Herpes Simplex Virus Type 1 Remains the Principal Cause of Initial Anogenital Herpes in Edinburgh, Scotland

Seroprevalence of herpes simplex virus type 1 among people living with HIV in Mbeya, Tanzania

Background

Despite the significant decline in the prevalence of HIV in Tanzania, the prevalence rates in Mbeya, Iringa, and Njombe regions are higher than the national average and have remained stable for years. The current stable HIV prevalence may be driven by factors such as a high incidence of sexually transmitted infections (STIs) and high-risk behaviours. In sub-Saharan Africa, it has previously been observed that up to 50% of HIV cases were attributed to herpes simplex type 2 (HSV-2) among low-risk populations. Because the proportion of sexually transmitted HSV-1 is rising, it is essential to study the interaction between HSV-1 and HIV infections.

Methods

We conducted a study in Mbeya region using the archived blood sera of participants from the recently completed EU-funded EMINI project. A specially designed questionnaire was used to obtain the social and demographic characteristics of the study participants in the database. We tested archived participants’ sera for herpes simplex virus type 1 using Virotech HSV-1 (gG1) IgG ELISA (Enzygnost, Behring, Germany). Univariate and multivariate Poisson regression models were used to identify factors associated with HSV-1.

Results

A total of 640 adults were randomly recruited after stratification by HIV status (318 were HIV positive), age, and sex. The overall seroprevalence of HSV-1 in the study population was 92.1%. The extrapolated seroprevalence estimate of herpes simplex virus type 1 in the general population was 95.0% (96.0% in males versus 94.0% in females). Males and females were equally affected by HSV-1. HSV-1 was less prevalent in HIV-positive individuals than in HIV-negative individuals.

Conclusion

People living with HIV were less likely to be HSV-1 seropositive. Further prospective studies are necessary to conclude a causal association.

Prevalence of Ureaplasma urealyticum, Chlamydia trachomatis, Neisseria gonorrhoeae and herpes simplex virus in Beijing, China

The prevalence of sexually transmitted infection (STI) pathogens in Beijing, China, is rarely reported. In this study, 34 911 symptomatic outpatients with suspected genital infections who attended outpatient clinics in a tertiary care hospital were included to investigate the updated prevalence of Ureaplasma urealyticum (UU), Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and herpes simplex virus (HSV) from 1 January 2013 to 31 December 2016 in Beijing, China. Results indicated that a decrease trend (UU, CT, NG and HSV) in male and an increase trend (UU, CT and NG) in female were observed during the period. Patients aged 20–39 years old were mostly affected by these pathogens, while the prevalence in patients aged 20–29 years old was the highest, The prevalence of UU in male was significantly lower than in female (31.5% vs. 49.3%, P < 0.05), while the prevalence of NG in male was significantly higher than in female (2.5% vs. 0.8%, P < 0.05). In patients with co-infections, 60.6% of male and 71.4% of female were co-infected by UU + CT. In total, 11.9% and 88.1% of patients with HSV infections were confirmed to be infected by HSV-1 and HSV-2. This study could contribute to a better understanding of the current epidemiological features of UU, NG, CT and HSV among symptomatic patients attending an outpatient clinic in Beijing, China, and thus facilitate to develop more effective intervention, prevention and treatment of STI.

