HIV & Monkeypox: More Answers Yield Even More Questions

By: Ranier Simons, ADAP Blog Guest Contributor

As the current Monkeypox outbreak continues to develop, so does ongoing research and discourse. A previous blog post, HIV & Monkeypox: What Patients Need to Know,[1] discussed early research regarding possible connections between HIV and Monkeypox. One main takeaway was that clinicians need to expand the list of symptoms they look for in Monkeypox infections. The current outbreak is not behaving as it has historically in the areas of Africa where it is endemic. Symptoms and related conditions can be mistaken for other sexually transmitted infections (STI's) or other illnesses. Additionally, it was noted that clinicians should adopt a heightened caution and suspicion of Monkeypox disease in at-risk groups. Recent research strongly reinforces the need for clinicians to increase their efforts to look for monkeypox disease in at-risk populations and the need for targeted education and messaging.

Photo Source: Medical Express

A report published September 9, 2022, in the U.S. Center for Disease Control & Prevention's (CDC) Morbidity and Mortality Weekly Report (MMWR) shows that people who are HIV-positive or have STI’s are disproportionately represented among those infected with Monkeypox.[2] Data from health departments in eight different U.S. jurisdictions was analyzed to examine Monkeypox clinical differences regarding HIV and STI status. Out of the 1,969 people infected with Monkeypox, who were 18 years of age or older, 38% (755) were HIV-positive, 41% (816) had another STI diagnosed in the previous year, and 18% (363) had both.[2] Additionally, those people living with HIV and also infected with Monkeypox had a higher prevalence of having an STI diagnosis in the preceding year than those diagnosed with Monkeypox who were HIV-negative.

A similar study published September 4, 2022, in HIV Medicine with a much smaller cohort was conducted in Germany.[3] In this study, 546 monkeypox infections from 42 sites were analyzed. All of the subjects were men who have sex with men (MSM). There were 256 (46.9%) patients living with HIV, mostly with viral suppression, 232 (42.5%) were taking pre-exposure prophylaxis  (PrEP), and 58 (10.6%) had no HIV infection or PrEP use. 

The likelihood of hospitalization of HIV-positive patients diagnosed with Monkeypox is still unclear. The CDC study indicates that co-infection with HIV may increase the risk of hospitalization but, the German study does not.[4] The CDC study confirmed hospitalization records from around 1,300 out of the 1,969 subjects. Eight percent of those hospitalized were HIV-positive and 3% were not. Conversely, the German study did not show a significant difference in hospitalization rates. Among those 546 men the overall hospitalization rates were 4% regardless of HIV status.

Both studies have limitations thus, cannot be used to provide definitive generalizations regarding clinical differences in Monkeypox infections between MSM with or without HIV. However, what is abundantly clear is the increased prevalence of the Monkeypox infections amidst MSM living with HIV, with STI’s or both. Evidence shows the heightened prevalence of HIV in populations that regularly receive HIV and STI health services. Thus, it is imperative that clinicians increasingly offer Monkeypox testing to those being treated for HIV and other STI’s in addition to increasing HIV and STI testing for those being treated for monkeypox.

Photo Source: ABC News / AP Photo / Neil Redmond, File

The ongoing research continues to support the observation that Monkeypox is being spread among MSM through social/sexual networks. Therefore, Monkeypox vaccination as prevention coupled with testing and treatment for HIV, Monkeypox and other STI’s remain to be where efforts need to be focused. The CDC reports that recent findings could lead to expanded Monkeypox vaccination recommendations. The findings may lead to vaccines being recommended for “people with recent STD infections, people with HIV, people taking pre-exposure prophylaxis (PrEP) medications to prevent HIV infection and, possibly, prostitutes”.[5] 

Continuing studies will eventually confirm whether HIV infection definitively causes worse outcomes with those infected with monkeypox and/or if simultaneous HIV/STI infection clinically makes someone  more susceptible to contracting Monkeypox. However, it is simultaneously important to work towards stopping the spread of the disease.

