An international team of clinicians has identified a severe form of mpox — formerly known as monkeypox — with high mortality in people with advanced HIV who have weaker immune systems.

The majority of mpox infections in the multi-country outbreak, which began in 2022, occurred in sexual networks of gay, bisexual, and other men who have sex with men. About 38-50 percent of people diagnosed with mpox in 2022 also live with HIV, the vast majority of whom are on HIV treatment and living healthy lives.

The team led by the Queen Mary University of London and the Fight Infections Foundation/Hospital Germans Trias of Barcelona looked at 382 people with advanced HIV disease and mpox, including 27 of the 60 people (at the time of writing) reported to have died of mpox during the multi-country outbreak.

In the paper published in the journal The Lancet, they described a very severe form of mpox characterized by widespread, large, necrotizing skin lesions; high rates of severe infections; and, in some cases, unusual lung lesions.

This form of the disease carries a 15 percent mortality in people with advanced HIV disease and immunosuppression. All 27 deaths occurred within this group.

The study provides evidence that the disease is behaving differently and very concerningly in people with advanced HIV disease and immunosuppression.

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“We describe a severe form of mpox affecting mostly young men who have sex with men and which results in death in 15 percent of people with advanced HIV. When clinicians recognize necrotizing skin lesions and/or lung involvement, they should use a differentiated clinical pathway and an intensified approach,” said Oriol Mitja, Associate Professor of Infectious Disease and Global Health, Fight Infectious Diseases Foundation, University Hospital Germans Trias I Pujol.

Mitja also called on health authorities to “prioritize the vaccination of people living with HIV, particularly in countries with low levels of diagnosis or without universal free access to antiretroviral treatment.”

Most mpox deaths have occurred in countries where there are low levels of HIV diagnosis and/or without universal access to antivirals for mpox and/or HIV and without access to intensive care units. A concerted global effort is needed to ensure equitable access to antivirals and vaccines in countries where the interaction of uncontrolled HIV infection and mpox is more prevalent.

The researchers have also called for the new form of mpox to be added to the World Health Organization and Center for Disease Control list of severe infections that are considered particularly dangerous to people with advanced HIV disease. They also recommend that all people with mpox be tested for HIV.