Sexually Transmissible Infections in Clinical Practice

17. A Woman with Recurrent Genital Herpes

Alexander McMillan1, 2  

(1)

Department of Genitourinary Medicine, NHS Lothian, Edinburgh Royal Infirmary, Edinburgh, Uk

(2)

University of Edinburgh, Edinburgh, Uk

Alexander McMillanFormerly, Consultant Physician, part-time Senior Lecturer

Email: a.amcmm@btinternet.com

Abstract

Carol (discussed in Case 16) attends you again some 2 years after the episode of primary genital herpes. She has become increasingly distressed by frequent recurrences of genital herpes – she has had about eight episodes in the past year. She understands that drugs are available for the treatment of recurrences but she is anxious to avoid taking medication unless it is considered necessary. Carol also is concerned that the virus could become resistant to the drugs should she use these regularly. She separated from Mark about 6 months previously, but she has recently met a man – William – with whom she would like to develop a relationship. Carol is most anxious that William who does not know that she has genital herpes does not become infected.

Carol (discussed in Case 16) attends you again some 2 years after the episode of primary genital herpes. She has become increasingly distressed by frequent recurrences of genital herpes – she has had about eight episodes in the past year. She understands that drugs are available for the treatment of recurrences but she is anxious to avoid taking medication unless it is considered necessary. Carol also is concerned that the virus could become resistant to the drugs should she use these regularly. She separated from Mark about 6 months previously, but she has recently met a man – William – with whom she would like to develop a relationship. Carol is most anxious that William who does not know that she has genital herpes does not become infected.

17.1 What Management Options Are Available for the Treatment of Recurrent Genital Herpes?

An approach to the management of the immunocompetent patient with recurrent genital herpes is shown in Fig. 17.1. Management, however, must be tailored to the needs of the individual and whose wishes must be taken into consideration.

I.

II.

III.

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Figure 17.1.

An approach to the patient with recurrent genital herpes.

Table 17.1.

Drug regimens for the episodic treatment of recurrent genital herpes.

Aciclovir 800 mg three times per day for 2 days

OR

Valaciclovir 500 mg twice daily for 3 days

OR

Famciclovir 1000 mg twice daily for 1 day

Table 17.2.

Drug regimens used as suppressive therapy for frequently recurring genital herpes.

Aciclovir 400 mg twice daily by mouth

OR

Aciclovir 200 mg four times per day by mouth

OR

Valaciclovir 500 or 1000 mg once daily by mouth

OR

Valaciclovir 250 mg twice daily by mouth

OR

Famciclovir 250 mg twice daily by mouth

Carol decides that she will initiate suppressive treatment with aciclovir 400 mg twice daily. She is reassured to learn that there are few side effects – nausea, headache, and skin rash are unusual adverse events – and she is also relieved to learn that viral resistance to aciclovir is rare in the immunocompetent person. Aciclovir-resistant HSV is well recognized in the context of an immunocompromised infected individual.

Suppressive treatment for a short period of time is sometimes used in patients who wish to avoid recurrence at a particularly stressful time. For example, students who are studying for important examinations and have infrequent but distressing recurrences may benefit.

17.2 What Steps Can Be Taken to Prevent Transmission of Infection to William?

Unfortunately, vaccines for the prevention of acquisition of HSV are not available. There should be abstinence from sexual intercourse during symptomatic recurrence or during the prodrome, if any. As has been noted previously, transmission of infection can occur from individuals who are apparently symptomless. A sizeable proportion of people who have minor recurrent lesions can be taught to recognize these, and hence can avoid intercourse at that time. Consistent condom use by an infected male is considered to reduce the acquisition of HSV-2 by a female. There is no evidence that the risk of transmission from a female to a male is reduced; there is also no evidence that the use of the female condom reduces risk of transmission of the virus. Antiviral drugs reduce symptomatic and symptomless viral shedding, and it has been shown that during suppressive therapy with valaciclovir, the risk of transmission of HSV-2 to a sexual partner is reduced.

Carol consults you 3 months after initiation of suppressive therapy. She has had no recurrences, and she feels very much happier than previously. Her relationship with William continues, but condoms are used consistently for vaginal intercourse. William is still unaware that Carol has genital herpes.

You issue a prescription for a further 9 months supply of aciclovir. You also advise Carol that should she develop recurrence while taking the drug, she can increase the dose to 400 mg three times per day.

Disclosure to William should be discussed again. As noted above, consistent condom use and suppressive antiviral drugs can reduce but not negate the risk of transmission. In a developing long-term relationship it is perhaps better that disclosure occurs. The partner then enters a sexual relationship fully informed of the risks. Fears of allegations of infidelity are also allayed should he develop symptomatic HSV infection. A joint counseling session is often useful.

Carol re-attends you 9 months later. She has had no recurrences, and she tells you that William who is now aware of her infection has had no clinical features suggestive of genital herpes. Carol uses the combined oral contraceptive pill and condoms are not used during sexual intercourse.

17.3 What Advice Would You Give Now?

As there is some evidence that individuals who have received suppressive aciclovir for a year are less likely to have recurrent lesions after cessation of the drug than if they had not been treated, it is recommended that antiviral therapy should be discontinued at this time. It should be explained that it is not uncommon to have one or two recurrences within a few months of cessation of therapy, followed by long symptom-free periods. Therefore, a decision on re-initiating suppressive therapy should not be made until the individual has had at least two recurrences. (It is helpful to provide supply of an antiviral drug so that treatment can be initiated as soon as possible after the development of symptoms). Should more frequent recurrences develop, however, it is perfectly justifiable to offer further suppressive treatment. Suppressive aciclovir therapy has now been used for many years, and there do not appear to be long-term adverse events.

Footnotes

1

In Carol’s case, the diagnosis of genital herpes had been confirmed virologically at her initial clinic attendance. However, if there had been no confirmation of the diagnosis, it is best to withhold suppressive treatment until this has been accomplished.