Genital Herpes: Insights into Sexually Transmitted Infectious Disease

Etiology, transmission and protection: Herpes simplex virus-2 (HSV-2) is a leading cause of sexually transmitted infections with recurring manifestations throughout the lifetime of infected hosts. Currently no effective vaccines or prophylactics exist that provide complete protection or immunity from the virus, which is endemic throughout the world. Pathology/Symptomatology: Primary and recurrent infections result in lesions and inflammation around the genital area and the latter accounts for majority of genital herpes instances. Immunocompromised patients including neonates are susceptible to additional systemic infections including debilitating consequences of nervous system inflammation. Epidemiology, incidence and prevalence: More than 500 million people are infected worldwide and most reported cases involve the age groups between 16-40 years, which coincides with an increase in sexual activity among this age group. While these numbers are an estimate, the actual numbers may be underestimated as many people are asymptomatic or do not report the symptoms. Treatment and curability: Currently prescribed medications, mostly nucleoside analogs, only reduce the symptoms caused by an active infection, but do not eliminate the virus or reduce latency. Therefore, no cure exists against genital herpes and infected patients suffer from periodic recurrences of disease symptoms for their entire lives. Molecular mechanisms of infection: The last few decades have generated many new advances in our understanding of the mechanisms that drive HSV infection. The viral entry receptors such as nectin-1 and HVEM have been identified, cytoskeletal signaling and membrane structures such as filopodia have been directly implicated in viral entry, host motor proteins and their viral ligands have been shown to facilitate capsid transport and many host and HSV proteins have been identified that help with viral replication and pathogenesis. New understanding has emerged on the role of autophagy and other innate immune mechanisms that are subverted to enhance HSV pathogenesis. This review summarizes our current understanding of HSV-2 and associated diseases and available or upcoming new treatments.

Human Herpesviruses as Copathogens of HIV Infection, Their Role in HIV Transmission, and Disease Progression

Of eight human herpesviruses (HHVs), often, only herpes simplex virus types 1 (HSV-1) and 2 (HSV-2) find mention in medical literature as both of these viruses are commonly associated with genital lesions and oral ulcers, commonly known as cold sores. However, role of human herpesviruses as copathogens and in aggravation and in the transmission of other human diseases, especially the Acquired immunodeficiency syndrome (HIV/AIDS) has only very recently been recognized. Therefore, screening and treating subclinical HHV infections may offer slowing of HIV infection, disease progression, and its transmission. Beside HSV-1 and HSV-2, HHV-3 a causative agent of herpes zoster remained one of the first manifestations of HIV disease before the era of highly active antiretroviral therapy (HAART). HHV-5 also known as human Cytomegalovirus infection remains a significant risk factor for HIV-associated mortality and morbidity even in HAART era. It is proposed that Cytomegalovirus viremia could be a better predictor of HIV disease progression than CD4+ T-lymphocyte count. The role of HHV-4 or Epstein-Burr virus and HHV-6, HHV-7, and HHV-8 is still being investigated in HIV disease progression. This review provides insight into the current understanding about these 8 HHVs, their co-pathogenesis, and role in HIV/AIDS disease progression. The review also covers recent literature in favor and against administering anti-HHV treatment along with HAART for slower AIDS progression and interrupted sexual transmission.

CD1d Expression and Invariant NKT Cell Responses in Herpesvirus Infections

Invariant natural killer T (iNKT) cells are a highly conserved subset of unconventional T lymphocytes that express a canonical, semi-invariant T cell receptor and surface markers shared with the natural killer cell lineage. iNKT cells recognize exogenous and endogenous glycolipid antigens restricted by non-polymorphic CD1d molecules, and are highly responsive to the prototypical agonist, α-galactosylceramide. Upon activation, iNKT cells rapidly coordinate signaling between innate and adaptive immune cells through the secretion of proinflammatory cytokines, leading to the maturation of antigen-presenting cells, and expansion of antigen-specific CD4+ and CD8+ T cells. Because of their potent immunoregulatory properties, iNKT cells have been extensively studied and are known to play a pivotal role in mediating immune responses against microbial pathogens including viruses. Here, we review evidence that herpesviruses manipulate CD1d expression to escape iNKT cell surveillance and establish lifelong latency in humans. Collectively, published findings suggest that iNKT cells play critical roles in anti-herpesvirus immune responses and could be harnessed therapeutically to limit viral infection and viral-associated disease.

