More Data Needed on Monkeypox, HIV Co-Infection

San Francisco has seen some of the highest case counts of monkeypox in the U.S., and Monica Gandhi, MD, MPH, of University of California San Francisco (UCSF), said she's seen plenty of co-infection with HIV.

Gandhi cautioned that she sees a skewed population as the medical director of a large HIV clinic, "Ward 86," at San Francisco General Hospital. However, she said there's a dearth of research on monkeypox in people living with HIV, and these cases need more attention.

"Definitely this has to be tracked," Gandhi, who directs the UCSF-Bay Area Center for AIDS Research, told MedPage Today. "Is there a proclivity in people living with HIV?"

There is practically no knowledge about the interaction between orthopoxviruses and HIV because smallpox was eradicated in 1980, prior to the HIV/AIDS epidemic, Gandhi said. She questioned whether there may be something about orthopoxviruses that could make someone with HIV more susceptible to one such as monkeypox.

For instance, with HIV, T-cell deficiencies can make an individual more prone to viral and fungal infections, she noted.

Though data are sparse, Gandhi pointed to a New England Journal of Medicine (NEJM) study published in July that looked at 528 monkeypox infections diagnosed between April 27 and June 24 at 43 sites in over a dozen countries. The researchers reported that 98% of people with infection were gay or bisexual men, and that 41% had HIV.

"This is not typical of the gay male population," Gandhi said, where the lifetime risk of HIV is closer to 17%. As a result, specialists in the field have been speculating on whether monkeypox infection could be worse for people living with HIV.

In the U.K., the British HIV Association has also called attention to the NEJM research, as well as a study published earlier this month in The Lancet, which looked at 181 monkeypox cases from Spain, of which 92% were in gay or bisexual men and 40% were in people living with HIV.

The British HIV Association's latest publicly issued guidance on monkeypox stated that, as of August 15, there have been 12 reported monkeypox-related deaths globally, with an overall mortality of 0.04%.

"Whether mortality in the 2022 outbreak is associated with immunosuppression, including HIV, remains unknown," the association stated.

Gandhi has not seen any studies showing people living with HIV are more likely to have severe illness from monkeypox, aside from a single case that researchers said showed the potential severity of monkeypox in the setting of severe immunosuppression and untreated HIV infection.

That said, because of a focus on vaccines and treatment during the current outbreak, "we may be modifying the natural history by early intervention, as we should be," Gandhi said.

It is absolutely true that, when it comes to people living with HIV, those with low CD4 counts and high viral load "tend to do more poorly across the board," she said. For instance, that has been seen in worse outcomes with COVID-19.

Sophia Nurani, ANP-BC, assistant director of community health at Ryan Chelsea-Clinton in New York City, told MedPage Today that, in general, people living with HIV who have good CD4 counts are recovering from monkeypox just like anyone else.

"HIV patients who are healthy are the ones who are probably more likely to get tested and treated," Nurani said.

However, she expressed concern for many people who may be living with uncontrolled HIV, who don't seek testing or treatment. "They are at risk for more severe outcomes," she said.

In terms of treatment with the antiviral tecovirimat (Tpoxx), the CDC does list some drug interactions with HIV medications, and Gandhi highlighted the potential for a weak interaction that has been noted regarding tecovirimat and lopinavir/ritonavir (Kaletra) for HIV.

One limitation for any patient taking tecovirimat, Nurani said, is that it's supposed to be taken after consuming a meal containing at least 25 grams of fat, or it can cause vomiting.

Overall, both Gandhi and Nurani called attention to the burdensome documentation required to prescribe tecovirimat, since the drug is only FDA approved for smallpox, and is available under the CDC's non-research expanded access investigational new drug protocol for monkeypox.

There is a movement for emergency use authorization, Gandhi said. It would be unprecedented without a randomized clinical trial testing efficacy, she said, but it may be a possibility.

Gandhi reiterated the importance of learning more about monkeypox infection in people living with HIV -- and getting resources to those who need them most. Years of being an HIV doctor has given her a unique perspective on the monkeypox outbreak.

"It's never felt stigmatizing to me to point out the risk group that's most affected by a disease," Gandhi said. "It fact, it just felt empowering, because then you can direct limited resources towards the group that's most affected."

Correction: A previous version of this article stated that CDC cited no interactions with tecovirimat and HIV drugs, but the agency does cite that some interactions may occur.

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