HSV 2014

Question 1

What is most common cause of genital HSV uk?

Answer 1

HSV 1 (used to be HSV 2)

Question 2

How many people will be symptomatic at time of acquisition HSV 2?

Answer 2

1/3
In this minority incubation is 2 days-2weeks

Question 3

How does the body deal with HSV?

Answer 3

Following primary infection virus becomes latent in local sensory ganglia-periodically reactivating to cause symptomatic lesions or asymptomatic but infectious shedding

Question 4

What is median recurrence rate HSV 2?

Answer 4

4 recurrences per year

Question 5

How does HIV affect HSV?

Answer 5

Both symptomatic and asymptomatic shedding increased

Question 6

What complications may be seen with HSV?

Answer 6

Secondary infection
Autonomic neuropathy (retention)
Autoinnoculation
Aseptic meningitis

Question 7

What is best test HSV?

Answer 7

NAAT

Question 8

When might antibody serology help?

Answer 8

Pregnant women-to try and determine if recent or established infection using IgG (IgM unreliable)

Question 9

How do you manage primary infection?

Answer 9

Saline bathing
Analgesia
5% lidocaine ointment
Aciclovir if <5 days or new lesions or persistent systemic symptoms-to reduce the severity and duration of current episode.

Question 10

What is recommended regimen for antivirals?

Answer 10

All 5 days
-but ? Continue if new lesions/complications/systemic still)

Preferred
Aciclovir 400mg tds
Valaciclovir 500mg bd

Alternative:
Aciclovir 200mg x 5 daily
Famciclovir 250mg tds

Question 11

What are options for episodic treatment of recurrent HSV?

Answer 11

Aciclovir 800mg tds 2 days
Famciclovir 1g bd 1 day
valaciclovir 500mg bd 3/7

Will reduce severity/duration of disease, may abort lesions with early rx
Short course more convenient and cost effective.

2nd line 5 day treatments

Question 12

Who should start suppressive antiviral?

Answer 12

Balance of frequency/cost/inconvenience of treatment-subjective. Trials were done on 6 recurrences a year but likely will reduce recurrence in all.
If significant anxiety associated may benefit.

Question 13

What monitoring is needed for suppressive rx?

Answer 13

None. Safe.
Reduce dose if severe renal disease.

Question 14

What are recommended regimens for suppressive treatment?

Answer 14

Aciclovir 400mg bd or 200mg qds
Famciclovir 250mg bd
Valaciclovir 500mg od

If breakthrough recurrence increase dose.

Depends on compliance/cost
Needs to stop after a year and reassess frequency (await 2 recurrences as often rebound recurrence on cessation)

Question 15

Who should be treated empirically for HSV without lesions?

Answer 15

MSM symptomatic proctitis

Question 16

Source of support?

Answer 16

HSV association helpline/leaflet

Question 17

What to tell people re transmission/disclosure?

Answer 17

Avoid sex during prodrome or if lesions
Transmission can occur if asymptomatic
Condoms may help
Suppressive antivirals may help
Avoid transmission to pregnant people
Disclosure always advised

Question 18

What are the different aciclovir doses for treatment/episodic/supression?

Answer 18

Treatment: 400mg tds 5 days
Episodic: 800mg tds 2 days
Suppressive: 400mg bd daily

Question 19

How do you manage rec hsv in pregnancy? (All trimester)

Answer 19

Treat episode if need
Suppressive aciclovir 400mg tds from 36/40
Vaginal delivery fine
If lesion at delivery (only) observe 24hrs

Question 20

How do you manage first infection hsv before third trimester?

Answer 20

Treat episode
36/40 400mg tds aciclovir
Vaginal del fine
If lesions at del (only) observe baby 24hrs

Question 21

How do you treat first hsv third trim?

Answer 21

Treat episode
Continue with supressive until delivery -recommend CS-esp if <6weeks

If CS
Observe 24 hrs
Inform paeds but nil to do if well

If NVD ensues
Inform paeds
If well-aciclovir 20mg/kg 10/7 a/w swabs
If unwell LP plus swabs and treat