Evasion of early antiviral responses by herpes simplex viruses

Besides overcoming physical constraints, such as extreme temperatures, reduced humidity, elevated pressure, and natural predators, human pathogens further need to overcome an arsenal of antimicrobial components evolved by the host to limit infection, replication and optimally, reinfection. Herpes simplex virus-1 (HSV-1) and herpes simplex virus-2 (HSV-2) infect humans at a high frequency and persist within the host for life by establishing latency in neurons. To gain access to these cells, herpes simplex viruses (HSVs) must replicate and block immediate host antiviral responses elicited by epithelial cells and innate immune components early after infection. During these processes, infected and noninfected neighboring cells, as well as tissue-resident and patrolling immune cells, will sense viral components and cell-associated danger signals and secrete soluble mediators. While type-I interferons aim at limiting virus spread, cytokines and chemokines will modulate resident and incoming immune cells. In this paper, we discuss recent findings relative to the early steps taking place during HSV infection and replication. Further, we discuss how HSVs evade detection by host cells and the molecular mechanisms evolved by these viruses to circumvent early antiviral mechanisms, ultimately leading to neuron infection and the establishment of latency.

Herpes simplex virus 2 infection: molecular association with HIV and novel microbicides to prevent disease

Infection with herpes simplex viruses is one of the most ancient diseases described to affect humans. Infection with these viruses produces vexing effects to the host, which frequently recur. Infection with herpes simplex viruses is lifelong, and currently there is no vaccine or drug to prevent or cure infection. Prevalence of herpes simplex virus 2 (HSV-2) infection varies significantly depending on the geographical region and nears 20 % worldwide. Importantly, HSV-2 is the first cause of genital ulcers in the planet. HSV-2 affects approximately 500 million people around the globe and significantly increases the likelihood of acquiring the human immunodeficiency virus (HIV), as well as its shedding. Thus, controlling HSV-2 infection and spread is of public health concern. Here, we review the diseases produced by herpes simplex viruses, the factors that modulate HSV-2 infection, the relationship between HSV-2 and HIV and novel therapeutic and prophylactic microbicides/antivirals under development to prevent infection and pathological outcomes produced by this virus. We also review mutations associated with HSV-2 resistance to common antivirals.

Herpes simplex virus in African American heterosexual males: the roles of age and male circumcision

BACKGROUND

Male circumcision is protective against human immunodeficiency virus (HIV) and select other STIs. The protective role of male circumcision in genital herpes simplex virus (HSV) infection and disease, however, remains controversial.

METHODS

We evaluated data from a sample of heterosexual black men attending a sexually transmitted diseases clinic to determine if circumcision status influenced HSV-1 and HSV-2 seroprevalence, clinical genital disease, or asymptomatic shedding. Consenting participants answered questionnaires detailing sexual history, then underwent a focused physical examination, serological testing for HSV-1 and HSV-2, and collection of genital swabs for virus detection. Univariate and multivariate analyses were performed to assess the relationship of circumcision status to HSV seroprevalence.

RESULTS

Of 460 men, 335 (73%) were circumcised and 125 (27%) were not circumcised; 61% were HSV-1 positive and 46% were HSV-2 positive. HSV-2 seroprevalence did not significantly differ between circumcised and uncircumcised men. However, uncircumcised men had a significantly higher HSV-1 seroprevalence than circumcised men (OR: 1.85; CI: 1.15-2.96). This difference in seroprevalence occurred only in men between 18 and 25 years of age (OR: 2.83; CI: 1.38-5.83) with men over 26 years of age having similar HSV-1 seroprevalence. Lack of circumcision remained independently associated with higher HSV-1 seroprevalence after adjusting for age, years since sexual debut, and lifetime number of sexual partners. For both groups, 20% of men had genital lesions on physical examination. Of circumcised and uncircumcised men with genital lesions, 33% and 31% were actively shedding HSV-1 or HSV-2 from lesions, respectively. Asymptomatic HSV shedding was observed in 12 participants, all of whom were circumcised.

