HSV-2 Outbreak Management

Treatment Overview

The Centers for Disease Control and Prevention recommends initiating oral antiviral therapy immediately with valacyclovir 1 gram twice daily for 7-10 days for first episodes, or valacyclovir 500 mg twice daily for 5 days for recurrent episodes, starting treatment within 24 hours of symptom onset for maximum effectiveness 1, 2

For first clinical episodes, the Centers for Disease Control and Prevention recommends valacyclovir 1 g orally twice daily for 7-10 days, acyclovir 400 mg orally three times daily for 7-10 days, acyclovir 200 mg orally five times daily for 7-10 days, or famciclovir 250 mg orally three times daily for 7-10 days 3, 1
For recurrent episodes, the Centers for Disease Control and Prevention recommends valacyclovir 500 mg orally twice daily for 5 days, valacyclovir 1 g orally once daily for 5 days, acyclovir 400 mg orally three times daily for 5 days, or acyclovir 800 mg orally twice daily for 5 days 3, 2

For HIV-infected patients, the Centers for Disease Control and Prevention recommends longer treatment courses, and does not recommend short-course therapy (1-3 days) 4, 3, 1
For pregnant women, the American College of Obstetricians and Gynecologists recommends acyclovir as first-choice therapy, and considers suppressive therapy starting at 36 weeks gestation to reduce viral shedding at delivery 1, 5

The Centers for Disease Control and Prevention recommends obtaining viral culture and HSV susceptibility testing for suspected treatment failure, and using IV foscarnet 40 mg/kg every 8 hours for confirmed acyclovir-resistant HSV 1, 2

The American Academy of Family Physicians recommends pain control strategies, including NSAIDs, acetaminophen, topical lidocaine, and sitz baths 5

The Centers for Disease Control and Prevention recommends educating patients that HSV-2 is not curable, and that asymptomatic viral shedding occurs and transmission can happen without visible lesions 3, 1
The American College of Physicians recommends counseling patients to abstain from sexual activity when lesions or prodromal symptoms are present, and to use condoms consistently during all sexual exposures to reduce transmission risk 3, 1