Treatment of HSV-2 in HIV-Infected Patients

Introduction to Treatment

The Centers for Disease Control and Prevention recommends higher doses and longer duration of antiviral therapy for HIV-infected patients with HSV-2, with valacyclovir 500 mg twice daily as the preferred suppressive regimen 1, 2

For first-episode genital herpes in HIV-infected patients, the Centers for Disease Control and Prevention recommends regimens including acyclovir 400 mg orally three times daily for 7-10 days, acyclovir 200 mg orally five times daily for 7-10 days, famciclovir 250 mg orally three times daily for 7-10 days, and valacyclovir 1 g orally twice daily for 7-10 days 1, 2
Treatment may be extended if healing is incomplete after 10 days of therapy, as recommended by the Centers for Disease Control and Prevention 2
For severe mucocutaneous HSV lesions requiring hospitalization, the Centers for Disease Control and Prevention recommends intravenous acyclovir as first-line therapy until lesions begin to regress, then transition to oral therapy 1, 2

For recurrent episodes in HIV-infected patients, the Centers for Disease Control and Prevention recommends regimens including acyclovir 400 mg orally three times daily for 5-10 days and valacyclovir 500 mg orally twice daily for 5-10 days 2, 3
Short-course therapy (1-3 days) should not be used in patients with HIV infection, as recommended by the Centers for Disease Control and Prevention 2, 3

The Centers for Disease Control and Prevention recommends suppressive therapy for HIV-infected patients who have frequent or severe recurrences 1, 2
The recommended suppressive regimen for HIV-infected patients is valacyclovir 500 mg twice daily, as recommended by the Centers for Disease Control and Prevention 1, 2, 3
Daily suppressive therapy in HIV-infected persons results in a decrease in HIV concentration in plasma and anal and genital secretions, according to the Centers for Disease Control and Prevention 2

Treatment failure related to resistance should be suspected if lesions do not begin to resolve within 7-10 days after initiation of therapy, as recommended by the Centers for Disease Control and Prevention 2, 4
Among immunocompromised patients with suspected acyclovir-resistant HSV, viral culture of the lesion should be obtained and, if virus is isolated, susceptibility testing performed to confirm drug resistance, according to the Centers for Disease Control and Prevention 4
The treatment of choice for acyclovir-resistant HSV is IV foscarnet, as recommended by the Centers for Disease Control and Prevention 4

No laboratory monitoring is needed in patients receiving episodic or suppressive therapy unless the patient has substantial renal impairment, according to the Centers for Disease Control and Prevention 4
For patients receiving high-dose IV acyclovir, monitoring of renal function and dose adjustment as necessary are recommended at initiation of treatment and once or twice weekly for the duration of treatment, as recommended by the Centers for Disease Control and Prevention 4
Acyclovir, valacyclovir, and famciclovir are occasionally associated with nausea or headache, according to the Centers for Disease Control and Prevention 4

HIV-infected patients receiving antiretroviral therapy who have immune reconstitution often experience improvement in the frequency and severity of their clinical episodes of genital herpes, according to the Centers for Disease Control and Prevention 4
Routine type-specific serologic testing for HSV-2 should be considered in persons who seek HIV care, as recommended by the Centers for Disease Control and Prevention 2
Diagnosis of HSV-2 should be accompanied by counseling that discusses the risk for transmission of infection to sex partners, according to the Centers for Disease Control and Prevention 2
Consistent use of latex condoms should be encouraged for prevention of transmission of HSV-2 and other sexually transmitted pathogens, as recommended by the Centers for Disease Control and Prevention 2, 3