CONCLUSIONS

Lack of male circumcision is associated with higher HSV-1, but not HSV-2, seroprevalence in young black heterosexual men.

The immunologic basis for severe neonatal herpes disease and potential strategies for therapeutic intervention

Herpes simplex viruses types 1 and 2 (HSV-1 and HSV-2) infect a large proportion of the world's population. Infection is life-long and can cause periodic mucocutaneous symptoms, but it only rarely causes life-threatening disease among immunocompetent children and adults. However, when HSV infection occurs during the neonatal period, viral replication is poorly controlled and a large proportion of infants die or develop disability even with optimal antiviral therapy. Increasingly, specific differences are being elucidated between the immune system of newborns and those of older children and adults, which predispose to severe infections and reflect the transition from fetal to postnatal life. Studies in healthy individuals of different ages, individuals with primary or acquired immunodeficiencies, and animal models have contributed to our understanding of the mechanisms that control HSV infection and how these may be impaired during the neonatal period. This paper outlines our current understanding of innate and adaptive immunity to HSV infection, immunologic differences in early infancy that may account for the manifestations of neonatal HSV infection, and the potential of interventions to augment neonatal immune protection against HSV disease.

Relationship between cervical disease and infection with human papillomavirus types 16 and 18, and herpes simplex virus 1 and 2

Persistent infection with high-risk HPV, particularly Type HPV 16 and 18, is necessary in the development of cervical cancer, but apart from HPV infection, other causative factors of most cervical cancers remain unknown. The aim of this study was to determine the prevalence of HPV 16 and HPV 18 and HSV 1 and HSV 2 in cervical samples, and to assess the role of HSVs in cervical carcinogenesis. Two hundred thirty-three healthy controls and 567 cases (333 of cervicitis, 210 of cervical intraepithelial neoplasia, and 24 of squamous cell carcinoma) in cervical exfoliative cells were tested for HPV 16, HPV 18, HSV 1, and HSV 2 DNA using the triplex real-time polymerase chain reaction method. In contrast to healthy women, positive rate of HPV is related significantly to cervical lesions (odds ratios (ORs) = 4.1, P < 0.01 for cervical intraepithelial neoplasia; ORs = 24.9, P < 0.01 for squamous cell carcinoma), but not cervicitis (ORs = 2.3, P > 0.05). HSV 2 prevalence in cervical intraepithelial neoplasia and squamous cell carcinoma was higher than in healthy women (ORs = 4.9, P < 0.05 for cervical intraepithelial neoplasia; ORs = 4.7, P < 0.05 for squamous cell carcinoma). HSV 2 coinfection with HPV in cervical intraepithelial neoplasia and squamous cell carcinoma was strongly higher than in healthy women (ORs = 34.2, P < 0.01 for cervical intraepithelial neoplasia; ORs = 61.1, P < 0.01 for squamous cell carcinoma). The obtained results indicated that the presence of HPV is associated closely with cervical cancer, and that HSV 2 infection or co-infection with HPV might be involved in cervical cancer development, while HSV 1 might not be involved.

Herpes simplex virus type 1 is the main cause of genital herpes in women of Natal, Brazil

OBJECTIVES

The purpose of this study was to assess the prevalence of HSV-1 and HSV-2 in sexually active women who participated in the cervical cancer screening program in Natal, Brazil.

STUDY DESIGN

The study included 261 sexually active women resident in the metropolitan area of Natal, Brazil and attending a public clinic for cervical screening. From each participant, a sample of exfoliated uterine cervical cells was collected, using a cytobrush which was conditioned in a tube containing a preserving solution (PBS+vancomycin+nystatin) and sent to a laboratory where it was processed for DNA extraction. The samples were analyzed for the presence of HSV-1 and HSV-2 DNA in separate reactions by PCRs using specific primers.

