Johns Hopkins POC-IT: Point of Care Information Technology [Home]
HIV Guide
 Zambia HIV National Guidelines
 


Introduction  

HIV Counseling and Testing  

Sexually Transmitted Infections (STIs)  

General Principles of Antiretroviral Therapy for Chronic HIV Infection in Adults and Adolescents  

When to Start ARV Therapy for Chronic HIV Infection in Adults and Adolescents  

Initial Regimen for ARV Therapy  

Adherence  

Baseline evaluation and Monitoring  

Calculations: Ideal Body Weight, Body Mass Index and Creatinine Clearance  

ARV Therapy for Individuals with Tuberculosis Co-Infection  

Adverse Effects and Toxicity  

Immune Reconstitution Inflammatory Syndrome (IRIS)  

Changing or Stopping ART  

Treatment Failure  

Stopping ARV Therapy  

Post Exposure Prophylaxis  

Cotrimoxazole Prophylaxis  

WHO Staging in Adults and Adolescents  

Nutrition Care and Support  

Palliative Care in HIV and AIDS  

 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS
 

 

 

Diagnosis>Opportunistic Infections>
Home Page

Herpes simplex

Emily J. Erbelding, M.D., M.P.H. and Khalil G. Ghanem, M.D.
05-01-2009

  • Due to synergy between HSV and HIV transmission, pts with HSV should be tested for HIV and pts with HIV should be evaluated for clinical evidence of HSV.
  • High seroprevalence rates in sub-Saharan Africa (30-80%). HIV+ pts have consistently higher HSV-2 prevalence than HIV-negative pts.
  • Dx of HSV lesions is clinical in Zambia as Cx, Bx, PCR, DFA, serology or Tzanck prep rarely performed.
  • Treatment in Zambia (per National Guidelines 2007 on HIV Management) are same as below with acyclovir; however, other antivirals (valacyclovir, famciclovir, foscarnet) not generally available in Zambia.

REFERENCES

Zambia Information Author: David Riedel, M.D.

PATHOGENS

  • Herpes simplex virus-1 (HSV-1)
  • Herpes simplex virus-2 (HSV-2)
  • HSV-1 and HSV-2 are double-stranded enveloped DNA viruses.
  • Chronic herpesvirus infection, establishes latency in sensory ganglia of nerves innervating site of initial mucocutaneous infection.
  • Prevalence of both HSV-1 or -2 infection up to 80% in clinical series of HIV+ persons.
  • Activates HIV replication and enhances sexual transmission of HIV.

CLINICAL

  • HSV-1: orolabial ulcers, herpetic whitlow (felon), stomatitis, keratitis, anogenital ulcerations, proctitis, esophagitis, tracheobronchitis/pneumonitis, retinal necrosis, encephalitis, transverse myelitis, disseminated infection.
  • HSV-2: ulcerative anogenital disease and proctitis more common than with HSV-1, though clinical syndromes overlap extensively; meningitis, lumbosacral radiculitis.
  • Genital herpes: classic presentation is grouped vesicles on erythematous base; "atypical" presentations (erythema, itching, tingling, shallow or linear erosions) are also common in both immunocompetent and in HIV+ hosts.
  • DDx of genital ulcers: syphilis, chancroid, Behcet's disease, herpes zoster, lymphogranuloma venereum, granuloma inguinale, leishmaniasis, blastomycosis, mucocutaneous manifestation of inflammatory bowel disease, idiopathic ulcers.
  • DDx of orolabial ulcers: aphthous ulcers, Behcet's disease, histoplasmosis.
  • DDx of perianal herpes/ proctitis: similar to genital ulcer disease; also consider HPV-associated anal lesions; gonorrhea and chlamydia.
  • More severe visceral disease (esophagitis, retinal necrosis) can be a complication of AIDS; other manifestations (pneumonitis, encephalitis, other dissemination) also describe in case reports or small clinical series.

DIAGNOSIS

  • Cx from lesion confirms Dx; sensitivity of vesicular fluid highest, especially with primary episode; lower yield with recurrence, if lesions in healing phase, or if antiviral therapy initiated.
  • "Tzanck prep" of lesion scrapings may demonstrate multinucleated giant cells (60% sensitive for infection with Herpesviridae family), not specific for HSV
  • PCR more sensitive than Cx; can discriminate HSV-1/2; "gold standard" in diagnosing HSV encephalitis.
  • Skin Bx: may be useful with atypical lesions; antigen detection by HSV-1/2 DFA staining diagnostic.
  • Chronic infection diagnosed by type-specific serologic testing, but not likely to be useful in diagnosing specific etiology of ulcerative lesions.

