How do you treat a healthy adult patient with Herpes Simplex Virus type 2 (HSV-2) without an active outbreak?

Treatment of HSV-2 Without Active Outbreak

Yes, you should treat HSV-2 without an active outbreak using daily suppressive antiviral therapy if the patient has frequent recurrences (≥6 episodes per year), wants to reduce transmission risk to sexual partners, or has significant psychosocial impact from the infection. 1, 2, 3

When Suppressive Therapy is Indicated

Daily suppressive therapy is recommended for:

• Frequent recurrences: Patients experiencing ≥6 outbreaks per year benefit most, with suppressive therapy reducing recurrence frequency by ≥75% 1, 2, 3
• Transmission reduction: Suppressive therapy reduces asymptomatic viral shedding and can decrease HSV-2 transmission to uninfected sexual partners by approximately 50% 2, 4
• HIV-infected patients: Higher doses and continuous suppressive therapy are recommended for HIV-positive individuals with HSV-2, even without frequent outbreaks, due to complex viral interactions 1, 3

Recommended Suppressive Regimens

First-line options include:

• Valacyclovir 500 mg once daily for patients with infrequent recurrences (<10 episodes/year) 1, 2, 3
• Valacyclovir 1000 mg once daily for patients with frequent recurrences (≥10 episodes/year) 1, 3
• Acyclovir 400 mg twice daily as an alternative option 5, 1, 2, 3
• Famciclovir 250 mg twice daily as another alternative 2, 3

For HIV-infected patients specifically:

• Valacyclovir 500 mg twice daily is the preferred regimen 1, 3

When Suppressive Therapy is NOT Routinely Indicated

You do not need to treat asymptomatic HSV-2 patients who:

• Have infrequent recurrences (<6 episodes per year) and prefer episodic treatment 1, 2
• Are not in a serodiscordant relationship where transmission prevention is a priority 2
• Have no history of symptomatic outbreaks and are not immunocompromised 1

Important Clinical Considerations

Duration and monitoring:

• After 1 year of continuous suppressive therapy, consider discontinuation to reassess the patient's natural recurrence rate 5, 2
• No laboratory monitoring is needed unless the patient has substantial renal impairment 5, 2
• Dose adjustment is required for patients with renal dysfunction 6

Limitations of suppressive therapy:

• Does not completely eliminate asymptomatic viral shedding or transmission potential 5, 1
• Does not eradicate latent virus 2
• Acyclovir-resistant strains can develop but are rarely associated with treatment failure in immunocompetent patients 5

Critical Counseling Points

All patients with HSV-2 should receive comprehensive counseling:

• Asymptomatic viral shedding occurs and transmission can happen even without visible lesions 5, 3
• Consistent condom use reduces transmission risk by approximately 50% and should be encouraged 5, 2
• Partners should be tested using type-specific serology and counseled about transmission risks 5, 3
• Patients should abstain from sexual activity when prodromal symptoms or lesions are present 5, 3

Special Population: Pregnancy

For pregnant women with a history of genital herpes:

• Suppressive therapy is NOT routinely recommended before 36 weeks gestation if there are no recent or current outbreaks 1
• Starting at 36 weeks gestation, consider acyclovir prophylaxis to reduce HSV shedding at delivery and decrease the need for cesarean delivery 1, 7
• Acyclovir is the preferred agent in pregnancy based on decades of safety data 1, 3

Common Pitfalls to Avoid

• Do not use short-course therapy (1-3 days) in HIV-infected patients, as it is ineffective 5
• Do not rely on topical acyclovir, which is substantially less effective than systemic therapy 2
• Do not assume treatment prevents all transmission—counsel patients that suppressive therapy reduces but does not eliminate transmission risk 5, 1
• Do not forget to adjust doses in patients with renal impairment to prevent toxicity 5, 2