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1 November 1996 | Volume 125 Issue 9 | Pages 776-777
We greatly appreciate the information provided by Straus and colleagues [1], which confirms our observation [2] that acyclovir reduces asymptomatic HSV shedding in the genital region.
We defined subclinical shedding as the detection of HSV from mucosal swabs without the presence of genital lesions; we believed that symptoms were insufficiently specific for the presence of viral shedding [3]. The women who participated in our study maintained a daily diary of genital symptoms (itching, burning, tingling, and pain). While receiving placebo, patients reported at least one genital symptom on 432 of 1754 days (24.6%). Herpes simplex virus type 2 was isolated on 173 days (9.9%); 90 cases were associated with a recognized genital lesion, and 83 occurred on days without genital lesions. Genital symptoms were reported on 17 (20%) of the days on which HSV was isolated without genital lesions. Thus, on 80% of days in which HSV was isolated without noticeable genital lesions, no symptoms were reported. Conversely, on 325 (75%) days on which genital symptoms were reported, viral shedding was not detected. Moreover, during daily acyclovir treatment, genital symptoms were reported on 210 of 1715 days (12.2%), whereas the virus was isolated on 8 of 1715 days (0.5%).
In individual patients, genital symptoms may be associated with viral shedding, especially immediately before recurrence of lesions [4, 5]. The high background prevalence of genital symptoms among women, however, indicates that such symptoms are neither specific nor sensitive for predicting HSV reactivation.
We agree with the conclusion that all available data show that suppressive acyclovir decreases but does not eliminate subclinical shedding and that the value of antiviral therapy in the prevention of sexual transmission of HSV remains to be determined.
1. Straus SE, Seidlin M, Takiff HE, Rooney JF, Felser JM, Smith HA, et al. Effect of oral acyclovir treatment on symptomatic and asymptomatic virus shedding in recurrent genital herpes. Sex Transm Dis. 1989; 16:107-13. 2. Wald A, Zeh J, Barnum G, Davis LG, Corey L. Suppression of subclinical shedding of herpes simplex virus type 2 with acyclovir. Ann Intern Med. 1996; 124(1 pt 1):8-15. 3. Koutsky LA, Stevens CE, Holmes KK, Ashley RL, Kiviat NB, Critchlow CW, et al. Underdiagnosis of genital herpes by current clinical and viral isolation procedures. N Engl J Med. 1992; 326:1533-9. 4. Sacks SL. Frequency and duration of patient-observed recurrent genital herpes simplex virus infection: characterization of the non-lesional prodrome. J Infect Dis. 1984; 150:873-7. 5. Wald A, Zeh J, Selke S, Ashley RL, Corey L. Virologic characteristics of subclinical and symptomatic genital herpes infections. N Engl J Med. 1995; 333:770-5. About Letters
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Acyclovir Suppresses Subclinical Shedding of Herpes Simplex Virus
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University of Washington Seattle, WA 98114.
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