People with HIV are more likely to be hospitalized with monkeypox?

Co-infection with HIV may increase the risk of hospitalization in patients with monkeypox, CDC researchers said, although other research hasn’t confirmed it.

Among more than 1,300 monkeypox patients in eight U.S. jurisdictions, hospitalizations were more common in patients with HIV (8%) than in 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.

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

However, Hoffmann made sure that his team “had hardly ever seen any patients with severe immunodeficiency. In addition, very few patients were viremic. I think that’s why we don’t see any 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 said MedPage today. “We shouldn’t get lost in discussions about what a sexually transmitted disease is [sexually transmitted disease] is.”

The problem is that STD clinics are not available for all patients, he noted. “In Germany, depending on the symptoms, patients are also visited by dermatologists, urologists and proctologists. These professional groups should be specifically informed. We still see many cases where monkeypox isn’t properly diagnosed because colleagues don’t carry it on their radar.”

Curran and colleagues pointed out that the percentage of monkeypox patients who had HIV (38%) is “disproportionate” to the US national HIV prevalence estimates for MSM (23%), suggesting that “monkeypox HIV infection could increasingly be transmitted between networks of people living with HIV, underscoring the importance of using HIV and STIs effectively [sexually transmitted infection] Care and Prevention Systems for Monkeypox Vaccination and Prevention Efforts,” they wrote.

“Our results highlight a critical opportunity to use systems that provide HIV and STI care for monkeypox prevention,” said Curran MedPage today in an email. “Providers could consider offering HIV and STI testing to patients screened for monkeypox — and offering monkeypox testing to patients screened for HIV and STIs.”

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

Among 1,308 patients with available hospitalization data, the proportion of patients hospitalized with monkeypox was lower in non-HIV patients (3%) than in those with HIV (8%). Of 45 patients with monkeypox and HIV who were not virally suppressed, 27% were hospitalized, and of 61 with a CD4 cell count < 350 cells/μl, 15% were hospitalized.

However, the authors noted that information on why these men were hospitalized was incomplete and “it is not known whether this represents a more serious monkeypox disease.”

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

“People with HIV had more rectal symptoms…we didn’t have enough information to understand exactly why, but this could be related to differences in site of exposure (i.e. part of the body), increased biological susceptibility due to HIV, or other factors,” said Curran.

In the study of 546 MSM with monkeypox (mean age 39 years) 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 in the last 6 months STI .

The most common sites of monkeypox infection were genital (49.9%) and anal (47.9%), and fever (53.2%) and lymphadenopathy (42.6%) were the most common generalized symptoms.

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

Hoffmann and team attributed all hospitalizations to “severity of disease or complications, principally massive lymph node and genital swelling, extensive total skin involvement, bleeding, or refractory pain that could not be managed on an outpatient basis, particularly in patients with anal or oral involvement.”

Both reports had some notable limitations. The CDC analysis was limited to diagnosed and reported cases of monkeypox in eight jurisdictions and may not be generalizable to all US cases. Curran and his team also said that incomplete data on clinical signs and symptoms and hospitalizations could affect the associations observed by HIV infection status.

With regard to the German study, the authors noted the observational nature and incomplete data collection. In addition, “given the small number of cases with concomitant diseases, severe immune deficiency and/or severe courses, we were not able to identify risk factors such as concomitant diseases.”

Curran said the CDC is expected to “notify state and local health departments that federal funding for HIV and STI prevention can now be used for monkeypox efforts.”