There is no difference in management between HSV-1 and HSV-2 infection. Few randomised, controlled trials have been performed in PLWHIV. Aciclovir, famciclovir and valaciclovir have all been shown to be safe and effective as both intermittent and continuous therapy for HSV-2 clinical and subclinical infection in HIV-positive individuals. (21)
In the majority of situations, mucocutaneous HSV responds to oral therapy with aciclovir (400 mg three times a day); valaciclovir (1g twice a day); or famciclovir (250 mg three times a day). Primary episodes are treated for 7 to 10 days; recurrent episodes are treated for 5 days (21). Higher doses may be useful with aciclovir 800 mg twice a day or valaciclovir 1g three times a day. Treatment of aciclovir-resistant HSV should be guided by Infectious Diseases specialists using resistance genotyping, and may include non-thymidine kinase dependent therapies such as foscarnet or cidofovir (22).
Chronic antiviral suppressive therapy is suggested for PLWHIV who experience frequent and severe recurrences of mucocutaneous HSV infection (23-25)],Valaciclovir (500 mg twice a day) or famciclovir (500 mg twice a day) is recommended as maintenance therapy for secondary prophylaxis. (21) In addition, PLWHIV and HSV-2 co-infection who are sexually active should be advised of the association between HSV-2 reactivation and mucosal HIV-1 shedding and risk of onward sexual transmission if they do not have an undetectable viral load on ART (11). Of note, incidence of the AIDS-defining clinical presentation of HSV necrotic ulcers steeply declined following introduction of ART (26).