The emergence of mpox as an HIV-related opportunistic infection

During the multinational mpox (formerly known as monkeypox) clade IIb outbreak in 2022, the emergence of severe mpox among people with HIV bore a striking resemblance to the emergence of opportunistic infections early in the HIV epidemic of the 1980s. Similar to HIV-associated opportunistic infections, mpox produces substantially greater morbidity and prolonged disease in people with advanced (ie, CD4 <350 cells per mm³) or untreated HIV infection.^1-3 A US report² of 57 hospitalised patients with severe mpox found that 82% had HIV infection, of whom almost three-quarters had a CD4 count less than 50 cells per mm³. Most patients were Black or African American (68%) and 23% were experiencing homelessness, reflecting inequities in access to resources for the prevention and treatment of HIV infection.² Approximately a third required intensive care support and 20% died, of whom nearly all had HIV infection.² Notably, fewer than 10% of the patients who had diagnosed HIV were taking antiretroviral therapy (ART).² These data support the decision made on Sept 28, 2022, to add mpox to the US Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV.⁴

HIV-associated opportunistic infections continue to affect mainly two risk groups. First are those who are unaware of their HIV infection and present to care late in the course of their disease with an opportunistic infection as the sentinel event that leads to their HIV diagnosis. Second are those who have been diagnosed with HIV but receive intermittent care, are unable to access ART due to structural barriers or psychosocial factors, or have limited adherence to ART. In the USA today, every opportunistic infection represents a failure within our nation’s HIV care continuum. The emergence of mpox as an opportunistic infection highlights the need for continued aggressive, comprehensive strategies for HIV testing, prevention, linkage to care, and treatment services to prevent HIV infection or disease progression that will reduce people’s risk for severe mpox and mitigate its impact. Taking these actions, alongside providing ready access to mpox vaccination and to services for sexual health and prevention to networks of people who are at risk for mpox and HIV, can diminish the potential of mpox to present as an HIV-associated opportunistic infection.