Information Concerning Monkeypox
Monkeypox in people with HIV
Available summary surveillance data from the European Union,1 as well as separate reports from Portugal, Spain, and England, report that 30% to 51% of patients with monkeypox for whom HIV status is known have HIV.
Regarding infection risk, it is currently unknown whether HIV alters (e.g., increases) a person’s risk of acquiring monkeypox disease after exposure.
Regarding illness after infection, the available data indicate that people with advanced and uncontrolled HIV can be at a higher risk of severe or prolonged disease. In a 2017–18 case series of 122 Nigerian patients with monkeypox, 4 of the 7 deaths occurred among persons with untreated advanced HIV; however, information was absent about the overall proportion of patients who had HIV to determine if this mortality was disproportionally large. A second 2017–18 case series, also from Nigeria, included 9 people with HIV for whom clinical data relevant to HIV status were provided: CD4 cell counts ranged from 20–357 cells/mm3 and most had either failed antiretroviral therapy (ART) or were newly diagnosed, suggesting a lack of viral suppression. Compared with other patients, those with HIV had higher rates of secondary bacterial infection, more prolonged illness (and thereby also longer period of infectiousness), as well as a greater likelihood of a confluent or partially confluent rash rather than discrete lesions. In contrast, reports from European countries where most patients are on effective ART have noted no deaths or evident excess in hospitalizations thus far among people with HIV and monkeypox. Additionally, the WHO has stated that
“people with HIV…who take antiretroviral therapy and have a robust immune system have not reported a more severe course of disease.”
Signs and Symptoms
The signs and symptoms of monkeypox virus infection are similar in people with or without HIV, including characteristic rash, fever, and lymphadenopathy. For immunocompromised people, monkeypox virus infection may present with atypical manifestations or more severe illness (e.g., sepsis, disseminated rash).
Symptoms of monkeypox can include:
- Muscle aches and backache
- Swollen lymph nodes
- Respiratory symptoms (e.g. sore throat, nasal congestion, or cough)
- A rash that may be located on or near the genitals (penis, testicles, labia, and vagina) or anus (butthole) but could also be on other areas like the hands, feet, chest, face, or mouth.
- The rash will go through several stages, including scabs, before healing.
- The rash can look like pimples or blisters and may be painful or itchy.
You may experience all or only a few symptoms:
- Sometimes, people get a rash first, followed by other symptoms. Others only experience a rash.
- Most people with monkeypox will get a rash.
- Some people have developed a rash before (or without) other symptoms
Monkeypox symptoms usually start within 3 weeks of exposure to the virus. If someone has flu-like symptoms, they will usually develop a rash 1-4 days later.
How it spreads
Monkeypox spreads in a few ways.
- Monkeypox can spread to anyone through close, personal, often skin-to-skin contact, including:
- Direct contact with monkeypox rash, scabs, or body fluids from a person with monkeypox.
- Touching objects, fabrics (clothing, bedding, or towels), and surfaces that have been used by someone with monkeypox.
- Contact with respiratory secretions.
- This direct contact can happen during intimate contact, including:
- Oral, anal, and vaginal sex or touching the genitals (penis, testicles, labia, and vagina) or anus (butthole) of a person with monkeypox.
- Hugging, massage, and kissing.
- Prolonged face-to-face contact.
- Touching fabrics and objects during sex that were used by a person with monkeypox and that have not been disinfected, such as bedding, towels, fetish gear, and sex toys.
- A pregnant person can spread the virus to their fetus through the placenta.
- It’s also possible for people to get monkeypox from infected animals, either by being scratched or bitten by the animal or by preparing or eating meat or using products from an infected animal.
A person with monkeypox can spread it to others from the time symptoms start until the rash has fully healed and a fresh layer of skin has formed. The illness typically lasts 2-4 weeks.
Scientists are still researching:
- If the virus can be spread when someone has no symptoms
- How often monkeypox is spread through respiratory secretions, or when a person with monkeypox symptoms might be more likely to spread the virus through respiratory secretions.
- Whether monkeypox can be spread through semen, vaginal fluids, urine, or feces.
Incubation and prodrome
Monkeypox disease is characterized by an incubation period (5-21 days), prodrome (the development of initial symptoms such as fever, malaise, headache, weakness), and rash (2-6 weeks). It is not known if people with HIV have different characteristics regarding the incubation or prodromal phase of illness.