[1] Simobns, Ranier. (2022, September 1). HIV & Monkeypox: What Patients Need to Know. The ADAP Blog. Retrieved from https://adapadvocacyassociation.blogspot.com/2022/09/hiv-monkeypox-what-patients-need-to-know.html
[2] Hoffman, C. et al. (2022). Clinical characteristics of monkeypox virus infections among men with and without HIV: A large outbreak cohort in Germany. HIV Medicine. Retrieved from https://onlinelibrary.wiley.com/doi/10.1111/hiv.13378
[3] Tarin-Vincente, E., Alemany, A., et al. (2022). Clinical presentation and virological assessment of confirmed human monkeypox virus cases in Spain: a prospective observational cohort study. The Lancet. 400(10353), 661-669. DOI:https://doi.org/10.1016/S0140-6736(22)01436-2
[4] Hein, I. (2022, September 2022). People with HIV more likely to be hospitalized with Monkeypox? Retrieved from https://www.medpagetoday.com/infectiousdisease/hivaids/100628
[5] Stobbe, M. (2022, September 8). US may expand monkeypox vaccine eligibility to men with HIV. Retrieved from https://abcnews.go.com/Health/wireStory/us-expand-monkeypox-vaccine-eligibility-men-hiv-89545619

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.

HIV & Monkeypox: What Patients Need to Know

By: Ranier Simons, ADAP Blog Guest Contributor

Presently, there is not much research data concerning monkeypox and HIV. Due to the novelty of the recent monkeypox outbreak, there has not been enough time or volume of subjects to complete many studies. Monkeypox is a type of virus known as orthopoxviral. Smallpox is also an orthopox virus which is why the smallpox vaccine is used to protect against monkeypox. However, smallpox was eradicated in 1980 before the HIV/AIDS epidemic.[1] Additionally, monkeypox has existed for years in areas where it has been endemic, yet research has been neglected and underfunded.[2] Many questions need to be investigated. Medical science has already proven that T-cell deficiencies due to HIV render HIV-positive people more susceptible to viral and fungal infections.[1] Two main questions are: does HIV infection increase the risk of contracting monkeypox, and is HIV an aggravating factor in monkeypox infection/progression/severity? 

Photo Source: International Business Times

There is some medical evidence that having underlying immune deficiencies increases the risk of infection if exposed and the possibility of severe illness if infected.[5] People living with HIV are immunocompromised. However, the increased risk and negative outcomes of infection is more likely for those with untreated HIV. Untreated HIV means a much weaker immune system than those in treatment. Those in consistent medical treatment usually have well controlled HIV with many reaching viral suppression. Being undetectable results in a characteristically immunocompetent immune system more like those who are not living with HIV.[5]

The U.S. Centers for Disease Control & Prevention (CDC) last month updated its Clinical Considerations for Treatment and Prophylaxis of Monkeypox Virus Infection in People with HIV. The CDC contends that people with advanced HIV or who are not virologically suppressed with antiretroviral therapy can be at increased risk of severe disease with monkeypox, but they also note  that these considerations are based upon limited evidence available.

Two recently published studies give some developing insight into the relationship between HIV and monkeypox. One such study is a multinational study published in the New England Journal of Medicine. The study was performed by a collaborative international group of clinicians that spanned 43 sites in 16 countries.[2] Together they compiled a case series of 528 infections. In this sample set, 98% were gay or bisexual men, 2% were heterosexual men, 75% were white, 41% were HIV positive (the majority was well controlled), and the median age was 38.[2] The clinical presentation of those living with HIV and those not HIV positive were very similar, with no significant differences. 

This study confirmed sexual activity, among gay and bisexual men, as a significant transmission route. Tracking of infection indicated reports of infection clusters associated with sex parties or saunas. International travel and attendance of large gatherings linked to sex-on-site activities by some subjects support the developing theory of enhanced infection rates through sexual networks.[2] Notably, the study did not conclude that monkeypox was transmitted through semen. The genital, anal, and oral mucosal lesions were found to result from close skin-to-skin contact during sexual activity. However, testing 32 semen samples indicated results are inconclusive as to if the amounts and kinds of viral DNA found in the seminal fluid are replication competent.[2] More research is needed.

Photo Source: Physicians' Research Network

The second study was conducted in Spain. It was an observational prospective cohort study of 181 subjects from 3 sexual health clinics in Madrid and Barcelona.[3] A prospective cohort study means that the subjects are followed and observed over time to monitor the development of their outcomes. Of the 181 subjects, 166 identified as gay men or bisexual men, 15 as heterosexual men or women (6 were female), and 72 (40%) were HIV positive.[3] All of the subjects had skin lesions. Seventy-eight percent had anogenital lesions, and 43% had them in the oral and perioral regions. Additionally, other complications were observed. Proctitis was seen in 45 subjects; 19 had tonsilitis, 15 had penile swelling, and 8 had a widely spread-out rash. Notably, systemic symptoms (fever, headache, flu-like sickness, sore throat) before the appearance of rash occurred more often in those who had participated in anal-receptive intercourse than those who did not.[3]

