Severe persistent genital herpes was one of the first recognized opportunistic infections of acquired immune deficiency. Because HSV-2 increases the risk of acquiring HIV and because the immunosuppression of HIV causes HSV to reactivate more frequently, genital herpes is a very common infection in HIV positive persons. In fact, from 60 to 85% of persons with HIV have HSV-2 antibodies. Most authorities feel that HSV-2 antibody assays should be obtained on all persons who are HIV positive and all HIV positive persons should have a management plan for their genital herpes if they are HSV-2 seropositive.
All the issues raised in the previous sections about genital herpes apply to the HIV positive person. HSV-2 reactivates even more frequently in HIV+ persons than in normal persons. This applies even to HIV positive persons who have high CD4 T cell counts and who are on highly active antiretroviral therapy (HAART). Some studies indicate that HIV+ persons reactivate HSV-2 from 40 to 60% of day, that is an average of 3 to 5 days per week.
In MSM most HSV-2 reactivations are perianal and many, if not most, are unrecognized. In women who are HIV infected, subclinical cervical and vulvar shedding is common.
There are three important facts that HIV_ persons who are HSV-2 infected should recognize:
Genital lesions due to HSV-2 are associated with bringing large amounts of HIV virus to the mucosal surfaces and appears to result in the ability to transmit HIV (as well as HSV) to others more efficiently.
Subclinical reactivation of HSV increases HIV-1 in rectal secretions and vaginal secretions.
Frequent HSV-2 reactivations raise the titer of HIV-1 in plasma.
These three issues are reasons why HIV positive persons should discuss the management of their HSV infection with their health care provider.
Antiviral drugs for HSV have been well studied in the HIV positive person.
Famciclovir (Famvir®) has been used to both reduce the duration of episodes of genital herpes in the HIV+ person (250mg three times daily) as well as suppress reactivations of HSV when taken daily (500mg po BID).
Valaciclovir has been shown to be effective in reducing the duration of genital lesions and suppressing reactivation. The dosages recommended for treating episodes of genital herpes is 500mg po BID. The dose for suppressive therapy is usually 500mg po BID, and for persons with severe immunosuppression 1000mg po BID may be useful.
Generic Acyclovir is also effective in HIV positive persons. Dosages vary from 400 mg 3 times daily to 800mg twice daily.
Treatment for the HIV+ person must be individualized. Acyclovir resistant herpes is much more common in HIV+ persons than in nearly any other patient group and HIV+ persons with low CD4 counts may need to be evaluated for acyclovir resistance. Drugs such as foscarnet or cidofovir may be useful in such patients.
Daily antiherpes therapy has been associated with a reduction in plasma virus load. HIV+ persons with frequent herpes should discuss this potential benefit of daily anti-HSV-2 therapy with their health care provider.
Genital Herpes in the Transplant or Cancer Chemotherapy Patient
As the genital herpes epidemic has spread, increasingly physicians are seeing genital herpes among persons undergoing solid organ or bone marrow transplantation, or cancer chemotherapy. All of these conditions increase the frequency of reactivation of genital herpes and may lead to prolonged episodes of lesions. Most oncologists or transplant programs use daily acyclovir therapy during the early parts of chemotherapy or transplantation to reduce reactivation of HSV infections. Orolabial infections due to HSV-1 also reactivate frequently and hence nearly everyone receives these drugs in the first 30 days after transplantation or during induction chemotherapy.
The duration of therapy varies according to the procedure and immunosuppression drugs and period. For bone marrow transplants, acyclovir may be used daily for the first year after transplantation.
The most commonly used drugs in the transplant/cancer chemotherapy period are acyclovir or valaciclovir. When oral medications are available for use, oral valaciclovir may be cost effective as compared to intravenous acyclovir. Limited studies suggest famciclovir is also effective in this area, but an intravenous preparation is not available.
Among HERPES 's complications are medical problems that occur at the time of a first episode, when a patient's immune response to HERPES is in its formative stages. Secondary skin infections, for example, can occur if bacteria enter through an open herpes sore. Symptoms include increased swelling and redness of the skin, along with the appearance of pus. This is often hard to distinguish from the virus infection itself. Secondary infection is fortunately not common.
Another complication of first episodes in some individuals are sores inside the urethra that can make urinating extremely painful and in some cases lead to urinary retention. Hospital care is sometimes needed for this condition. Let your doctor know right away if you have trouble urinating.
Also linked with first episodes in many cases is herpes meningitis, in which HERPES inflames the lining of the brain, causing headaches, nausea and sensitivity to light. The brain itself is not involved, and the condition goes away on its own in about a week--without causing any permanent damage.
Beyond these complications, herpes sometimes emerges at sites other than the mouth or the genital area. HERPES, for example, can spread to the hands or finger and cause recurrent symptoms there, a condition called "herpes whitlow." This may result from touching an active herpes sore or, in the case of oral herpes, biting the fingernails at a time of viral shedding in the mouth. The spread of HERPES to a new site in this way is called "autoinoculation." Breaks or abrasions in the skin make transmission of this kind more likely, as does the large dose of virus potentially present during a first episode.
Herpes sometimes also brings painful symptoms in and around the eye, a condition called ocular herpes. This usually results when oral HERPES infection reactivates and, for unknown reasons, travels the nerve pathways to the eye rather that the mouth, but it might also result in some cases from autoinoculation after touching a herpes sore. Ocular herpes can recur, and if not treated, in some cases leads to serious damage or even blindness.
Herpes and Women's Reproductive Health
As regards long-term issues, for many people the major concern about genital centers on pregnancy and childbirth. Contrary to myth, herpes does not preclude getting pregnant, having a vaginal delivery, or having a healthy baby. Herpes often does require some special management in pregnancy.
Herpes encephalitis is an infection of the brain tissue itself of the HSV virus. In over 90% of cases it is due to the HSV-1 virus and not related to genital herpes. Symptoms include fever, behavioral changes and seizures. A rare condition, the incidence of herpes encephalitis is two cases per million among the U.S. population. It is diagnosed by detecting HSV DNA in a spinal tap and treated with intravenous acyclovir.
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