• New York State Department of Health. Genital herpes simplex virus (HSV). New York (NY): New York State Department of Health; 2007 Oct. 9 p. [24 references]

This is the current release of the guideline.

• Human immunodeficiency virus (HIV) infection
• Genital herpes simplex virus (HSV) infection

Diagnosis
Evaluation
Management
Prevention
Treatment

Allergy and Immunology
Family Practice
Infectious Diseases
Internal Medicine
Obstetrics and Gynecology

Advanced Practice Nurses
Health Care Providers
Physician Assistants
Physicians
Public Health Departments

To provide guidelines for diagnosis and treatment of genital herpes simplex virus (HSV) infection in human immunodeficiency virus (HIV)-infected patients

Human immunodeficiency virus (HIV)-infected patients with genital herpes simplex virus (HSV) coinfection

Diagnosis/Evaluation

1. Physical examination and assessment of lesions
2. Diagnostic confirmation by culture or histologic or pathologic examination

Management/Treatment/Prevention

1. Antiviral treatment (e.g., acyclovir, valacyclovir, famciclovir)
2. Obtaining drug-susceptibility tests if indicated
3. Referral to a human immunodeficiency virus (HIV) or Infectious Disease Specialist
4. Transmission prevention including patient education about the use of latex condoms, the frequency of HSV reactivation, and the increased risk of HIV transmission
5. Management of sex partners including assistance with partner notification, management of HIV and HSV exposure

Effectiveness of treatment

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Not stated

Not stated

Expert Consensus (Committee)

Not applicable

Review

Not stated

Expert Consensus

AIDS Institute clinical guidelines are developed by distinguished committees of clinicians and others with extensive experience providing care to people with HIV infection. Committees* meet regularly to assess current recommendations and to write and update guidelines in accordance with newly emerging clinical and research developments.

The Committees* rely on evidence to the extent possible in formulating recommendations. When data from randomized clinical trials are not available, Committees rely on developing guidelines based on consensus, balancing the use of new information with sound clinical judgment that results in recommendations that are in the best interest of patients.

* Current committees include:

• Medical Care Criteria Committee
• Committee for the Care of Children and Adolescents with HIV Infection
• Dental Standards of Care Committee
• Mental Health Committee
• Women's Health Committee
• Substance Use Committee
• Physician's Prevention Advisory Committee
• Pharmacy Committee

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review

All guidelines developed by the Committee are externally peer reviewed by at least two experts in that particular area of patient care, which ensures depth and quality of the guidelines.

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.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

Appropriate diagnosis and management of genital herpes simplex virus (HSV) infection in human immunodeficiency virus (HIV)-infected patients

Not stated

The AIDS Institute's Office of the Medical Director directly oversees the development, publication, dissemination and implementation of clinical practice guidelines, in collaboration with The Johns Hopkins University, Division of Infectious Diseases. These guidelines address the medical management of adults, adolescents and children with HIV infection; primary and secondary prevention in medical settings; and include informational brochures for care providers and the public.

Guidelines Dissemination

Guidelines are disseminated to clinicians, support service providers and consumers through mass mailings and numerous AIDS Institute-sponsored educational programs. Distribution methods include the HIV Clinical Resource website, the Clinical Education Initiative, the AIDS Educational Training Centers (AETC) and the HIV/AIDS Materials Initiative. Printed copies of clinical guidelines are available for order from the New York State Department of Health (NYSDOH) Distribution Center for providers who lack internet access.

Guidelines Implementation

The HIV Clinical Guidelines Program works with other programs in the AIDS Institute to promote adoption of guidelines. Clinicians, for example, are targeted through the Clinical Education Initiative (CEI) and the AIDS Education and Training Centers (AETC). The CEI provides tailored educational programming on site for health care providers on important topics in HIV care, including those addressed by the HIV Clinical Guidelines Program. The AETC provides conferences, grand rounds and other programs that cover topics contained in AIDS Institute guidelines.

Support service providers are targeted through the HIV Education and Training initiative which provides training on important HIV topics to non-physician health and human services providers. Education is carried out across the State as well as through video conferencing and audio conferencing.

The HIV Clinical Guidelines Program also works in a coordinated manner with the HIV Quality of Care Program to promote implementation of HIV guidelines in New York State. By developing quality indicators based on the guidelines, the AIDS Institute has created a mechanism for measurement of performance that allows providers and consumers to know to what extent specific guidelines have been implemented.

Finally, best practices booklets are developed through the HIV Clinical Guidelines Program. These contain practical solutions to common problems related to access, delivery or coordination of care, in an effort to ensure that HIV guidelines are implemented and that patients receive the highest level of HIV care possible.

Living with Illness
Staying Healthy

Effectiveness
Patient-centeredness

• New York State Department of Health. Genital herpes simplex virus (HSV). New York (NY): New York State Department of Health; 2007 Oct. 9 p. [24 references]

Not applicable: The guideline was not adapted from another source.

2007 Oct

New York State Department of Health - State/Local Government Agency [U.S.]

New York State Department of Health

Not stated

Not stated

Not stated

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI Institute on October 31, 2007.