The goals of therapy

The International Herpes Management Forum has identified the following objectives for management of genital herpes:¹

• To treat symptoms
• To prevent sequelae
• To prevent transmission to sexual partners and neonates

All genital herpes patients should be managed effectively - to help improve public health in general, as well as providing individual care.

With the introduction of oral anti-viral therapy in the 1980s, health professionals could for the first time offer patients a proven treatment to improve their symptoms.²

Now, all patients presenting with genital herpes are candidates for oral anti-viral therapy, as part of their overall management.¹ Guidelines from the International Herpes Management Forum state that "all patients diagnosed with genital herpes should be offered oral anti-viral therapy and advised that recurrences can be reduced".¹

The value of oral anti-viral treatment

The clinical value of oral anti-viral treatment for genital herpes is now well-established:

Episodic (intermittent) therapy only treats recurrences as they occur and has no effect on subsequent recurrences. Patients can self-initiate therapy at the first sign or symptom of a recurrence - this allows treatment to begin earlier (than if the patient had to visit a doctor to get a prescription) and can produce better clinical results.^3-6 Episodic therapy:

• reduces duration of the outbreak
• reduces duration of pain
• speeds lesion healing
• reduces duration of viral shedding
• can prevent (abort) development of vesicular and ulcerative lesions*.

Preventative (suppressive) therapy must be taken continually to reduce the frequency of recurrences. ^7-9 Preventative therapy:

• can prevent or delay recurrences by up to 85 percent
• can improve patient psychological well-being¹⁰
• reduces asymptomatic shedding^11-13
• has the potential to reduce transmission**

* This endpoint only conclusively demonstrated in a valaciclovir clinical trial⁵
** Up to 70% of HSV transmission is believed to occur during periods of asymptomatic viral shedding. Clinical trial ongoing with valaciclovir to assess the impact of antivirals on transmission of HSV to non-infected partners.

Indications for episodic and preventative (suppressive) treatment

Whether to treat a patient with genital herpes with episodic or suppressive therapy will depend on several factors, such as the frequency and severity of recurrences and psychological considerations. Patients need to be educated and counselled in order to participate fully in the decision-making process. The management strategy should be reviewed regularly with the patient, as their needs may change with time.¹

Adapted from IHMF Recommendations for the IHMF Management Strategies Workshop: The medical importance of genital herpes simplex virus infection. Ed: L Corey and A Simmons. PPS, Worthing: 1997

Psychological considerations

It is important to consider the patient's psychological well-being, as well as the apparent severity of the attacks, in deciding the most appropriate treatment approach.

The psychological implications of a genital herpes diagnosis and subsequent recurrences are far-reaching and effective medication can boost confidence and give the patient a feeling of being in control.² Patients should be educated about the disease and involved in making an informed treatment choice.

References:

1. IHMF Recommendations for the IHMF Management Strategies Workshop: The medical importance of genital herpes simplex virus infection. Ed: L Corey and A Simmons. PPS, Worthing: 1997
2. Kinghorn, GR. Genital herpes: Natural history and treatment of acute episodes. J Med Virol: 1993 (Suppl 1): 33-38.
3. Reichmann RC, Badger GJ, Mertz GJ et al. Treatment of recurrent genital herpes simplex infections with oral aciclovir: a controlled trial. JAMA 1984; 251:2103-2107.
4. Nilsen AE, Aasen T, Halsos AM et al. Efficacy of oral aciclovir in the treatment of initial and recurrent genital herpes. Lancet 1982; 2:571-573.
5. Spruance SL, Tyring SK, Degregorio B et al. A large-scale placebo-controlled dose-ranging trial of peroral valaciclovir for episodic treatment of recurrent herpes genitalis. Arch Int Med 1996; 156: 1729-1735.
6. Sacks SL, Aoki FY, Diaz-Mitoma F et al. Patient initiated, twice-daily oral famciclovir for early recurrent genital herpes. A randomized, double-blind clinical trial. JAMA 1996; 276:44-49.
7. Goldberg LH, Kaufman R, Kurtz TO et al. Long term suppression of recurrent genital herpes with acyclovir: a five-year benchmark. Archives of Dermatology 1993; 129: 582-587.
8. Mertz GJ, Loveless MO, Levin MJ et al. Oral famciclovir for suppression of recurrent genital herpes simplex virus infection in women. Arch Int Med 1997; 157: 343-349.
9. Reitano M. Tyring S, Lang W et al. Valaciclovir for the suppression of recurrent genital HSV infection: a large-scale dose-range finding study. J Infect Dis 1998; 178:603-610.
10. Tyring S, Price MJ, Grant DM. Impact of suppressive antiviral therapy on the health-related quality of life of patients with recurrent genital herpes infection. 8th International Congress on Infectious Diseases, Boston, USA, May 10-12 1998. Poster 82.012.
11. Wald A, Corey L, Cone R. Frequent genital herpes simplex virus 2 shedding in immunocompetent women. Effect of acyclovir treatment. J Clin Invest 1997; 99:1092-1097.
12. Wald A, Warren T, Hu H et al. Suppression of subclinical shedding of herpes simplex virus type 2 in the genital tract with valaciclovir. 38th Interscience Conference on Antimicrobial Agents and Chemotherapy. San Diego, California, September 24-27, 1998. Abstract H-82.
13. Sacks SL, Hughes A, Rennie B et al. Famciclovir (FCV) for suppression of asymptomatic (Asx) and symptomatic (Sx) recurrent genital herpes (RGH) shedding: a randomized, double-blind, double-dummy, parallel-group, placebo-controlled trial. 37th Interscience Conference on Antimicrobial Agents and Chemotherapy, Toronto, Canada September 28 - October 1, 1997. Abstract H-73.