Approach to antiviral therapy for genital herpes

Antiviral therapy for genital herpes simplex virus (HSV) infection is not curative, but it reduces the duration and severity of an acute episode – see Initial antiviral therapy for genital herpes (first clinical episode) and Episodic antiviral therapy for genital herpesWHO, 2016Patel, 2017. Suppressive antiviral therapy for genital herpes reduces recurrences and transmission.

Evidence comparing valaciclovir or famciclovir with aciclovir suggests that these drugs are therapeutically equivalent; consider differences in dosing schedules, tablet burden and cost when selecting therapyWHO, 2016Patel, 2017.

Limited data suggest that valaciclovir (a prodrug of aciclovir) is safe in pregnancy, and some prescribers prefer it because it has a more convenient dosing regimenAustralian Society for Infectious Diseases (ASID), 2022. There are insufficient data to support the use of famciclovir in pregnancyAustralian Society for Infectious Diseases (ASID), 2022.

Patients with immune compromise (eg patients with advanced HIV infection) can have prolonged, widespread and more painful episodes of genital or perianal herpes. If patients with immune compromise do not respond to the relevant antiviral regimen below, seek expert advice – although rare, antiviral resistance may be a reason for nonresponse.