The important takeaway from both studies is that clinicians need to expand the symptoms of what they look for in monkeypox infection. The current outbreak is not behaving like the outbreaks in the endemic area of Africa, which typically had hundreds of rashes with some as pustules. These studies showed cases where people have only had one lesion on the surface skin. Clinicians should be extra cautious and suspicious of monkeypox disease in at-risk populations. The virus can be present in atypical ways that may appear as other STIs, such as chlamydia or syphilis. Moreover, both studies showed the incubation period was, on average, about 7 to 8 days; thus, focusing energies on pre-exposure intervention is essential. 

Photo Source: The Nation

It is currently unknown how long people can spread disease after lesions have crusted over and healed. Condom use is suggested for eight weeks after healing. HIV subjects are overrepresented in the populations of the studies due to the way subjects were obtained. Subjects were picked from places like sexual health clinics where many HIV-positive patients receive treatment. Additionally, HIV-positive people with well-controlled disease are more likely to seek testing. The overrepresentation in the studies does not indicate that an HIV diagnosis necessarily equates to an increased likelihood of infection. However, more research is needed to investigate that. A recent study has also shown that a person can be simultaneously infected with HIV, Covid, and monkeypox.[4] Exploring the interaction with HIV is imperative.

Getting ahead of the current monkey pox infection wave with prevention is the most effective way to stop the current trajectory. Prevention includes behavior modification as well as testing and vaccination. Targeted  messaging to vulnerable groups will encourage behavior modification as well as testing. Widespread adoption of expanded protocols of symptom investigation by clinicians  will also increase the identification of monkeypox infection in those presenting with atypical symptoms. Halting the spread is paramount, before it has the chance to reach pandemic levels.

[1] Henderson, J. (2022, August 19). More data needed on monkeypox, HIV co-infection. Retrieved from https://www.medpagetoday.com/special-reports/exclusives/100279
[2] Thornhill, J., Barkati, S., Walmsley, S., et al. (2022). Monkeypox virus infection in humans across 16 countries — April–June 2022. New England Journal of Medicine. 387, 679-691. DOI: 10.1056/NEJMoa2207323
[3] Tarin-Vincente, E., Alemany, A., et al. (2022). Clinical presentation and virological assessment of confirmed human monkeypox virus cases in Spain: a prospective observational cohort study. The Lancet. 400(10353), 661-669. DOI:https://doi.org/10.1016/S0140-6736(22)01436-2
[4] Kneisel, K. (2022, July 26). How monkeypox can present like common STIs. Retrieved from https://www.medpagetoday.com/infectiousdisease/generalinfectiousdisease/99912
[5] World Health Organization. (2022, August 4). Monkeypox. Retrieved from https://www.who.int/news-room/questions-and-answers/item/monkeypox#:~:text=Anyone%20who%20has%20close%20contact,illness%20or%20dying%20from%20monkeypox

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.   

Spike in Monkeypox Disease Among MSM Causes Alarm, Too

By: Ranier Simons, ADAP Blog Guest Contributor

On Saturday, July 23, 2022, the World Health Organization (WHO) declared monkeypox a PHEIC, public health emergency of international concern.[1] Internationally, the number of cases has reached over 16,000 in over 75 European countries, North and South America, the Middle East, South Asia, Australia, and other parts of Africa not previously exposed.[1] In the United States, there have been roughly 2,900 cases. 

It is important to note that anyone can contract monkeypox. Monkeypox was first identified in 1958 in a colony of research monkeys.[2] Since 1970 human outbreaks have been reported in 11 African countries. The first outbreak outside of Africa was in 2003 in the United States. It occurred in several midwestern states and was linked to infected prairie dogs that people had as pets. Those pets likely contracted the disease from being housed with infected rats and door mice shipped from Ghana.

Photo Source: National Institute for Communicable Diseases

Although anyone can contract the disease, the recent outbreak disproportionately affects gay, bisexual, and men who have sex with men (MSM).[2] The U.S. Centers for Disease Control & Prevention (CDC), the media, and health professionals have consciously not labeled monkeypox a gay disease. It indeed is not a gay disease. However, given that the current outbreak mainly affects gay men, it is essential to clarify that explicitly. The award-winning blogger Mark S. King points out, "Gay men are getting monkeypox and suffering greatly. When gay men understand the threat, we are more likely to take precautions, get vaccinated, or be informed about treatment”.[3]

Concerns about stigma are valid. Gay men historically have and continue to face stigma and apathy in the healthcare arena and public opinion regarding healthcare issues. But, King also points out that it is dangerous to bury facts with vague and evasive messaging.[3] Vague messaging leads the general public to think that their present odds of contracting the disease are higher than the reality of the numbers. Conversely, labeling monkeypox a gay illness would make the public complacent about being mindful of their activities and being tested when they should be. 

