Fulminant mpox as a defining condition of AIDS: useful or stigmatizing? The 2022 mpox outbreak was declared a public health emergency of international concern in July 2022 by the WHO within 2 months of initial reports. With more than 85,000 confirmed cases and 86 deaths, the outbreak has primarily affected men, many of whom identify as men who have sex with men (MSM). In the current outbreak, a high proportion of people with mpox are people living with HIV . These findings have raised concerns that advanced HIV could predispose to more severe mpox. However, although mpox outcomes are similar regardless of HIV status, current evidence indicates that mpox deaths, to our knowledge, have occurred only in people living with HIV . |
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An international collaboration of doctors, led by Queen Mary University of London and the Fight Infections Foundation/Hospital Germans Trias in Barcelona, has identified a severe, necrotizing form of mpox with high mortality in immunocompromised people living with HIV.
The authors call for this form of mpox to be added to the World Health Organization and Center for Disease Control’s list of serious infections that are considered particularly dangerous for people with advanced HIV disease. They also recommend that all people with mpox get tested for HIV.
An international collaboration of clinicians, who have previously published two pivotal global case series on mpox, have today (February 21) published the largest case series of mpox infection in people with advanced HIV disease in The Lancet , in which identify a new severe form of mpox .
Most mpox infections in the current multinational outbreak have occurred in sexual networks of gay, bisexual, and other men who have sex with men. 38-50% of people diagnosed with mpox in 2022 are also living with HIV, the vast majority of whom are on HIV treatment and leading healthy lives.
Investigation of previous outbreaks in historically affected countries and of a small number of people in the current outbreak suggested that mpox infection may be more severe in people with advanced HIV. However, until now, there has been no large global study to examine this further.
SHARE-net doctors looked at 382 people with advanced HIV disease and mpox, including 27 of the 60 people (at the time of writing) who had died of mpox during the outbreak in several countries. The group describes a very severe form of mpox characterized by large, widespread, necrotizing skin lesions; high rates of serious infections; and, in some cases, unusual lung lesions. This form of the disease carries a mortality of 15% in people with advanced HIV disease and immunosuppression. All 27 deaths occurred within this group .
The study provides evidence that the disease is behaving differently and of great concern in people with advanced HIV disease and immunosuppression, and the authors call for it to be added to the definitions of AIDS-defining diseases established by the Center for Disease Control and Prevention. of Diseases (CDC) and the WHO. which are used by doctors around the world to guide the management of people at highest risk of dying from these infections.
AIDS-defining conditions are a group of conditions that are serious and life-threatening for people with advanced HIV-related illness. A person with HIV is defined as having advanced HIV-related disease when their CD4 cell count, a type of immune system cell, is less than 200 cells/mm3. A healthy person living with or without HIV has CD4 counts of more than 500 cells/mm3.
Adding this severe form of mpox to the existing list of AIDS-defining conditions will help healthcare professionals protect immunocompromised people who are most at risk of dying from mpox infection. All people with mpox should be tested for HIV, and all people at risk with HIV and immunosuppression should be prioritized for preventive mpox vaccination and antivirals.
Most deaths from mpox have occurred in countries where there are low levels of HIV diagnosis and/or without universal access to antivirals for mpox and/or HIV and without access to intensive care units. A concerted global effort is needed to ensure equitable access to antivirals and vaccines in countries where the interaction of uncontrolled HIV infection and mpox is most common.
Lead author of the research Chloe Orkin, Professor of HIV Medicine at Queen Mary University of London and director of the SHARE collaboration, said: “There is currently a list of fourteen infections that behave differently and are particularly dangerous. for immunocompromised people with advanced HIV infection. These are called "AIDS-defining conditions" by international public health agencies. Doctors around the world use this classification to guide their management of people at highest risk of dying from these infections. We therefore ask that mpox be added to this list of "AIDS-defining conditions" as it is an opportunistic infection. “No new or emerging infections have been added to CDC classification I since 1993.”
Oriol Mitjà, first author and associate professor of Infectious Diseases and Global Health, Foundation Fight Infectious Diseases, Germans Trias i Pujol University Hospital, said: "We describe a severe form of mpox that mainly affects young men who have sex with men and which causes death in 15% of people with advanced HIV. When doctors recognize necrotizing skin lesions and/or lung involvement, they must use a differentiated clinical pathway. In addition, health authorities must prioritize the vaccination of people who living with HIV, particularly in countries with low levels of diagnosis or without universal free access to antiretroviral treatment.
Matthew Hodson, chief executive of NAM aidsmap, said: Our success in curbing new mpox infections may have led us to believe that mpox is “no longer a cause for concern”. These data highlight that mpox remains a significant threat to the lives of people with advanced HIV , a group who may not be receiving the medical care they need, including mpox vaccination.
Although mpox is rarely serious for those of us whose HIV is controlled with treatment, the rates of serious illness and mortality as a result of mpox for people with untreated or unsuppressed HIV are concerning. This again highlights the urgency of ensuring that people with HIV are diagnosed and have safe access to treatment. Routine HIV testing for all people diagnosed with mpox has the potential to reduce mpox-related deaths and advanced HIV disease. “The progress we have made in our ability to treat HIV is an impressive scientific achievement, we must ensure that everyone benefits.”