RESULTS

HSV-1 in genital infection is four times more prevalent than HSV-2 in the population analyzed. The highest prevalence rates for both viruses were found in women aged 31-39years. We did not observe any association between the presence of both virus serotypes and socio-demographic characteristics in the population studied, nor with some classical risk factors for sexually transmitted diseases.

CONCLUSIONS

HSV-1 was the major cause of genital infection by Herpes simplex virus in the women included in this study. No association was found between HSV infection and the socio-demographic characteristics or some classical risk factors for sexually transmitted diseases.

Helicase–primase inhibitors as the potential next generation of highly active drugs against herpes simplex viruses

Since the introduction of the nucleoside analogs decades ago, treatment of herpes simplex virus (HSV) infections has not seen much innovation, except for the development of their respective prodrugs. The inhibitors of the helicase–primase complex of HSV represent a very innovative approach to the treatment of herpesvirus disease, and this article considers the development of some representatives of this class of therapeutics. The molecular and biochemical features of the helicase–primase complex are considered and the development of three inhibitors of helicase–primase, BILS 179 BS, AIC316 and ASP2151, is described. The clinical development of AIC316 is at an advanced stage and displays general safety as well as favorable, long-lasting exposures in healthy volunteers. The first efficacy data from a Phase II trial with more than 150 HSV-2-positive subjects demonstrated dose-dependent antiviral activity.

Using centralized laboratory data to monitor trends in herpes simplex virus type 1 and 2 infection in British Columbia and the changing etiology of genital herpes

OBJECTIVES

Understanding the regional epidemiology of genital Herpes Simplex Virus (HSV) infections is important for clinical and public health practice, due to the increasing availability of type-specific serologic testing in Canada and the contribution of genital HSV-2 infection to ongoing HIV transmission. We used centralized laboratory data to describe trends in viral identifications of genital HSV in BC and assess the utility of these data for ongoing population surveillance.

METHODS

Records of viral identifications (1997-2005) were extracted from the Provincial Public Health Microbiology & Reference Laboratory database. Classification as genital or other site was based on documented specimen site. We conducted a descriptive analysis of trends over time, and calculated odds of HSV-1 infection among individuals with genital herpes.

RESULTS

Of 48,183 viral identifications, 56.8% were genital, 10.0% were peri-oral and 9.1% cutaneous; site was unknown for 22.9%. Among genital identifications, HSV-1 infection was more likely in females, younger age groups, and later time periods. The proportion of genital herpes due to HSV-1 increased over time from 31.4% to 42.8% in BC.

CONCLUSIONS

Our analysis of population-level laboratory data demonstrates that the proportion of genital herpes due to HSV-1 is increasing over time in BC, particularly among women and younger age groups; this has implications for clinical practice including the interpretation of type-specific serology. Provincial viral identification data are useful for monitoring the distribution of genital HSV-1 and HSV-2 infections over time. Improving clinical documentation of specimen site would improve the utility of these data.

Identifying potential pitfalls in conventional herpes simplex virus management

In recent years, it has become increasingly clear that genital ulcers from herpes simplex virus (HSV) are associated with HIV acquisition. In light of this evolving synergy in transmission and the availability of effective antiviral therapy, proper diagnosis and management of HSV becomes increasingly important. Unfortunately, conventional HSV management is founded on several popular misconceptions. Herein, we hope to dispel these common misconceptions and expand the current model of herpetic reactivation. By doing so, we aimed to unveil potential pitfalls in current herpetic management.

Anal sexually transmitted infections and risk of HIV infection in homosexual men

BACKGROUND

We examined a range of common bacterial and viral sexually transmitted infections as risk factors for HIV seroconversion in a community-based cohort of HIV-negative homosexual men in Sydney, Australia.

METHODS

Detailed information about HIV risk behaviors was collected by interview twice yearly. Participants were tested annually for HIV, anal and urethral gonorrhea and chlamydia, herpes simplex virus types 1 and 2, and syphilis. In addition, they reported annual diagnoses of these conditions and of genital and anal warts.

