Clinical Manual for Management of the HIV-Infected ... - myCME.com

6–46 | Clinical Manual for Management of the HIV-Infected Adult/2006
Treatment
Empiric treatment for suspicious lesions is often
initiated in the absence of laboratory confirmation. In
some instances, treatment can be started empirically
and, if no response is seen within 7-10 days, laboratory
studies could be undertaken.
Episodic outbreak
♦ Acyclovir (Zovirax) can be given 400 mg orally
3 times daily or 200 mg orally 5 times daily until
ulcers heal, usually within 5-10 days. This treatment
helps the healing of lesions but does not prevent
recurrences. Large, extensive ulcers may need to be
treated for a longer period of time.
♦
♦
Famciclovir (Famvir) 500 mg orally for 5-10 days is
another option but is more expensive than acyclovir.
Valacyclovir (Valtrex) 1,000 mg orally twice daily for
5-10 days is also more expensive than acyclovir.
Adjust the dosage for renal impairment.
Severe disease
♦ Treat initially with intravenous acyclovir.
Acyclovir-resistant HSV
♦ The diagnosis of acyclovir-resistant HSV should
be confirmed with culture and sensitivities. Crossresistance
to famciclovir, valacyclovir, and ganciclovir
will be present as well. The usual alternative is
foscarnet (40 mg/kg every 8 hours intravenously);
other possibilities include topical trifluridine and
topical cidofovir.
Chronic suppressive therapy
♦ Consider suppressive therapy with acyclovir (400-
800 mg orally 2-3 times daily), famciclovir (500
mg orally twice daily), or valacyclovir (500 mg
orally twice daily) for patients with frequent or
severe recurrences. Treatment should be continued
indefinitely. Note that suppressive therapy also
reduces the risk of transmission of HSV.
HSV during Pregnancy
Acyclovir appears to be safe and effective for use by
pregnant women. Few data are available on valacyclovir
and famciclovir during pregnancy.
It is important to avoid peripartum transmission of
HSV. For women with recurrent or new genital HSV
late in pregnancy, obstetric and/or infectious disease
specialists should be consulted. All women should be
evaluated carefully for symptoms or signs of genital
HSV.
Patient Education
♦
♦
♦
♦
♦
Patients should be told that HSV has no cure, and
outbreaks may occur at intervals for the rest of their
lives.
HSV is easily spread through kissing (if mouth
or lips are infected) and sexual contact (oral, anal,
or vaginal). HSV is often is transmitted when no
lesions are present, so it is important that patients
inform their sex partners of their herpes infection
before sex. Patients must avoid all sexual contact
while lesions are visible, because a lot of virus is
present at those times. Condom use at each sexual
encounter offers the best chance of preventing HSV
transmission. If HSV is transmitted, sexual partners
also will have it for life.
Instruct patients to avoid use of occlusive dressings
or ointments, which can prevent healing of sores.
Treatment is most effective when taken early in the
outbreak, so patients not taking suppressive therapy
should keep medication on hand and start treatment
at the first signs of eruption.
Genital HSV in a pregnant woman around the time
of delivery can cause severe illness in the newborn.
Women must inform their obstetricians and
pediatricians if they have a history of HSV or are
exposed to or infected with HSV during pregnancy.
Pregnant women who do not have HSV should
avoid having sex with partners who have HSV, and
men who have HSV should avoid having sex with
pregnant women who do not have HSV.