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HIV & Monkeypox
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67% in Georgia HIV+
Clinical presentation and virological assessment of confirmed human monkeypox virus cases in Spain: a prospective observational cohort study
Aug 8 2022
181 patients had a confirmed monkeypox diagnosis and were enrolled in the study. 166 (92%) identified as gay men, bisexual men, or other men who have sex with men (MSM) and 15 (8%) identified as heterosexual men or heterosexual women. Median age was 37•0 years (IQR 31•0-42•0). 32 (18%) patients reported previous smallpox vaccination, 72 (40%) were HIV-positive, eight (11%) had a CD4 cell count less than 500 cells per μL, and 31 (17%) were diagnosed with a concurrent sexually transmitted infection. Median incubation was 7•0 days (IQR 5•0-10•0).
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01436-2/fulltext
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Monkeypox Virus Infection in Humans across 16 Countries μ April-June 2022
We report 528 infections diagnosed between April 27 and June 24, 2022, at 43 sites in 16 countries. Overall, 98% of the persons with infection were gay or bisexual men, 75% were White, and 41% had human immunodeficiency virus infection; the median age was 38 years. Transmission was suspected to have occurred through sexual activity in 95% of the persons with infection.
https://www.nejm.org/doi/full/10.1056/NEJMoa2207323
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BHIVA Guidance
https://www.bhiva.org/BHIVA-rapid-guidance-on-monkeypox-virus
Impact of HIV on MPV
Prior to the current outbreak the evidence as to how HIV impacts risk of MPV acquisition or its disease course was limited to two case series from Nigeria:
• 118 MPV cases: 6% mortality rate; 4/7 deaths in people with HIV, at least 3 with advanced HIV and not on ART; total number of people with HIV not described [1]
• 40 MPV cases (9 with HIV; at least 7 with high viraemia and/or low CD4 counts): people with HIV experienced more prolonged illness, larger lesions, and higher rates of both secondary bacterial skin infections and genital ulcers [2]
Another case series from the US included 34 MPV cases, but HIV status was not reported; there were no deaths [3]
Since then, two large case series have been published, including:
• 528 cases from 16 countries across 5 continents [4]: 98% GBMSM and 41% living with HIV (96% on ART, 95% with viral suppression, median CD4 680 cells/mm3). Clinical presentation was similar amongst those with and without HIV, including frequency of hospital admission. Three people experience serious complications: 1 case of epiglottitis in a person with HIV; 2 cases of myocarditis, one in a person living with HIV.
• 181 cases from Spain [5]: 92% GBMSM, 40% living with HIV of whom 11% had CD4 <500 cells/mm3. HIV status did not impact incubation period, clinical features, or lesion number. Median time from lesion onset to dry crusting was 11 days (QR 8-14 days) for people with HIV vs 10 days (IQR 7-12 days) for people without HIV.
As of 15 August 2022, there have been 12 reported MPV-related deaths globally, with an overall mortality of 0.04% (1.9% and 0.015% in countries that have and have not reported MPV historically, respectively) [6]. Whether mortality in the 2022 outbreak is associated with immunosuppression, including HIV, remains unknown.
Currently, beyond vaccine considerations (see below), we do not recommend any specific actions for people with HIV beyond vigilance about clinical presentations and history of exposure. We suggest the following to be potentially at higher risk of MPV infection and complications, and thus to be prioritised for specialist review:
• CD4 cell count <200 cells/mm3
• Recent HIV-related illness (e.g., AIDS diagnosis in the prior six months)
• Persistent HIV viraemia (e.g., >200 copies/mL)
• Concomitant conditions or treatments that may cause immune suppression
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