TREATMENT

General Principles

  • HIV+ pts with relatively preserved immune function may be managed similarly to HIV-negative pts; those with low CD4 may benefit from higher dose of antivirals and/or longer duration of therapy.
  • Extend duration of therapy for all clinical episodes if lesion healing incomplete after the term stated; consider possibility of drug resistance.
  • Bacterial superinfection may complicate genital outbreaks causing perineal cellulitis, requiring antibacterial as well as more aggressive antiviral therapy.
  • Higher rates of subclinical HSV shedding in immunosuppressed HIV+ persons (compared to HIV-).
  • Goal of therapy and common endpoints in clinical efficacy trials include Sx resolution, lesion healing, and preventing new lesion occurrence. Pt and provider may elect to not treat mildly symptomatic herpes, especially in HIV+ with normal CD4.
  • Recent RCTs using acyclovir in HIV-/ HSV+ patients did not decrease risk of HIV acquisition; results of a study using acyclovir to decrease HIV transmission in HSV+/HIV+ patients are anticipated.
Genital or orolabial herpes, first clinical episode.

  • Acyclovir 400 mg PO three times a day x 7-10 d, OR 200 mg PO 5x/d x 7-10 d.
  • Valacyclovir 1 gm PO twice-daily x 7-10 d.
  • Famciclovir 250 mg PO three times a day x 7-10 d.
Recurrent clinical episodes in HIV

  • Acyclovir 400 mg PO three times a day x 5d.
  • Valacyclovir 1 gm PO twice-daily x 5-10 d.
  • Famciclovir 500 mg twice-daily x 5-10d.
  • Orolabial herpes: penciclovir 1% cream to lesions q2h while awake x 4d (not evaluated in HIV+ pts.)
  • Orolabial herpes: valacyclovir 2 gm q12h x 2 doses (not evaluated in HIV+ pts.)
Severe mucocutaneous, visceral or disseminated herpes.

  • Acyclovir 5-10 mg/kg IV q8hr (preferred for severe or progressive disease), continue until clinical improvement observed.
  • Valacyclovir 1 gm PO three times a day may be useful for mucocutaneous disease of less clinical severity.
Acyclovir -resistant herpes

  • Thymidine kinase-deficient mutations most frequent cause of acyclovir resistance; cross-resistant to valacyclovir and famciclovir. May be preventable in immunosuppressed patients by initial use of higher dose ACV (or valacyclovir, famciclovir).
  • Foscarnet 40 mg/kg IV q8h.
  • Cidofovir 1-3% cream applied daily has had reported success in case reports for acyclovir resistance in refractory mucocutaneous lesions.
  • Consider viral resistance testing when clinically significant disease progresses or persists despite therapy.
Herpes keratitis

  • Acyclovir 3% ophth ointment 5 x/d x 7-14 d.
  • Addition of systemic antiviral therapy indicated if more extensive or complicated ocular disease.
Suppressive therapy in HIV

  • Acyclovir 400 mg PO twice-daily or three times a day.
  • Valcyclovir 500 mg PO twice-daily.
  • Famiciclovir 500 mg PO twice-daily.
  • Suppressive therapy clinically indicated if herpes outbreaks frequent or severe.
  • Some experts recommend type-specific serologic testing in HIV+ pts with chronic suppressive antiviral therapy based on results: not currently standard of care.

Drug Comments

DrugRecommendations/Comments
Acyclovir Less convenient due to higher dosing frequency than oral alternatives.
Cidofovir Topical preparation not commercially available; drug + vehicle must be prepared by pharmacist.
Famciclovir Orally bioavailable prodrug of penciclovir and more convenient dosing than acyclovir; not useful if ACV-resistant.
Foscarnet For ACV-resistant HSV: 40 mg/kg IV q8h; rare cases of foscarnet -resistant HSV in immunocompromised hosts have been reported.
Penciclovir Active product of famciclovir; topical application of 1% cream more effective than placebo in treating herpes labialis of lips and face, but use not endorsed in genital herpes, on mucous membranes, or in immunocompromised hosts.
Valacyclovir Better absorption, more convenient dosing than acyclovir; not useful if acyclovir-resistant.

Basis for Recommendations

  • Centers for Disease Control and Prevention ; Sexually transmitted diseases treatment guidelines 2006. Centers for Disease Control and Prevention.; MMWR Recomm Rep; 2006; Vol. 55-11 ; pp.  16-21;
    ISSN: 1057-5987;
    PUBMED:  16888612
    Rating: Basis for recommendation
    Comments:Consensus panel guidelines on approach to HSV diagnosis and management.

REFERENCES

REFERENCED WITHIN THIS GUIDE


 
Diagnosis
 


Complications of Therapy


Malignancies


Miscellaneous


Opportunistic Infections


Organ System

Drugs
 


Antimicrobial Agents


Antiretrovirals


Miscellaneous

Guidelines
 


Zambia HIV National Guidelines

Management
 


Antiretroviral Therapy


Laboratory Testing


Miscellaneous

Pathogens
 


Bacteria


Fungi


Parasites


Viruses

View All Modules
 
Index
 
 
Contacts    Help    Copyright    Acknowledgments    Abbreviations