Monkeypox can be spread from the time symptoms start until the rash has healed, all scabs have fallen off, and a fresh layer of skin has formed. The illness typically lasts 2-4 weeks, but has been shown to take up to 42 days (6 weeks).
Immunocompromised persons, including persons with advanced HIV or untreated HIV, may present with an atypical rash, including a disseminated rash, which may make diagnosis more challenging. In one study, people with poorly controlled HIV were more likely to have genital and/or anal/rectal lesions and a confluent or partially confluent rash, as opposed to discrete lesions. Additionally, people in this study with poorly controlled HIV were more likely to have prolonged illness.
However, even though prior strains of Monkeypox were spread by skin-to-skin contact and respiratory droplets, this variant of Monkeypox has been demonstrated to be in semen, rectal tissue, as well as saliva, urine and feces, although it is currently unknown if it is found in amounts high enough to be considered sexually transmitted. Nonetheless, this pandemic is presenting with painful mouth/oral lesions and rectal/anal lesions, and we believe it is only time before science catches up and demonstrates sexually transmission.
Monkeypox virus infection should also be considered when evaluating for other causes of rash, including herpes zoster (shingles), scabies, molluscum contagiosum, herpes, syphilis, chancroid, lymphogranuloma venereum, allergic skin rashes, and drug eruptions. Monkeypox can be confused with disseminated herpes zoster or herpes simplex virus infections. These herpesvirus infections more commonly affect persons with immunocompromising conditions, especially disseminated herpes zoster.
Managing monkeypox in people with HIV
People with HIV may be at increased risk of severe disease and prolonged infectiousness. Therefore, prophylaxis (e.g., vaccination), medical treatment and close monitoring are a priority for this population. Providers should consider both viral suppression and CD4 count in weighing the risk of severe outcomes for any patient with HIV. As noted earlier, severe outcomes have been observed in people with inadequately treated HIV who have CD4 counts ≤ 350/mm3 and are likely not virologically suppressed; however, the available data are presently insufficient to define actionable thresholds.
Managing HIV in people with monkeypox
ART and opportunistic infection prophylaxis should be continued in all people with HIV who develop monkeypox. Treatment interruption may lead to rebound viremia that could complicate the management of monkeypox virus infection (e.g., worsen the severity of illness). People taking antiretrovirals for HIV pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP) should likewise continue taking these medications.
Tecovirimat (a.k.a. TPOXX, ST-246)
Tecovirimat is an antiviral medication available as a pill or as an injection for intravenous (IV) administration. It is approved by the FDA for treatment of smallpox in adults and children but not for monkeypox because data are not available on the effectiveness of tecovirimat in treating monkeypox in humans.
Tecovirimat can be administered under an expanded access Investigational New Drug (EA-IND) protocol and is available from the Strategic National Stockpile (SNS). In CT, our DPH has made TPOXX available to anyone who fits the criteria for treatment. The dosage is 3-200mg capsules taken twice daily for 7-14 days.
Studies using a variety of animal species have shown that tecovirimat is effective in treating orthopoxvirus-induced disease. Human clinical trials indicated the drug was safe and tolerable with only minor side effects. A case report from the UK suggested that tecovirimat may shorten the duration of illness and viral shedding.
CONTACT: if you have any questions or concerns, please do not hesitate to contact us at HCAI, (203)345-0404. Based on CT Department of Health recommendations, we are offering a limited supply of Jynneos to eligible patients who meet the following criteria:
1. Persons identified by state and local public health as being close contacts to someone who has tested positive for monkeypox
2. Connecticut residents who meet the following criteria:
- Men who have sex with men, gay, bisexual, transgender, gender non-conforming, or gender non-binary AND
- Age 18 or older AND
- Have had multiple or anonymous sex partners in the last 14 days
If eligible to be vaccinated, persons should especially consider getting vaccinated if:
- Your partners are showing symptoms of monkeypox, such as a rash or sores
- You met recent partners through online applications or social media platforms (such as Grindr, Tinder or Scruff), or at clubs, raves, sex parties, saunas or other large gatherings
- You have a condition that may increase your risk for severe disease (HIV or another condition that weakens your immune system, history of atopic dermatitis or eczema)
Gary Blick, MD and Elysia Cerreta, DNP, NP-C
"Partnering to End the Global HIV Epidemic by 2030"
(and now the Monkeypox pandemic)