Background:
People living with HIV (PLWH) represent 38-50% of the 2022 global MPOX outbreak. Most PLWH included in case series had CD4 counts >500 cells/mm3 and similar outcomes to persons without HIV. Existing data suggest poorer outcomes in immunosuppressed PLWH. 60 deaths with MPOX outside of Africa were reported in 2022 – only 9 have been described and published. We describe clinical characteristics and deaths in PLWH with low CD4 cell counts ( < 350 cells/mm3) and MPOX.
Methods:
International collaborators from 18 countries contributed data from PLWH with CD4 counts < 350 cells/mm3 & confirmed MPOX between May 11th and December 24th, 2022. We describe in detail the clinical course, complications & causes of death with respect to both CD4 & viral load (VL) strata. Analyses were descriptive (continuous variables described as mean and standard deviation (SD); categorical variables as counts & percentages).
Results:
We report on 258 persons (mean age 36 years): 251 cisgender men, 2 cisgender women, 5 transgender women. At (MPOX) diagnosis, 234 were known PLWH (205/234 on ART); 24/258 were undiagnosed, 26/258 had a concurrent opportunistic illness. Mean CD4 count was 210 cells/mm3 (SD 96); mean VL was 1.6 log c/mL (SD 2). A total of 39 (15%), 70 (27%), 87 (34%), 53 (21%) persons had CD4 counts of < 100, 101-200, 201-300, & 301-350 cells/mm3, respectively. 66/258 persons were hospitalised with MPOX, of whom 1 survived an ITU admission & 14 died. Among those who died, the mean CD4 count was 63 cells/mm3, mean VL was 4.5 log c/mL. 13/14 had severe coalescing/necrotising skin lesions, secondary bacterial infections and rectal complications, 10/14 had respiratory symptoms and respiratory failure, 5/14 had neurological involvement (all described as confusion not encephalitis). More deaths occurred in persons with lower CD4 counts and higher viral loads (CD4 < 100, 18% vs. CD4 >300, 0%), & (VL ≥4 log 16% vs. VL < 50 c/mL 0.7%) respectively (Figure). More complications occurred in 39 persons with CD4 < 100 compared to 53 persons with CD4 >300 cells/mm3: respiratory (59% vs 25%), rectal (59% vs 25%), skin (51% vs 8%), bacterial (38% vs 9%), gastrointestinal (26% vs 6%), CNS (10% vs 2%). Immune reconstitution inflammatory syndrome was suspected in 15/46 persons started or re-started on ART with MPOX.
Conclusions:
In our case series in PLWH with MPOX, severe systemic complications and deaths occurred most commonly in persons with CD4 < 100 cells/mm3 and viraemia.
FIGURE. OUTCOME BY CD4 COUNT (A) AND HIV VIRAL LOAD (B)