CDC: People with Untreated or Advanced HIV May be at Risk for Severe Monkeypox

The Centers for Disease Control and Prevention (CDC) released its Interim Guidance for Prevention and Treatment of Monkeypox in Persons with HIV Infection, which was published in the CDC’s Morbidity and Mortality Weekly Report on August 5, to offer clinicians information as well as alerting people in these populations to be aware and take precautions to avoid catching the virus.

“Persons with advanced HIV might be at increased risk for severe monkeypox. Postexposure prophylaxis and antiviral treatments are available for persons with HIV infection,” the MMWR wrote. “Prompt diagnosis and treatment and enhanced prevention efforts might reduce the risk for severe outcomes.”

In the MMWR, the authors said it was “not known whether HIV infection affects a person’s risk for acquiring monkeypox. [Men who have Sex With Men] (MSM) with HIV infection are at present disproportionately represented among monkeypox cases.”

The authors noted that it is challenging to ascertain the roles of exposure and biologic risks. They did say that sexual behavior confers risk of HIV acquisition and sexually transmitted infections and the risk for monkeypox through sexual contact is “likely similarly increased.”

“Although it is possible that poorly controlled HIV would increase risk for monkeypox after exposure, evidence from other diseases suggests that persons with HIV infection who are receiving [antiretroviral therapy] ART and have robust CD4 counts are not at increased risk for most infections, including opportunistic infections, and therefore might not be at increased risk for monkeypox after exposure,” the authors wrote.

Treating People with HIV and Monkeypox
The authors of the MMWR recommend that all patients with HIV and contract monkeypox continue on their ART and opportunistic infection prophylaxis. “Treatment interruption might lead to rebound HIV viremia that could complicate the management of monkeypox, including worsening illness severity,” they wrote.

Tecovirimat is the first-line medication recommended for treatment of monkeypox, including people with HIV. For clinicians, they should consider treatment interactions among tecovirimat, cidofovir, and brincidofovir and certain ARTs. The authors note that no drug interactions should preclude coadministering tecovirimat and ART. Cidofovir is contraindicated in patients with serum creatinine >1.5 mg/dL because of the associated nephrotoxicity. There are no specific contraindications for use of VIGIV among persons with HIV infection.

Potential Mortality
This particular strain of monkeypox that has been prevalent in the United States is the West African variant, which is reported to be the milder of the two strains. The other strain is the Central African variant, which causes more severe illness and mortality.

Still CDC offered some data from the field in the form of a small case series. “Available data indicate that persons with advanced and uncontrolled HIV infection might be at higher risk for severe or prolonged monkeypox disease following infection,” the MMWR indicated. “In a 2017–2018 case series describing 122 Nigerian patients with monkeypox caused by the same strain responsible for the current outbreak, four of the seven deaths occurred among persons with untreated advanced HIV infection; however, information about the overall proportion of patients with HIV infection was not available, precluding the ability to determine whether this mortality was disproportionately large.”

Vaccines

There are 2 vaccines licensed by the FDA for the prevention of monkeypox: JYNNEOS and ACAM2000. The safety and immunogenicity of the former has been evaluated in people with HIV. “Clinical trials demonstrate that JYNNEOS is well-tolerated with similar immunogenicity and rates of adverse events in persons with HIV infection with CD4 cell counts of 200–750 per μL and persons without HIV infection,” the authors reported.

“When vaccination is used for prevention of monkeypox in persons with HIV infection, JYNNEOS is preferred over ACAM2000,” the MMWR authors wrote. “Based on current recommendations from ACIP, ACAM2000 is contraindicated for persons with HIV infection because of the risk for severe adverse effects resulting from the spread of vaccinia virus.”