Screening for Asymptomatic Genital Herpes

Is Serologic Testing Worth It?

Leia Raphaelidis, FNP

Disclosures

Journal for Nurse Practitioners. 2014;10(3):194-199. 

In This Article

Treatment for Transmission Reduction

An area of needed study is to determine whether daily suppressive therapy with antiviral medications such as acyclovir or valacyclovir can help reduce the risk of transmitting asymptomatic herpes. In a landmark 2009 article, Corey et al[29] showed that daily therapy with valacyclovir produced a 48% reduction in HSV transmission in couples with discordant HSV-2 status in which 1 partner had outbreaks and the other partner was initially seronegative. The Corey study prompted the Food and Drug Administration to approve the reduction of transmission in heterosexual partners as a new indication for valacyclovir.[30] Whether this prevention strategy can be expected to succeed for asymptomatic seropositive people remains an unanswered question. A small 2008 study by Sperling et al[31] found that daily valacyclovir reduced viral shedding in asymptomatic individuals by 71% although the authors caution that further research is needed to demonstrate whether this effect can be expected to produce a comparable reduction in transmission. Recent findings indicate that even high doses of daily acyclovir and valacyclovir do not completely suppress shedding.[32] Current pharmacologic options ultimately may be proven to reduce but not entirely prevent transmission from asymptomatic seropositive individuals.

Without citing sources, the CDC posits in its 2010 guidelines that suppressive antiviral therapy is likely to reduce transmission when used by HSV-2 seropositive people without a history of genital outbreaks.[8] (p22) Clinicians should certainly discuss this option with patients, emphasizing, however, that the evidence about efficacy for this measure is still limited.

When patients opt for suppressive therapy, there are 3 available options: acyclovir, valacyclovir, and famciclovir. The standard dosing is acyclovir 400 mg twice a day, valacyclovir 500–1,000 mg every day, or famciclovir 250 mg twice a day. All 3 are available in generic versions, but acyclovir is by far the most affordable choice and can often be found on pharmacies' low-cost formularies.[33,34] These medications have been shown to have a favorable safety profile for long-term use with minimal microbial resistance.[35]

For some patients, serologic testing for sexual partners may help determine whether suppressive therapy would be of potential benefit. If 2 asymptomatic monogamous partners are both HSV-2 IgG positive, the need for suppressive therapy to reduce transmission is obviated. In a different clinical situation, if the partner of a seropositive person is pregnant and is herself seronegative, clinicians should counsel regarding the prevention of primary maternal herpes, which carries a higher risk for perinatal transmission and neonatal complications.[11] (p1491-1492)

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