Nonsuppressed HIV status increases risk for severe mpox

Among patients with mpox (previously monkeypox), those with nonsuppressed HIV infection are more likely to experience severe disease than HIV-negative patients and HIV-positive patients with suppressed viral loads, according to study results published in The Journal of Infectious Diseases.

Investigators conducted a cohort study to evaluate HIV-related factors associated with severe mpox disease. Data were sourced from 4 academic medical centers in Atlanta, Georgia. Eligible patients (N=395) were diagnosed with mpox infection between June and October of 2022 and evaluated for mpox outcomes on the basis of HIV status. Two multivariable logistic regression analyses were performed to assess associations between HIV status, HIV-related immunosuppression, and severe mpox. The primary outcome was severe mpox as defined by the Centers for Disease Control and Prevention.

The final analysis comprised 324 patients with and 66 without HIV infection, as well as 5 for whom HIV status was unknown. Of patients with and without HIV infection, the median ages at mpox diagnosis were 35 (IQR, 30-41) and 35 (IQR, 29-41) years, 100% and 98.5% were assigned male sex at birth, 88.6% and 66.6% were Black, 89.8% and 75.8% reported sex with cisgender men, 8.0% and 6.1% were unhoused, and 85.2% and 77.3% were not vaccinated against mpox, respectively.

Data captured from 257 HIV-positive with known viral loads showed 167 (65.0%) were and 90 (35.0%) were not virologically suppressed at mpox diagnosis. Among 242 HIV-positive patients with available data on immune function, CD4⁺ counts at mpox diagnosis were below 100 cells/µL in 19 (7.9%) and between 100 and 200 cells/µL in 51 (21.1%).

In regard to mpox outcomes for the total population, 77 (19.5%) patients experienced severe disease, 66 (16.7%) required hospitalization, and 68 (17.2%) reported complications.

The rate of severe mpox was highest in patients with nonsuppressed HIV infection (43.3%), followed by those with suppressed HIV infection (18.6%) and those without HIV infection (9.1%). Further analysis of these groups showed that hospitalization (41.1%, 13.2%, and 9.1%, respectively) and complications (31.1%, 15.0%, and 9.1%, respectively) also occurred more frequently in patients with nonsuppressed HIV infection.

Among all patients, severe mpox was associated with homelessness (odds ratio [OR], 6.661; 95% CI, 3.005-14.766), non-HIV immunosuppression (OR, 3.239; 95% CI, 1.338-7.840), HIV positivity (OR, 2.519; 95% CI, 1.012-6.272), and older age (OR, 1.032; 95% CI, 1.002-1.062).

In patients with HIV infection, severe mpox was associated with lack of engagement in HIV care (OR, 3.474; 95% CI, 1.804-6.689), nonsuppressed viral load status (OR, 2.100; 95% CI, 1.004-4.392), and older age (OR, 1.041; 95% CI, 1.004-1.079).

Study limitations include the reliance on data collected from medical charts, changes in mpox testing practices that occurred over time, and the small number of patients with low CD4⁺ counts.

“The 2022 mpox epidemic disproportionately affected people who are Black and those with HIV in the Southeastern United States,” the investigators noted. “Additional studies will be needed to further understand the interplay of HIV, host function, and mpox pathogenesis,” they concluded.

By Jessica Nye, PhD

References:

Aldred B, Scott JY, Aldredge A, et al; and the Emory Mpox Analysis Patient Series (MAPS) Study Group. Associations between hiv and severe mpox in an Atlanta cohort. J Infect Dis. Published online November 24, 2023. doi:10.1093/infdis/jiad505