RESULTS

Among 1427 enrolled participants, 53 HIV seroconverters were identified, giving an incidence of 0.78 per 100 person-years. After controlling for number of episodes of insertive and receptive nonseroconcordant unprotected anal intercourse, there were independent associations with anal gonorrhea (adjusted hazard ratio = 7.12, 95% confidence interval: 2.05 to 24.79) and anal warts (hazard ratio = 3.63, 95% confidence interval: 1.62 to 8.14).

CONCLUSIONS

Anal gonorrhea and anal warts were independently associated with HIV acquisition. The added HIV prevention value of more frequent screening of the anus to allow early detection and treatment of anal sexually transmitted infections in homosexual men should be considered.

Left out but not forgotten: Should closer attention be paid to coinfection with herpes simplex virus type 1 and HIV?

Herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) are among the most common coinfections seen in individuals infected with HIV-1. Most research on HSV-HIV coinfection has focused on HSV-2, and in particular, on its impact on HIV transmission. HSV-2 is associated with micro- and macroulcerations in genital mucosal surfaces, increased numbers of HIV target cells in genital mucosal tissue and increases in plasma HIV viral load of up to 0.5 log(10) copies/mL, such that HSV-2 infection increases the risk of both HIV acquisition and transmission. Because plasma HIV RNA levels are a major determinant of rates of CD4 cell decline, HSV-2 coinfection may also adversely affect the progression of HIV disease. Anti-HSV medications have in fact been associated with reciprocal decreases in HIV viral load in short-term studies. These findings have led to the development of several clinical trials of HSV-2 suppression as strategies for preventing HIV transmission and slowing the rate of HIV disease progression. HSV-1 coinfection has largely been ignored from this growing body of research, yet there are several reasons that this coinfection remains an important issue for study. First, the seroprevalence of HSV-1 is consistently higher than that of HSV-2 among both HIV-infected and HIV-uninfected populations, underscoring the relevance of HSV-1 coinfection to the majority of HIV-infected persons. Second, pre-existing HSV-1 antibodies in individuals may modulate the course of subsequently acquired HSV-2 infection; the implications of such changes on HSV-HIV coinfection remain unexplored. Third, HSV-1 and HSV-2 are closely related viruses that share 83% genetic homology. Their virological and pathobiological similarities suggest that their implications on HIV pathogenesis may be similar as well. Finally, HSV-1 is becoming increasingly relevant because the incidence of genital HSV-1 has risen. Although genital herpes is traditionally associated with HSV-2, recent studies have shown that the majority of serologically confirmed primary genital herpes in some settings is attributable to HSV-1. Because the genital tract is an important site of biological interaction between HSV and HIV, this epidemiological change may be clinically important.

[Herpes serology for genital herpes]

The epidemiology of genital herpes is changing. The seroprevalence of HSV-2 infections is increasing, while HSV-1 is an increasingly common cause of herpetic ulcerations. The reference examination provides direct diagnosis after viral isolation in a cell culture or genome amplification. Herpes serology is indicated principally if direct examination is negative and in the absence of lesions. Non-type-specific serology detects antibodies common to HSV-1 and HSV-2. Its specificity and sensitivity are excellent, and it is approved as a reimbursable laboratory procedure. It cannot specify the viral type involved. Type-specific serology can distinguish between anti-HSV-1 and anti-HSV-2 antibodies. Currently available kits have a sensitivity and specificity, depending on the population studied, of 90 to 100%. It is not approved as a reimbursable laboratory procedure. HSV-1-specific serology cannot diagnose old HSV-1 genital infections, but seropositivity for HSV-2 generally suffices to diagnose HSV-2 genital herpes. The indication for type-specific serology must be discussed according to clinical context. The value of non-type-specific serology is limited.

