Since both the infections are sexually transmitted, having similar risk factors, the prevalence of herpes simplex virus (HSV) type 2 infections in HIV-infected patients is high (50 to 90 percent), and recurrent infections can be more frequent, severe, and of longer duration than in HIV-seronegative patient populations.
Antiviral treatment of first-episode HSV-2 infection certainly reduces the disease duration but does not eliminate the hidden, inactive virus, which can subsequently reactivate. Clinical HSV recurrences are a common problem among HIV-infected patients, particularly those with advanced immunosuppression ( patients with deficient white blood cells that give immunity to the body).
Antiviral Medications
The drug class nucleoside analogs (acyclovir, famciclovir, and valacyclovir) have well-established safety and efficacy for the treatment of genita7 ybl HSV infections in HIV-infected patients; these drugs are generally well tolerated at the presently recommended doses.
Each of the recommended agents has been showed to decrease pain, duration of sores, and viral shedding with comparable efficacy and safety among HIV-seronegative patients with primary and recurrent HSV-2 infection. As the efficiency appears to be almost similar among all of these antiviral agents, the selection of any one drug (e.g., acyclovir, famciclovir, or valacyclovir) should be decided based on cost, formulary considerations, and frequency of dosing for patient convenience.
Main Treatment Priciples
The principles of treatment of HSV-2 in HIV-infected persons are similar to those for HIV-uninfected persons. The antiviral therapy is recommended for all patients with first-episode genital HSV infection. However, the clinicians should be aware that the treatment of HSV-related disease in the HIV-infected host should continue until all lesions have completely healed. Also, some patients may even require hospitalization depending on disease severity, although most cases can be managed by oral medications.
The HSV antiviral therapy in HIV-infected patients with clinical recurrences of HSV-2 infection compared takes precedence over no intervention at all. Management options of recurrent disease include episodic therapy (e.g., self-administration of antiviral drugs for individual outbreaks as they arise) or suppressive therapy (daily use of antiviral medications for long-term maintenance).
The recommended doses of antiviral treatment are higher for both suppressive and episodic therapy for HSV recurrences in HIV-infected patients as compared to those in HIV-seronegative patients. In the HIV-infected patient with HSV ulcerative disease, treatment should continue for a minimum of five days or until lesion resolution.
Although most of the patients can be treated with oral regimens, patients with severe ulcerative disease or brain involvement may require intravenous therapy initially with acyclovir.
Immune Reconstitution Syndrome
The initiation of antiretroviral therapy (ART) for HIV-infected patients with advanced immunosuppression can lead to a paradoxical worsening of underlying HSV infection. Therefore, clinicians may sometimes prescribe coadministration of antiretroviral therapy for HIV and suppressive HSV antiviral therapy.
