The patient wanted empirical treatment for herpes. He was given valacyclovir, 1 gm for 7 days, taken twice daily, with the option to call in for more if the ulcers did not resolve by day 7. He was told he might apply petrolatum and clean gauze to the ulcers to diminish the pain when open ulcers rub against underwear. Acetaminophen or other analgesics were recommended for pain, and he was advised to avoid sexual activity until the ulcers had fully healed.
Preventing transmission
The patient is appropriately concerned about the transmission of this condition to a new partner. Not having a firm diagnosis makes definitive counseling more difficult. However, general principles of safe sex and condom use were discussed. On the follow-up visit the patient was told that the result of his herpes test was positive for HSV-2. Results of his RPR, HIV antibody test, and H ducreyiculture were all negative.
Information about condom use was reinforced, and the patient was told there is definitive evidence that condom use does diminish the risk of transmission of herpes from a man to a woman (LOE=1b).2 That same study did not show that condom use prevents transmission from women to men. Also, changes in sexual behavior, correlated with counseling about avoiding sex when a partner has lesions, were associated with reduction in HSV-2 acquisition over time (LOE=1b).2
One study showed that the overall risk of genital HSV transmission in couples is low (10%/year). The risk may be significantly increased in women and in seronegative individuals.3 This speaks for serologic testing for the potential partner of this patient.
When recurrences are frequent, antiviral agents can decrease the frequency (LOE=1a).1 If this patient has frequent recurrences, antiviral agents would be appropriate and would decrease the times when the patient is shedding virus asymptomatically.
Herpes is transmitted between sexual partners during asymptomatic shedding.1 Acyclovir 400 mg twice daily can reduce asymptomatic viral shedding significantly among women with recurrent herpes simplex (LOE=1b).4 While it is likely this will decrease transmission from women to men, this has not been proven. Data on decreasing viral transmission from men to women by antiviral therapy is not available. At some point, the Glycoprotein-D-adjuvant vaccine may be an option to prevent genital herpes transmission to his partner.5
Note. The CDC 2002 sexually transmitted diseases treatment guidelines are available for download and use on a Palm handheld computer at www.cdcnpin.org/scripts/std/pda.asp.