Genital herpes

Genital herpes is the main cause of genital ulcers worldwide; the prevalence of herpes simplex virus (HSV) type 2 infections in the general population ranges from 10% to 60%. Most genital herpes is caused by HSV-2, although HSV-1 accounts for about half of new cases in developed countries. The risk of HIV acquisition is three times higher in people with HSV-2. Neonatal herpes is an uncommon but serious complication of genital herpes. Most genital HSV-2 infections are unrecognised and undiagnosed; infected individuals, even with mild symptoms, shed HSV, and can infect sexual partners. Since clinical diagnosis is neither sensitive nor specific, virological and type-specific serological tests should be used routinely. Oral antiviral drugs for HSV infections are safe and effective and can be used both to treat episodes and to prevent recurrences. Antiviral treatment of the infected partners and condom use reduce the risk of sexual transmission of HSV-2.

Minimal change in HSV-2 seroreactivity: a cross-sectional Swedish population study

The prevalence of antibodies to herpes simplex virus type 2 (HSV-2) was determined in sera collected from 2 Swedish cross-sectional populations during 1990/91 and 1996/97. A glycoprotein G2 (gG-2) peptide ELISA was used to analyse 2899 sera from adults. We found a prevalence of 13.0% in 18-70-y-olds in 1990/91 and 16.4% in 31-55-y-olds in 1996/97. Seropositivity to HSV-2 was somewhat higher in women than in men; 14.4% compared to 11.6% in 1990/91 and 18.9% compared to 13.6% in 1996/97. Overall there was a significant difference in female prevalence of HSV-2 compared to prevalence in males of the same age groups (p=0.013). Total antibody prevalence to HSV-1 of 88% in HSV-2 negative individuals above 18 y of age was found. HSV-2 positive individuals were found seropositive to HSV-1 in approximately 95% of the cases. 12% were negative for both HSV-1 and HSV-2 antibodies. In addition, there was no serological sign that the reported increase of HSV-1 as an early sexual disease had reduced the frequency of HSV-2 seropositivity in the sexually most active age groups. In conclusion, our investigation has shown no significant increase of HSV-2 seroprevalence in randomly selected Swedish subjects during the defined time period.

Macrophages and cytokines in the early defence against herpes simplex virus

Herpes simplex virus (HSV) type 1 and 2 are old viruses, with a history of evolution shared with humans. Thus, it is generally well-adapted viruses, infecting many of us without doing much harm, and with the capacity to hide in our neurons for life. In rare situations, however, the primary infection becomes generalized or involves the brain. Normally, the primary HSV infection is asymptomatic, and a crucial element in the early restriction of virus replication and thus avoidance of symptoms from the infection is the concerted action of different arms of the innate immune response. An early and light struggle inhibiting some HSV replication will spare the host from the real war against huge amounts of virus later in infection. As far as such a war will jeopardize the life of the host, it will be in both interests, including the virus, to settle the conflict amicably. Some important weapons of the unspecific defence and the early strikes and beginning battle during the first days of a HSV infection are discussed in this review. Generally, macrophages are orchestrating a multitude of anti-herpetic actions during the first hours of the attack. In a first wave of responses, cytokines, primarily type I interferons (IFN) and tumour necrosis factor are produced and exert a direct antiviral effect and activate the macrophages themselves. In the next wave, interleukin (IL)-12 together with the above and other cytokines induce production of IFN-gamma in mainly NK cells. Many positive feed-back mechanisms and synergistic interactions intensify these systems and give rise to heavy antiviral weapons such as reactive oxygen species and nitric oxide. This results in the generation of an alliance against the viral enemy. However, these heavy weapons have to be controlled to avoid too much harm to the host. By IL-4 and others, these reactions are hampered, but they are still allowed in foci of HSV replication, thus focusing the activity to only relevant sites. So, no hero does it alone. Rather, an alliance of cytokines, macrophages and other cells seems to play a central role. Implications of this for future treatment modalities are shortly considered.