Diagnosis
Clinicians should diagnose typical genital herpes through the presence of consistent clinical findings upon examination. Diagnosis of chronic nonhealing ulcerated herpes simplex or atypical lesions should be confirmed by culture or either histologic or pathologic examination. Recurrences do not require laboratory confirmation.
Clinicians should exclude coinfection with another pathogen, such as syphilis, when a recurring lesion is atypical.
Treatment
Acyclovir, valacyclovir, or famciclovir should be used to treat herpes simplex virus (HSV). Specific dosing recommendations and caveats are listed in Table 1 of the original guideline document.
Clinicians should consider the possibility of antiviral resistance if herpetic lesions fail to heal with standard antiviral therapy. Nonadherence and poor absorption should also be considered. The clinician should refer the patient to a human immunodeficiency virus (HIV) or Infectious Disease Specialist when acyclovir-resistant HSV is suspected.
Acyclovir-Resistant HSV
Clinicians should obtain HSV drug-susceptibility tests, if available, when patients receiving antiviral treatment have persistent or recurrent HSV lesions.
Prevention of Transmission
Clinicians should educate HIV/HSV coinfected patients with genital herpes about the following:
- The use of latex condoms to decrease the risk of transmission, including the risk of superinfection if the partner has one or both viruses
- The significance of the role of genital HSV infection in potentiating the spread of HIV even in the absence of clinically apparent ulcers and during chronic suppressive therapy
- The frequency of potentially infectious viral HSV reactivation even in the absence of clinically apparent ulcers
- Viral HSV shedding and infectivity are decreased but not eradicated with chronic suppressive therapy
Prevention of HIV Transmission
Key Point:
The risk of HIV transmission by patients coinfected with genital ulcer disease is increased by 2 to 6 times because of increased levels of HIV virus in semen and vaginal secretions. Conversely, genital ulcers in non-HIV-infected patients disrupt the genital tract lining or skin, which creates a direct entry for HIV.
Management of Sex Partners
Clinicians should consider both the HIV exposure and the sexually transmitted infection (STI) exposure to partners when HIV-infected patients present with a new STI. Clinicians should also assess for the presence of other STIs.
Management of HIV Exposure
When HIV-infected patients present with a new STI, clinicians should encourage their partner(s) to undergo HIV testing at baseline, 1, 3, and 6 months. In New York State, if the test result is positive, a Western blot assay must be performed to confirm diagnosis of HIV infection.
Clinicians should be vigilant for any post-exposure acute febrile illness accompanied by rash, lymphadenopathy, myalgias, and/or sore throat. If the partner presents with signs or symptoms of acute HIV seroconversion, a quantitative ribonucleic acid polymerase chain reaction (RNA PCR) should be obtained, and consultation with an HIV Specialist should be sought. Positive RNA tests should be confirmed with HIV antibody testing performed within 6 weeks of the RNA test.
Clinicians should offer assistance with partner notification if needed.
Management of HSV Exposure
Clinicians should counsel patients to inform all sex partners of their HSV exposure and should educate HSV-infected patients about the risk of transmission to their sex partner(s), including the risk of superinfection if both partners are infected with HSV or HIV.
Sex partners who are symptomatic for genital herpes should be treated or referred for treatment.
