People With HIV More Likely to Be Hospitalized With Monkeypox?

Co-infection with HIV may increase the risk of hospitalization in patients with monkeypox, CDC researchers said, though other research did not confirm this.

Among over 1,300 patients with monkeypox in eight U.S. jurisdictions, hospitalization was more common among those with HIV (8%) than those without the virus (3%), reported Kathryn G. Curran, PhD, of the CDC's Monkeypox Emergency Response Team, and colleagues in the Morbidity and Mortality Weekly Report.

However, in a cohort of 546 men who have sex with men (MSM), about half of whom were living with HIV, clinical characteristics were similar between those with and without HIV, and hospitalization rates were low overall (4%), reported Christian Hoffmann, MD, of University Hospital of Schleswig-Holstein in Kiel, Germany, and colleagues in a study published in HIV Medicine.

But Hoffmann was careful to note that his team had "hardly seen any patients with severe immunodeficiency so far. Also, very few patients were viremic. I think that is the reason why we do not see differences between HIV-positive and HIV-negative cases."

"I think we need to communicate very clearly that the vast majority of monkeypox infections are sexually transmitted," he told MedPage Today. "We should not get lost in discussions about what an STD [sexually transmitted disease] is."

The problem is that STD clinics are not available to all patients, he noted. "In Germany, patients are also seen by dermatologists, urologists, and proctologists, depending on the symptoms. These professional groups should be informed in a targeted manner. We still see many cases where monkeypox is not diagnosed correctly because colleagues do not have it on their radar."

Curran and colleagues pointed out that the percentage of patients with monkeypox who had HIV (38%) is "disproportionate" to national HIV prevalence estimates for U.S. MSM (23%), which suggests that "monkeypox might be increasingly transmitted among networks of persons with HIV infection, underscoring the importance of leveraging HIV and STI [sexually transmitted infection] care and prevention delivery systems for monkeypox vaccination and prevention efforts," they wrote.

"Our findings highlight a critical opportunity to use systems that deliver HIV and STI care for monkeypox prevention," Curran told MedPage Today in an email. "Providers may consider offering HIV and STI testing to patients evaluated for monkeypox -- and offering monkeypox testing to patients evaluated for HIV and STIs."

The mounting evidence of disproportionate monkeypox cases in populations already accessing HIV and STD health services prompted the CDC to issue a letter last week to 59 state, local, and territorial health department STD prevention programs, awarding supplemental funds for monkeypox treatment under STD and HIV prevention activities.

"Most monkeypox transmission is occurring through sexual transmission in the same populations who experience the highest risk for HIV and other STDs," noted the letter signed by Jonathan Mermin, MD, MPH, director of the CDC's National Center for HIV, Viral Hepatitis, STD, and TB Prevention. It grants use of funds for monkeypox activities in conjunction with other STD activities, including testing and vaccination targeting populations disproportionately affected, and conducting community mobilization and education events and activities.

In the CDC report, Curran and colleagues looked at 1,969 patients (median age 35, mostly men) diagnosed with monkeypox from May 17 to July 22 in eight U.S. jurisdictions; 38% had HIV, 41% had an STI in the prior year, and 18% had both.

Among 1,308 patients with data on hospitalization available, the proportion of those hospitalized with monkeypox was lower among those without HIV (3%) versus those with HIV (8%). Among 45 patients with monkeypox and HIV who were not virally suppressed, 27% were hospitalized, and among 61 with a CD4 count <350 cells/μL, 15% were hospitalized.

The authors noted, however, that information on the reason for hospitalization in these men was incomplete and it is "not known whether this represents more severe monkeypox illness."

The 755 patients who had monkeypox and HIV were more likely than those without HIV to have rectal pain (34% vs 26%), tenesmus (20% vs 12%), rectal bleeding (19% vs 12%), purulent or bloody stools (15% vs 8%), and proctitis (13% vs 7%), but were less likely to report lymphadenopathy (48% vs 53%).

"People with HIV had more rectal symptoms ... we had insufficient information to understand exactly why, but this could be related to differences in site (i.e., body part) of exposure, increased biologic susceptibility due to HIV, or other factors," Curran said.

In the study of 546 MSM with monkeypox (median age 39) from 42 German health centers, 46.9% had HIV, 42.5% were taking HIV pre-exposure prophylaxis (PrEP), and 52.4% had at least one STI in the last 6 months.

The most frequent localizations of monkeypox infection were genital (49.9%) and anal (47.9%), and fever (53.2%) and lymphadenopathy (42.6%) were the most frequent general symptoms.

Of the men with HIV, 2.7% were hospitalized compared with 5.2% of those without the virus.

Hoffmann and team attributed all hospitalizations to the "severity of the clinical picture or complications, mainly massive swelling of lymph nodes and genitals, extensive involvement of the entire integument, hemorrhage, or refractory pain that could not be managed on an outpatient basis, especially in patients with anal or oral involvement."

Both reports had some notable limitations. The CDC analysis was limited to diagnosed and reported monkeypox cases in eight jurisdictions and might not be generalizable to all U.S. cases. Curran and team also said that incomplete data on clinical signs and symptoms, as well as hospitalization, might affect the associations observed by HIV infection status.

As for the German study, the authors noted the observational nature and incomplete data collection. Furthermore, "given the small number of cases with comorbidities, severe immunodeficiency, and/or severe courses, we could not determine risk factors such as comorbidities."

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