Monkeypox and HIV Coinfection: Interim Guidance on Prevention and Treatment

Patients with advanced HIV infection who have not achieved virologic suppression with antiretroviral therapy (ART) may be at increased risk for severe monkeypox infection, according to study findings published in Morbidity and Mortality Weekly Report.

Current evidence from the United States and Europe suggests up to 51% of monkeypox cases are among patients with HIV coinfection.

Although no treatment has been approved for monkeypox infection by the Food and Drug Administration (FDA), tecovirimat is recommended as first-line treatment for monkeypox infection. Case reports from the United Kingdom found tecovirimat to be safe and well-tolerated among patients with monkeypox infection, resulting in shorter infection duration and reduced viral shedding.

Management of Monkeypox and HIV Coinfection

Tecovirimat also is recommended as first-line treatment for patients with monkeypox and HIV coinfection. Study authors noted clinically relevant interactions may occur in HIV-positive patients who receive tecovirimat in combination with ART, including a reduction in serum doravirine, rilpivirine, and maraviroc concentrations.

Further consideration was given to cidofovir, brincidofovir, and vaccinia immune globulin intravenous (VIGIV) as potential treatment options for this patient population.

The study authors recommended against the coadministration of cidofovir in patients receiving tenofovir disoproxil fumarate; however, if unavoidable, kidney function should be closely monitored. Additionally, cidofovir is contraindicated in patients with serum creatinine levels greater than 1.5 mg/dL due to the risk for nephrotoxicity.

In regard to the use of brincidofovir in patients with HIV and monkeypox coinfection, clinicians should closely monitor patients for adverse reactions, including increases in serum transaminases and bilirubin, as well as the occurrence of diarrhea or other gastrointestinal events. Patients receiving cobicistat, fostemsavir, or protease inhibitors should delay treatment for at least 3 hours following receipt of brincidofovir.

Although VIGIV may be considered in patients with severe disease, no contraindications were noted in regard to its use in patients receiving ART.

Vaccinations

Two vaccines have been licensed by the FDA for the prevention of orthopoxvirus infections: the Jynneos live replication-deficient vaccine, and the ACAM2000 live replication-competent vaccine.

For patients with HIV infection, the study authors recommended the Jynneos vaccine as the ACAM200 vaccine may increase the risk for adverse events related to progressive vaccinia virus infection. Clinical trial results showed similar immunogenicity and adverse event rates between HIV-negative patients and HIV-positive patients with CD4 counts of 200 to 750 cells/μL. The immunogenicity of the Jynneos vaccine among patients with CD4⁺ counts below 100 cells/μL is unkown. Although the Jynneos vaccine is safe in patients with HIV infection, no information is known on its clinical efficacy as postexposure prophylaxis among those coinfected with monkeypox.

Additional Guidance

For both HIV-positive and HIV-negative patients, recommendations for the prevention of monkeypox infection include avoiding sexual contact with infected individuals and postexposure vaccination.

“Persons identified as close contacts of persons with monkeypox should follow any additional guidance from their state or local health department,” the study authors concluded.