What is the appropriate treatment for an acute genital herpes outbreak in a 5‑month pregnant patient living with HIV?

Treatment of Genital Herpes in a 5-Month Pregnant Patient Living with HIV

For an acute genital herpes outbreak in a pregnant patient with HIV at 5 months gestation, treat with oral acyclovir 400 mg three times daily for 7-10 days, using higher doses and longer duration than in HIV-negative patients. 1

Treatment Regimen for Acute Outbreak

First-line therapy options for this acute episode include:

• Acyclovir 400 mg orally three times daily for 7-10 days 1
• Acyclovir 200 mg orally five times daily for 7-10 days 1
• Valacyclovir 1 g orally twice daily for 7-10 days 1

Key modifications for HIV-positive patients:

• Use higher doses and longer treatment duration compared to HIV-negative pregnant women 1
• Extend treatment beyond 10 days if healing is incomplete 1
• Do NOT use short-course therapy (1-3 days), as it is ineffective in HIV-infected patients 1

Safety in Pregnancy

Acyclovir is the preferred first-choice antiviral for HSV infections during pregnancy:

• No pattern of adverse pregnancy outcomes has been documented after acyclovir exposure 2, 1
• Decades of safety data support its use throughout all trimesters 1
• The CDC registry shows no increased risk of major birth defects compared to the general population 3

Suppressive Therapy Considerations

After the acute outbreak resolves, consider suppressive therapy starting at 36 weeks gestation:

• Valacyclovir 500 mg twice daily is the recommended suppressive regimen for HIV-infected pregnant women 1
• Alternative: Acyclovir 400 mg twice daily 1
• Suppressive therapy starting at 36 weeks reduces HSV shedding at delivery and decreases cesarean delivery rates 1, 4

For patients with frequent, severe recurrences before 36 weeks:

• Acyclovir prophylaxis might be indicated even earlier in pregnancy 2
• This decision should be based on documented history of frequent or severe recurrent genital HSV disease 1

Monitoring and Follow-up

Clinical monitoring requirements:

• Monitor renal function at treatment initiation if the patient has substantial renal impairment 1
• Assess lesion healing at 7-10 days; if lesions do not begin to resolve, suspect acyclovir resistance 1
• For suspected resistance, perform viral culture and susceptibility testing 1

Treatment of acyclovir-resistant HSV:

• IV foscarnet is the treatment of choice for acyclovir-resistant HSV 1
• This is more common in HIV-infected patients and may require expert consultation 5

Delivery Planning

At labor onset, perform careful examination:

• If visible genital lesions or prodromal symptoms are present, cesarean delivery is mandatory regardless of prior suppressive therapy 1
• If no lesions or prodrome, vaginal delivery is permitted 1
• The primary goal is preventing neonatal transmission, which occurs mainly through maternal genital shedding at delivery 1

Critical Pitfalls to Avoid

Common errors in management:

• Do not use short-course therapy in HIV-infected patients—it is ineffective 1
• Do not assume suppressive therapy eliminates all transmission risk; asymptomatic viral shedding still occurs 1
• Do not forget to adjust doses in patients with renal impairment to prevent toxicity 1
• Do not delay treatment initiation; begin at the first sign of lesions to maximize effectiveness 1

Patient Counseling

Essential counseling points:

• Explain the chronic nature of HSV infection with potential for recurrent episodes 3
• Advise abstaining from sexual activity when lesions or prodromal symptoms are present 2, 1
• Emphasize that consistent condom use reduces transmission risk by approximately 50% 1
• Discuss the importance of suppressive therapy at 36 weeks to reduce neonatal transmission risk 1, 4