The Washington Post’s Benjamin Ryan points out that “…public health experts know well, epidemiology is less concerned with whether someone could contract an infection; instead, the much more vital questions focus on which groups of people are most likely to be exposed to a pathogen, to contract it and why.”[4] There need to be targeted education and prevention efforts aimed at gay men to emphasize the specifics that make them more susceptible to the spread of monkeypox. Facts show that the sexual and social networks of gay men are why it is hitting the population hard. There have been clusters of infections traced back to events such as large circuit parties, nightclub events, and pool parties. Bathhouses are the settings of some clustered outbreaks, as well. Gay men need to be informed of the statistical fact of gay men having an increased incidence of multiple sex partners, especially in combination with certain events and travel, which also increases the likelihood of the spread of monkeypox amidst their demographic.

Monkeypox is contracted through close skin-to-skin contact. Transmission comes from exposure to broken skin, mucus membranes, respiratory droplets, infected bodily fluids, and even contact with contaminated linens. It is not airborne like Covid-19. Rubbing, kissing, and physical contact are enough to cause infection. Sexual intercourse is not necessary. Seven to fourteen days after infection is when symptoms usually appear. Fever, chills, exhaustion, headaches, and muscle weakness are typically initial signs.[2] Progression includes the swelling of lymph nodes and widespread body rash that can include the mouth, hands, and feet. Then fluid-filled painful pox can appear on the body, surrounded by red circles. There is increased reporting that some infected individuals only see some rash and painful pox sores in the genital and anal regions instead of all over the body.

Photo Source: PBS

Over 190,000 doses of the two-dose Jynneos vaccine have been pulled from the Strategic National Stockpile. Jynneos is used for the prevention of monkeypox and smallpox. There is still not enough in circulation to meet the demand for vaccination nor to vaccinate all those in the highest risk categories. There is also an antiretroviral effective against monkeypox named TPOXX (tecovirimat), approved by the U.S. Food & Drug Administration (FDA) for use against smallpox in 2018.[5] Unfortunately, TPOXX was only authorized for smallpox because it is deadly and can be considered a possible bioterrorism weapon. Monkeypox is not fatal like smallpox. Thus obtaining TPOXX requires many pages of paperwork to get it from the Strategic National Stockpile. Additionally, protocol requires doctors to submit pictures of a patient's lesions to the local health department or CDC and a folio of pages of detailed information to get TPOXX. After getting the drug, patients are required to keep a daily journal while they are taking it.[5]

Presently, monkeypox prevention is paramount as vaccination and treatment options are scarce. Effectively educating gay, bisexual, and men who have sex with men with the unadulterated details of their demographics’ statistically documented behaviors put them at high risk is the best weapon against the spread of the disease. Targeted explicit information delivered with respect and dignity is the best way to avoid stigma while undergirding the importance of the information.

[1] Branswell, H. (2022, July 23). WHO declares monkeypox outbreak a public health emergency. Retrieved from https://www.statnews.com/2022/07/23/who-declares-monkeypox-outbreak-a-public-health-emergency/
[2] Howard, J. (2022, July 21). Monkeypox spreading in 'cluster events,' but vaccines can help stop it, local health officials say. Retrieved from https://www.cnn.com/2022/07/21/health/monkeypox-clusters-local-officials/index.html
[3] King, M. (2022, July 19). Monkeypox is a gay thing. We must say it. Retrieved from https://marksking.com/my-fabulous-disease/monkeypox-is-a-gay-thing-we-must-say-it/
[4] Ryan, B. (2022, July 18). You are being misled about monkeypox. Retrieved from https://www.washingtonpost.com/opinions/2022/07/18/monkeypox-gay-men-deserve-unvarnished-truth/
[5] Walsh, D. (2022, July 21). There Is a monkeypox antiviral. But try getting it. Retrieved from https://nymag.com/intelligencer/2022/07/tpoxx-is-a-monkeypox-antiviral-but-try-getting-it.html

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.