Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV

The information in the brief version is excerpted directly from the full-text guidelines. The brief version is a compilation of the tables and boxed recommendations.

Herpes Simplex Virus

Last Updated: May 26, 2020; Last Reviewed: May 26, 2020

Recommendations for Treating Herpes Simplex Virus Infections

Note: Compared to acyclovir, valacyclovir has improved bioavailability and requires less frequent dosing.

Treating Orolabial Lesions (Duration: 5–10 Days)

  • Valacyclovir 1 g PO twice a day (AIII), or
  • Famciclovir 500 mg PO twice a day (AIII), or
  • Acyclovir 400 mg PO three times a day (AIII)
Treating Initial Genital Lesions (Duration: 7–10 Days) or Recurrent Genital Lesions (Duration: 5–10 Days)
  • Valacyclovir 1 g PO twice a day (AI), or
  • Famciclovir 500 mg PO twice a day (AI), or
  • Acyclovir 400 mg PO three times a day (AI)
Treating Severe Mucocutaneous HSV Infections (AIII)
  • For initial therapy, acyclovir 5 mg/kg IV every 8 hours
  • After lesions begin to regress, change to oral therapy as above.
  • Continue treatment until lesions have completely healed.
Chronic Suppressive Therapy
Indications:
  • For patients with severe recurrences (AI), or
  • Patients who want to minimize the frequency of recurrences (AI), including pregnant women, or
  • To reduce the risk of genital ulcer disease in patients with CD4 counts <250 cells/mm3 who are starting ART (BI)
Treatment:
  • Valacyclovir 500 mg PO twice a day (AI), or
  • Famciclovir 500 mg PO twice a day (AI), or
  • Acyclovir 400 mg PO twice a day (AI)
  • Evaluate ongoing need for suppressive therapy annually.

For Acyclovir-Resistant Mucocutaneous HSV infections
Preferred Therapy:

 IV Foscarnet 80–120 mg/kg/day in 2–3 divided doses until clinical response (AI)

Alternative Therapy (Duration: ≥21–28 Days, Based on Clinical Response) (CIII):

  • IV cidofovir 5 mg/kg once weekly, or
  • Topical trifluridine 1% three times a day, or
  • Topical cidofovir 1% gel once daily, or
  • Topical imiquimod 5% cream three times a week, or
  • Topical foscarnet 1% five times a day

Notes:

  • Topical formulations of trifluridine, cidofovir, and foscarnet are not commercially available.
  • Extemporaneous compounding of topical products can be prepared using trifluridine ophthalmic solution and the IV formulation of cidofovir and foscarnet.
  • An expanded access program of oral pritelivir is now available for immunocompromised patients with acyclovir-resistant HSV infection; for more information see AiCuris Pritelivir Early Access website

Key: ART = antiretroviral therapy; HSV = herpes simplex virus; IV = intravenously; PO = orally

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