Interim Guidance for Prevention and Treatment of Monkeypox in Persons with HIV Infection — United States, August 2022

Abstract

On August 5, 2022, this report was posted as an MMWR Early Release on the MMWR website (https://www.cdc.gov/mmwr).Monkeypox virus, an orthopoxvirus sharing clinical features with smallpox virus, is endemic in several countries in Central and West Africa. The last reported outbreak in the United States, in 2003, was linked to contact with infected prairie dogs that had been housed or transported with African rodents imported from Ghana (1). Since May 2022, the World Health Organization (WHO) has reported a multinational outbreak of monkeypox centered in Europe and North America, with approximately 25,000 cases reported worldwide; the current outbreak is disproportionately affecting gay, bisexual, and other men who have sex with men (MSM) (2). Monkeypox was declared a public health emergency in the United States on August 4, 2022. † Available summary surveillance data from the European Union, England, and the United States indicate that among MSM patients with monkeypox for whom HIV status is known, 28%-51% have HIV infection (3-10). Treatment of monkeypox with tecovirimat as a first-line agent is available through CDC for compassionate use through an investigational drug protocol. No identified drug interactions would preclude coadministration of tecovirimat with antiretroviral therapy (ART) for HIV infection. Pre-and postexposure prophylaxis can be considered with JYNNEOS vaccine, if indicated. Although data are limited for monkeypox in patients with HIV, prompt diagnosis, treatment, and prevention might reduce the risk for adverse outcomes and limit monkeypox spread. Prevention and treatment considerations will be updated as more information becomes available. BackgroundSigns and Symptoms: Classically, monkeypox occurs in three stages. After an incubation period of approximately 1-2 weeks, a prodrome, characterized by fever and lymphadenopathy occurs, which is followed by the onset of a deep-seated vesicular or pustular rash that often begins centrally and spreads to the limbs (11). Transmission of monkeypox can occur through direct contact with the infectious rash, scabs, or body fluids, through respiratory secretions during prolonged face-to-face contact or intimate physical contact, or through touching items, such as clothing or linens, that previously touched a patient's infectious rash or body fluids. § * These authors contributed equally to this report. † h t t p s : / / w w w. w a s h i n g t o n p o s t . c o m / h e a l t h / 2 0 2 2 / 0 8 / 0 4 / monkeypox-public-health-emergency-united-states-becerra/ § https://www.cdc.gov/poxvirus/monkeypox/transmission.html

Epidemiologic and Clinical Characteristics of Monkeypox Cases — United States, May 17–July 22, 2022

“…Recent reports have found that concurrent sexually transmitted infections were common in persons with monkeypox ( 3 , 7 ). Clinicians and health officials implementing monkeypox education, testing, and prevention efforts should also incorporate recommended interventions for other conditions occurring among gay and bisexual men, including HIV infection, sexually transmitted infections, substance use, and viral hepatitis §§ ( 8 ).…”

HIV and Sexually Transmitted Infections Among Persons with Monkeypox — Eight U.S. Jurisdictions, May 17–July 22, 2022

“…Public health efforts should continue to ensure equitable access to monkeypox screening, prevention, and treatment, particularly among MSM. It is important that systems for delivering HIV and STI care and prevention be leveraged for monkeypox evaluation, vaccination and other prevention interventions, and treatment (10)…”

First case report of monkeypox in Brazil: clinical manifestations and differential diagnosis with sexually transmitted infections

“…Despite being a mild and self-limiting disease in most cases, some conditions, such as immunosuppressive diseases, pregnancy and lactation, pediatric population, and people with a history of active exfoliative skin dermatoses may be associated with complications and worse prognosis 16 . These conditions may benefit from drugs approved for smallpox and cytomegalovirus treatment and which may have some activity against monkeypox virus, such as tecovirimat (approved treatment for smallpox) and cidofovir (approved treatment for cytomegalovirus) 17 .…”

“…In terms of pre- and post-exposure prophylaxis, there are two vaccines licensed by the Food and Drug Administration (FDA), USA, recommended primarily for people at risk of occupational exposure to orthopoxviruses, such as those working with diagnostic tests for monkeypox virus detection and now, as the multinational monkeypox outbreak continues, vaccines are also recommended for groups most at risk for acquiring severe monkeypox 17 . JYNNEOS is a live virus vaccine using non-replicating modified vaccinia Ankara (MVA) licensed for smallpox prevention and now, also for monkeypox in adults aged ≥ 18 years, being administered in two doses with 28 days interval 18 .…”