Mpox

Management of Mpox in Persons with HIV

Epidemiology and prevention

An outbreak of Mpox Clade II (formerly known as Monkeypox) is ongoing since May 2022 outside west/central Africa. More recently, a Mpox Clade Ib outbreak has emerged, mostly affecting african countries. Sexual intercourses have been reported as a major route of diffusion, and transmission has disproportionally affected MSM, particularly people with HIV and PrEP users
Counselling should be offered to these persons to reduce the risk of Mpox transmission
Close contacts of an individual with Mpox should be identified and monitored according to local guidelines
See Immunisation in Persons with HIV for recommendations regarding Mpox preventive and post-exposure vaccination
Individuals recently diagnosed with Mpox should be tested for concomitant STIs. See also STI

Clinical features and diagnosis

Fever, lymphadenopathy and enanthema in prodromal phase, followed by cutaneous lesions (most frequently vesiculopustular, but multiple morphologies may occur). Atypical presentations, such as single genital ulcer, proctitis and anorectal involvement, or conjunctival involvement may occur
Aggressive disseminated infection with large necrotizing skin/mucosal lesions and multisystemic involvement (pulmonary, ocular or central nervous system manifestations; secondary cutaneous or bacterial superinfection) may occur in individuals with immunosuppression, including persons with advanced/uncontrolled HIV infection (CD4 T cells<200 cells/mm³, having most cases <100 cells/mm³)
Definitive diagnosis requires Mpox DNA detection by PCR on cutaneous lesion/crust swab. PCR on oropharyngeal/conjunctival/rectal swab may be useful in atypical presentations. See also WHO guidelines and CDC guidelines

Management and treatment

All individuals with Mpox should be offered appropriate symptomatic treatment (pain and fever management, care of skin lesions)
Isolation measures for confirmed cases and effective contact-tracing should be implemented to reduce the risk of Mpox spreading, according to local guidelines
Non-severe cases without immunosuppression or other high-risk clinical manifestations and able to self-isolate at home may be managed conservatively. Close monitoring of clinical conditions and early recognition of complications (e.g.: bacterial superinfection; difficult breathing; deterioration of general conditions) should be ensured
Severe cases or cases at high-risk of severe disease, defined as persons with any of the following:

CD4 T cells <200 cells/mm³ (see also CDC guidelines)

fulminant disseminated infection (confluent, necrotic skin lesions; pulmonary or CNS complications; sepsis)

mucosal or genital lesions with the potential for causing strictures

ocular involvement

lymphadenopathy causing difficulties in breathing/oral intake

skin and deep tissues bacterial superinfection

severe, uncontrolled pain

pre-existing skin conditions affecting skin integrity

pediatric, pregnant or breast-feeding populations

other conditions requiring hospitalization
Should be evaluated for hospitalization and initiation of antiviral treatment (see also WHO guidelines and CDC guidelines)

Therapeutic considerations for severe cases

Severe cases and persons at risk of severe disease should be admitted for close monitoring.

In immunocompromised patients, it is critical to optimize immune function to maximize chances of recovery.
To date, effectiveness of antiviral therapies in Mpox has not been systematically evaluated, and randomized trials are ongoing.
Tecovirimat has been approved for the treatment orthopox viruses infections. Clinical trials to assess benefit of tecovirimat treatment in people with Mpox are ongoing. Administration of tecovirimat (600 md bid with fatty meal po or 200 mg bid infused over 6 hours IV for 10-14 days) may be considered in severe cases, see also MMWR-Interim clinical treatment considerations for Mpox. Tecovirimat may reduce RPV levels. Consider additional drug-drug interactions when prescribing tecovirimat; See also Anti-infective/ART interaction table
A recent clinical trial on Mpox clade I showed that tecovirimat was safe but not effective in improving Mpox in this setting, see also NIH press release

Several additional agents have been proposed as therapies for Mpox.

Brincidofovir and cidofovir may be effective against Mpox. The use of these agents may be considered in patients not eligible to tecovirimat, or in addition to tecovirimat for severely immunocompromised individuals. Monitor closely for adverse events.
Vaccinia immune globulin intravenous (VIGIV) can be considered for severely immunocompromised patients unable to mount an effective immune response. Caution should be applied in administering VIGIV in patients with corneal involvement. See also MMWR-Interim clinical treatment considerations for Mpox
Topical application of trifluridine could be considered in patients with ocular involvement

Considerations for ART start

Cases of clinical deterioration attributable to immune reconstitution inflammatory syndrome (IRIS) have been observed in persons with advanced HIV infection antiretroviral-naïve or re-initiating ART. Monitor carefully for signs of IRIS after ART introduction