Monkeypox and HIV/AIDS: When the outbreak faces the epidemic

Human monkeypox (MPX) is a zoonotic viral disease caused by a member of the Orthopoxvirus genus, the monkeypox virus (MPXV). MPX has been reported primarily in endemic countries in Central and West Africa, with few imported cases to other regions. However, a rapidly emerging outbreak of monkeypox infection in over 20 non-endemic countries commenced in May 2022 and raised concerns because most patients had no travel history to endemic areas and were diagnosed through primary care and sexual health services and were mainly reported in men who have sex with men (MSM). Several men who developed monkeypox are living with HIV, but there are limited data on monkeypox and people living with HIV/AIDS (PLWHA). Previous studies in Africa found that people with uncontrolled HIV had worse outcomes, including more extensive and longer-lasting lesions, more complications, and several deaths. In 2017–2018, an extensive study of 118 confirmed cases of MPX in Nigeria reported a case fatality rate of 6%, seven people with monkeypox virus infection died, four of whom had HIVwith features ofAIDS, not on antiretroviral therapy (ART). However, the total number of people with MPX who were livingwithHIVwas not described.Also, in a study of 40MPX cases in Nigeria (9 with HIV type 1 coinfection; at least 7 with high viremia and low CD4 counts), PLWHAwere significantly more likely to have skin rashes ≥2 cm, genital ulcers, secondary bacterial skin infection, and longer duration of illness. More recently, in Portugal, the first 27 confirmed cases appear to be mainly among MSM aged 30–39, living with HIV (14/27) and having a mild form of the disease. Likewise, in a report of four MPX cases among MSM in Italy, two were HIV-positive and on effective antiretroviral therapy, two were HIV-negative and on PrEP, and all recovered without treatment. Mild forms of MPX in PLWHA presenting with genital ulcers and rash have been reported in the current outbreak so far. Although there are limited data among people living with HIV, it appears that those with undetectable viral load and a high CD4 count on ART are less likely to have a severe disease course. Furthermore, the British HIV Association (BHIVA) suggests that those with a CD4 count below 200 cells/ mm, persistent detectable viral load (e.g. >200 copies/mL), or a recent HIV-related illness should be considered at higher risk. In the current outbreak, it is obligatory to consider the diagnosis of monkeypox in all MSM patients with typical rash and sexual behaviour that may place them at risk of acquisition of MPXV. For these cases, it is necessary to ensure active contact tracing, reliable tests and prompt treatment in severe disease, and the possibility of post-exposure prophylaxis of contacts to prevent further spread of the disease. In addition, while anyone can acquire the virus through close personal contact, there is an urgent need for education and awareness, especially among the PLWHA and the LGBTQI+ community, on the signs and symptoms of MPX and how to reduce transmission, particularly during Pride season.