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News From the Centers for Disease Control and Prevention
September 27, 2022

Interim Guidance for Monkeypox Among Patients With HIV

JAMA. 2022;328(12):1173-1174. doi:10.1001/jama.2022.14727

A new CDC interim guidance outlines considerations for preventing and treating monkeypox virus infections among people living with HIV.

Men who have sex with men (MSM) and are living with HIV infection are overrepresented in the current multinational monkeypox outbreak. Preliminary data from the European Union, England, and the US suggest that, for those whose HIV status is known, 28% to 51% of MSM who have monkeypox also have HIV, according to the guidance authors. But whether HIV infection or shared risk factors for monkeypox and HIV acquisition explain the risk is unknown.

“Although it is possible that poorly controlled HIV would increase the risk for monkeypox after exposure, evidence from other diseases suggests that persons with HIV who are receiving [antiretroviral therapy] and have robust CD4 [cell] counts are not at increased risk for most infections, including opportunistic infections,” the authors wrote.

The guideline recommends that all individuals with new or existing HIV infection and monkeypox infection should continue to receive antiretroviral therapy and opportunistic infection prophylaxis as indicated for HIV to prevent rebounding HIV or other conditions that could complicate monkeypox treatment. Pre-HIV or post-HIV exposure prophylaxis should also begin or continue among individuals with monkeypox.

To assess the risk of serious illness in individuals with HIV and monkeypox, the guideline recommends that clinicians should consider patients’ CD4 cell counts and HIV viral suppression and should consider using tecovirimat, the recommended first-line treatment for monkeypox. If this treatment is indicated, drug interactions should not preclude using both tecovirimat and antiretroviral therapy. Clinicians should also weigh the benefits and risks of premonkeypox and postmonkeypox exposure vaccine prophylaxis. The JYNNEOS vaccine, which uses a live, nonreplicating modified vaccinia Ankara virus licensed for smallpox and monkeypox prevention, is the preferred vaccine for people with HIV, according to the guideline.

The replication-competent live vaccinia virus vaccine ACAM2000 licensed for smallpox prevention is contraindicated for people with HIV because of the risk of severe adverse effects in immunocompromised persons, according to recommendations from the CDC’s Advisory Committee on Immunization Practices. People with HIV should also take precautions to prevent monkeypox infection, including isolating from infected individuals and their pets, avoiding close contact or sexual activity with infected people, and seeking postexposure vaccination if exposed.

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