Management of Mpox in Persons with HIV

Management of Mpox in Persons with HIV

Epidemiology and prevention

  • An outbreak of Mpox (formerly known as Monkeypox) outside West/Central Africa is ongoing since May 2022. In the context of the current outbreak, sexual intercourses have been the major route of transmission. It 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 Vaccination 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 bacteriaemic 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, but preliminary data suggest that their use may be beneficial in severe cases. See also MMWR-Interim clinical treatment considerations for Mpox

First-line therapy: Tecovirimat

Dose Comments

Oral dosing:

  • 40-120 kg: 600 mg bid
  • >120 kg: 600 mg tid
  • To be administered with high-fat meal

IV dosing:

  • 35-120 kg: 200 mg every 12 hours over 6 hours
  • > 120 kg: 300 mg every 12 hours over 6 hours
  • Do not administer IV formulation in patients with CrCl< 30mL/min, and use caution in people with milder degrees of renal impairment

Treatment duration: 10 to 14 days

  • Tecovirimat has been approved for the treatment orthopox viruses infections (including Mpox) based on animal studies. Studies to assess benefit of tecovirimat treatment in people with Mpox are ongoing. Data on special population (pregnant women; pediatric patients) are limited.
  • Tecovirimat may reduce RPV levels. Consider additional drug-drug interactions when prescribing tecovirimat; See also Anti-infective/ART interaction table

Additional therapeutic options

Several agents have been proposed as adjunctive or alternative therapies for Mpox.

  • Brincidofovir and cidofovir are effective against other poxviruses, and anecdotical data suggest that they could be effective against Mpox. The use of these agents may be considered in patients not eligible to or failing first-line therapy with tecovirimat. In addition, either brincidofovir or cidofovir may be considered in combination with tecovirimat as first-line therapy for severely immunocompromised patients.
  • 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