Topical Imiquimod for Acyclovir-Unresponsive Herpes Simplex Virus 2 Infection

A 34-year-old Hispanic man who had been diagnosed as having human immunodeficiency virus 5 years earlier presented with a 5-month history of herpes simplex virus (HSV) 2 infection of the penis. His CD4 cell count was 200/μL, and his viral load was undetectable. He had been receiving highly active antiretroviral therapy for 11 months. Before he developed HSV-2 infection, he had no history of genital herpes infection. Treatment was begun with acyclovir (400 mg 3 times daily for 1 month), with no improvement. Subsequently, the patient was treated with valacyclovir hydrochloride (1 g twice daily for 4 weeks) and then with famciclovir (500 mg 3 times daily for 4 weeks). Despite these multiple treatment attempts, he experienced no improvement and remained culture positive for HSV-2 (Figure 1).