Q&A: Does HIV affect the clinical course of monkeypox?
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The monkeypox outbreak has disproportionately affected gay and bisexual men, including those with HIV.
A study published last week in MMWR found that among U.S. cases with available data, 99% occurred in men, 94% of whom reported recent male-to-male sexual or close intimate contact. Additionally, 41% also had HIV.
Another study published in The New England Journal of Medicine that assessed more than 500 cases in 16 countries also found that an overwhelming majority — 98% — occurred among gay or bisexual men, and that 41% of the patients had HIV.
The CDC has published interim guidance for the prevention and treatment of monkeypox in people with HIV. Per the guidance, no drug interactions have been identified that would prevent someone on ART from taking the antiviral tecovirimat for monkeypox. Likewise, the guidance says people on ART can safely receive the Jynneos monkeypox vaccine.
We asked Infectious Disease News Editorial Board Member Peter Chin-Hong, MD, professor of medicine and director of the transplant infectious disease program at the University of California, San Francisco, to answer some other questions about concurrent HIV and monkeypox infection.
Healio: Does HIV affect the course of monkeypox?
Chin-Hong: Yes and no. In the current global outbreak, 30% to 50% of the current infected individuals whose serostatus is known are infected with HIV. There is no evidence so far that they have a more prolonged or severe illness course, but it is likely that these patients had very well-controlled HIV.
The course of monkeypox likely depends on CD4 count — likely less than 350 — because HIV status encapsulates a wide range of immune status. In previous outbreaks in West Africa, HIV-infected patients with untreated advanced disease had severe complications — for example, bacterial superinfection and more severe monkeypox rash (confluent) and more prolonged disease. This is borne out by my own clinical experience, as well seeing more advanced illness and health care use in HIV-infected patients with low CD4 counts.
Healio: Does HIV affect a person’s susceptibility to it?
Chin-Hong: No evidence of that so far.
Healio: Are there any other clinically relevant questions about concurrent HIV and monkeypox infection?
Chin-Hong: The questions are: How long are patients with HIV transmissible for regardless of CD4 count? When can they safely resume unprotected sex with their partners? What is the spectrum of clinical presentation? Do they respond the same to monkeypox vaccines, including the dose-sparing intradermal administration planned? How does tecovirimat interact with some of the HIV and opportunistic infection medications? Do patients with HIV need more prolonged courses of tecovirimat? What is the interaction of coinfection and opportunistic infections common in HIV-infected patients with monkeypox?
References:
O’Shea J, et al. MMWR Morbid Mortal Wkly Rep. 2022;doi:10.15585/mmwr.mm7132e4.
Philpott D, et al. MMWR Morbid Mortal Wkly Rep. 2022;doi:10.15585/mmwr.mm7132e3.
Thornhill JP, et al. N Engl J Med. 2022;doi:10.1056/NEJMoa22073232.
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Healio Interview
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