Deadlier Mpox Infections Discovered In People With Advanced HIV



Mpox, formerly known as monkeypox, can produce a more severe and more deadly form of disease in people living with advanced HIV infections, researchers wrote in the Lancet medical journal on Tuesday, an important finding as experts and officials work to keep cases down as the global outbreak subsides.

Key Facts

Mpox can produce a 15% mortality rate in people living with advanced HIV disease and suppressed immune systems, researchers said, according to global data from 382 people with advanced HIV disease and mpox.

The study, which included 27 of the 60 people reported to have died of mpox at the time the work was written up, identified the concerning and potentially life-threatening form of mpox in people living with HIV who had CD4 counts—a measure of the immune system cells attacked by HIV—below 200 (a healthy person living with or without HIV has counts of over 500).

The disease is characterized by “widespread, large… and coalescing skin lesions” that can kill surrounding tissue, the researchers wrote, with high rates of other infections and, in some cases, “unusual” lung nodules or lesions.

Given the risks of mpox for people living with HIV and immunosuppression, the researchers said all people with mpox should be screened for HIV and that those with HIV and immunosuppression be prioritized for vaccination and antiviral treatment.

The findings, based on the largest study of its kind, justify mpox being added to the list of 14 infections that “behave differently and are particularly dangerous to immunosuppressed people with advanced HIV infection,” said Chloe Orkin, the study’s lead researcher and a professor of HIV medicine at Queen Mary University of London.

Orkin, who described mpox as “an opportunistic infection” in such cases, said clinicians use the list of “AIDS-defining conditions” to manage people most at risk of dying from these infections, adding that no new or emerging infection has been added to the list since 1993.

Big Number

85,922. That’s how many cases of mpox have been recorded in 110 territories, according to CDC data. Fewer than 1,350 infections have been recorded in seven areas where the disease has historically been reported, all in Central and Western Africa and the vast majority reported in Nigeria (789) and the Democratic Republic of the Congo (370). Many are likely to have gone unreported or undetected. Some 96 deaths linked to mpox have been reported, 15 in locations that historically reported outbreaks.

What To Watch For

Left untreated, HIV can attack and destroy parts of the body’s immune system needed to fight off infection. Some intruders—including tuberculosis and fungi responsible for thrush—and cancers that the body normally keeps under control are opportunistic in the face of a diminished, or even absent, immune response, acting more aggressively than is otherwise expected, possibly even lethally. The WHO and CDC maintain a list of such conditions that serves as international guidelines for those treating people living with advanced HIV disease and immunosuppression. It is this list that the researchers think mpox should be added to. Meg Doherty, Director of Global HIV, Hepatitis and STIs Programmes at the World Health Organization, said the work “makes a very compelling case.” Mpox behaves “like other opportunistic infections” in these circumstances, Doherty said, as well as bringing an elevated risk of severe disease and death. “WHO will review relevant data with global experts to assess if severe mpox in people living with HIV is a marker for advanced HIV disease,” Doherty said.

What To Watch For

Though the mpox outbreak has largely subsided in wealthy countries, the disease has not gone and outbreaks still rage in a number of African countries. Mpox was a well-known problem in the region for decades before the global outbreak, though attention, funding, awareness and research in the area was limited. Developments in knowledge, vaccines and treatments from the global outbreak have largely benefited wealthy nations and passed these countries by.

News Peg

Mpox has been known for decades but was largely ignored by most of the world as outbreaks were sporadic, small and limited to specific regions of Africa, only leaving under rare circumstances linked to travel. That changed in 2022, when the virus erupted onto the global scene in an outbreak that differed from previous outbreaks in scale and in scope, affecting many countries that had never seen the virus before. The outbreak was also profoundly different from past outbreaks in terms of who was most affected, with data indicating the virus to be almost exclusively spreading through sex among gay, bisexual and other men who have sex with men. The outbreak also raised a host of different symptoms compared to previous outbreaks, largely reflective of the way in which it is spread. Significant numbers of those infected—up to half, by some counts—were people living with HIV. Fatality rates for recent outbreaks are around 3-6%, according to the WHO. Options for treating and vaccinating against mpox were, and remain, limited. Few options exist and of those that do, all are in very short supply and most were developed for use against smallpox, a related disease that has been eradicated, and had not been field tested against mpox.

Further Reading

Monkeypox In Women Frequently Misdiagnosed As Sexually Transmitted Infections, Study Finds (Forbes)

Monkeypox Has a New Name: Mpox (NYT)

WHO may soon end mpox emergency — but outbreaks rage in Africa (Nature)

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