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People with monkeypox have higher than expected rates of HIV and other concurrent sexually transmitted infections (STIs), according to a new report by the Centers for Disease Control and Prevention (CDC). Individuals living with HIV diagnosed with monkeypox were also hospitalized more often than people without HIV infection, is 5mg folic acid safe during pregnancy but it is not known if this is the result of more severe monkeypox illness, the study authors noted.

“Increasing HIV prevalence among persons with monkeypox over time suggests that monkeypox might be increasingly transmitted among networks of persons with HIV infection,” they write, “underscoring the importance of leveraging HIV and STI care prevention delivery systems for monkeypox vaccination and prevention efforts.”

As of September 8, there were over 21,500 monkeypox cases in the United States, which makes up about 38% of global cases. Monkeypox has been primarily spreading in men who have sex with men, and is transmitted through close physical contact or contact with materials that may contain the virus, such as bedsheets or towels.

In a new Morbidity and Mortality Weekly Report published last week, CDC researchers analyzed health data from eight jurisdictions that matched probable or confirmed monkeypox cases diagnosed through July 22 to local HIV and STI surveillance data. The large majority of the study cohort (96%) identified as male, and only 10 individuals said they were assigned female at birth. Of the nearly 2000 individuals included in the analysis, 38% were living with HIV and 41% had at least one other reportable STI in the past year. HIV prevalence was higher among older individuals — 59% of people aged 55 and older were positive compared with 21% of adults aged 18-24 years. Black and Hispanic individuals in the analysis also had higher rates of HIV than their White and Asian counterparts.

More than 90% of people with HIV in the analysis had received HIV care in the past year, and 82% were virally suppressed (defined as an HIV viral load of less than 200 copies/mL). Compared with individuals with monkeypox without HIV, those living with the HIV virus were more likely to report rectal pain and bleeding, tenesmus, proctitis, and purulent or bloody stools. Rectal symptoms did not vary by HIV immune status, the authors noted, which suggested that this higher prevalence of symptoms in patients with HIV could be explained by differences in site of exposure. In a previous monkeypox study in Spain, for example, individuals who reported receptive anal sex had higher rates of proctitis and systemic systems prior to the appearance of a rash.   

Individuals living with HIV also had higher rates of hospitalizations compared to those without the virus (8% vs 3%). In previous monkeypox outbreaks in Nigeria, people with HIV did have poor monkeypox clinical outcomes, but it is unknown whether the hospitalizations captured in this analysis were because of more severe monkeypox illness.

That HIV prevalence is higher in people with monkeypox is likely because the monkeypox virus is spreading in sexual networks, said Ina Park, MD, a professor of community medicine and STI specialist at the University of California San Francisco, in an interview with Medscape Medical News. She was not involved with the research.

“I don’t think HIV makes you more likely to get monkeypox,” she said, especially if someone has well-controlled HIV. People with HIV tend to be more engaged with the healthcare system, which also could contribute to the higher HIV prevalence in this population, both Park and the study authors agree.

“Referral bias might partially explain these findings, as persons with monkeypox signs and symptoms who have established connections with HIV or sexual health providers might be more likely to seek care,” the authors write, “and these providers might be more likely to recognize and test for monkeypox virus.”

The findings suggest that monkeypox infection, HIV, and STIs are closely linked, Park said, and providers testing for monkeypox should also screen for HIV and other STIs. “This an opportunity to provide like comprehensive sexual health care,” she said, “and not just testing and treatment for monkeypox.”

MMWR Morb Mortal Wkly Rep. Published online September 9, 2022. Full text

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