frequent recurrences 4
• Most immunocompetent patients with recurrent disease do not benefit substantially from episodic treatment unless initiated during prodrome or within 2 days of lesion onset 3

Transmission Risk to Partners

Without antiviral therapy, you pose a significantly higher transmission risk to sexual partners:

• Prolonged viral shedding (8 days versus 1 day for first episodes) increases the window of infectivity 1, 2
• Asymptomatic viral shedding continues between clinical episodes, and many cases are acquired from persons who don't know they have genital HSV infection or were asymptomatic at time of contact 3
• Sex partners of patients with genital herpes benefit from evaluation and counseling, as most persons with genital HSV infection do not have a history of typical genital lesions 3

Long-Term Implications

Without Suppressive Therapy (for Frequent Recurrences)

If you have frequent recurrences (≥6 per year) and opt not to take daily suppressive acyclovir:

• Recurrence frequency remains at baseline (approximately 1.1 episodes per 28 days) 4
• Daily suppressive therapy reduces recurrence frequency by at least 75% (to approximately 0.11 episodes per 28 days during treatment) 3, 4
• After stopping suppressive therapy, recurrence rates decrease to 0.71 per 28 days—still significantly less than pre-treatment rates 4

Important caveat: Acyclovir neither eradicates latent virus nor affects subsequent risk, frequency, or severity of recurrences after the drug is discontinued 3. Suppressive treatment does not totally eliminate symptomatic or asymptomatic viral shedding or the potential for transmission 3.

Special Population Risks

Immunocompromised Patients

Without treatment, immunocompromised patients face severe consequences:

• Prolonged and/or severe episodes of genital or perianal herpes 3
• Lesions may be severe, painful, and atypical 3
• Higher risk of disseminated infection, encephalitis, or pneumonitis 3
• Potential for chronic ulcerations with persistent viral replication 5

Pregnancy

The first clinical episode during pregnancy may be treated with oral acyclovir, though safety in pregnant women has not been definitively established 3. Current registry findings do not indicate increased risk for major birth defects after acyclovir treatment compared with the general population 3.

Quality of Life Impact

Choosing not to treat means accepting:

• Prolonged pain and discomfort lasting days longer than necessary 1, 2
• Extended time away from sexual activity due to active lesions and transmission risk
• Psychological burden of knowing you're infectious for longer periods
• Delayed return to normal activities due to slower healing 1, 2

Common Pitfall to Avoid

The most critical mistake is delaying the decision about treatment. For first episodes, acyclovir is most effective when initiated within the first 3 days of symptom appearance 6. Waiting to decide whether to treat effectively removes the option for optimal benefit, as the therapeutic window narrows rapidly.