To date, information about the risk of severe monkeypox virus (MPXV) disease in PLWH is not well established. Therefore, the aim of this study was to assess the impact of HIV on the clinical course of MPXV infection.
National case-series study. Patients from 18 Spanish hospitals, with PCR-confirmed MPXV infection since April 27th to September 30th were included in this study. The duration of the clinical course was computed from the onset of symptoms until mucocutaneous lesions complete clearance or MPXV infection-related complications resolution. Disseminated disease was defined as the presence of mucocutaneous lesions involving 6 or more areas of the body surface. Severe complications included extensive superinfection of skin lesions without response to treatment, pain refractory to non-opioid analgesia, sepsis, odynophagia with obstructive sensation, myopericarditis, gastrointestinal bleeding, encephalitis, or ophthalmologic complications. The main outcome was the development of severe MPXV disease, defined as: i) duration of the clinical course ≥21 days, or; ii) disseminated disease, or: iii) emergence of severe complications, or iv) requirement of hospital admission.
1,028 individuals were included. Overall, 928 (90%) were MSM. 448 (43%) were PLWH, of whom 26 (2%) had a CD4 cell count < 350 cells/mm3. HIV viral load ≥1,000 cp/mL was found in 19 (4%) PLWH. 18 of them (94%) were not on ART. Severe MPXV disease was observed in 16 (62%) PLWH with CD4 < 350 cells/mm3, 164 (41%) PLWH with CD4 ≥350 cells/mm3 and 208 (40%); i.e, 61% PLWH and CD4 < 350 cels/mm3 vs. 372 (40%), (p=0.032) of the remaining study participants showed severe MPXV disease. Regarding plasma HIV viremia, 14 (74%) PLWH with HIV-RNA ≥1,000 cp/mL showed severe disease vs. 174 (41%) PLWH with plasma HIV-RNA load < 1,000 copies/mL and 222 (38%) individuals without HIV infection (p=0.008). In multivariate analysis, adjusted by age, sex, CD4 cell count and HIV viral load at the time of MPXV infection, only plasma HIV-RNA ≥1,000 cp/mL was associated with a greater risk of developing severe MPXV disease among PLWH [adjusted OR= 5.6 (95% confidence interval 1.5-20.6), p=0.009].
PLWH, considered as a whole, are not at a greater risk of MPXV severe disease. However, those with uncontrolled HIV infection, due to lack of effective ART, develop more severe outcomes. Efforts should be done to increase HIV testing and to ensure linkage to HIV care services. In this setting, ART must be immediately started.