HIV-infected patients should use male latex condoms consistently and correctly during sexual intercourse to reduce the risk of exposure to herpes simplex virus (HSV) and other sexually transmitted pathogens (AI*). They should specifically avoid sexual contact when herpetic lesions (genital or orolabial) are evident (AIII).
Although use of acyclovir or valacyclovir, beginning at 36 weeks of pregnancy to reduce the need for cesarean delivery, is recommended in HIV-uninfected women with recurrent genital herpes, data are insufficient to make a specific recommendation for HIV and HSV coinfected women (BIII).
For pregnant women who have active genital HSV lesions at the onset of labor, delivery by elective cesarean delivery, preferably before rupture of membranes, is recommended (BII*).
Acyclovir is the drug of choice for treatment of local and disseminated HSV in infants and children, regardless of HIV-infection status (AI).
Neonatal HSV disease should be treated with high-dose intravenous (IV) acyclovir (20 mg/kg body weight), administered for 21 days for central nervous system (CNS) and disseminated disease and for 14 days for disease of the skin, eyes, and mouth (AI). IV acyclovir therapy should not be discontinued in neonates with CNS disease unless a repeat cerebrospinal fluid HSV DNA polymerase chain reaction assay is negative near the end of treatment (BIII). Oral acyclovir prophylaxis for 6 months after treatment of neonatal disease involving the CNS or skin, eyes, and mouth can prevent cutaneous recurrences and may be associated with superior neurodevelopmental outcome in those with CNS disease (AI).
Beyond the neonatal period, HSV encephalitis should be treated with IV acyclovir for 21 days (AIII).
First-episode orolabial or genital lesions in HIV-infected children or adolescents can be treated with oral acyclovir for 7 to 10 days (AI). Children or adolescents with severe immunosuppression and moderate-to-severe mucocutaneous HSV lesions should be treated initially with IV acyclovir and may require longer therapy (AI*).
Recurrent mucocutaneous lesions, if treated, are generally treated with oral acyclovir for 5 days (AI*).
Alternatives to oral acyclovir in adolescents and adults include valacyclovir and famciclovir (AI*).
Patients with acute retinal necrosis should receive combination antiretroviral therapy and high-dose IV acyclovir for 10 to 14 days, followed by prolonged (i.e., 4–6 weeks) oral therapy, such as valacyclovir or acyclovir (AIII).
HSV keratoconjunctivitis is usually treated with topical trifluridine or oral acyclovir alone, although many experts recommend the combination (AII*).
The treatment of choice for acyclovir-resistant HSV is IV foscarnet (AI*).
Children or adolescents who have frequent or severe orolabial or genital recurrences can be given daily suppressive therapy with oral acyclovir (AI*). Valacyclovir and famciclovir also are options for adolescents (AI*).
