As mpox cases continue to rise, individuals with HIV are increasingly represented among those affected. While the direct impact of HIV on the likelihood of contracting mpox virus is unclear, it is well-established that people with advanced HIV, particularly those who are immunocompromised, face a higher risk of severe illness and death if they contract mpox. This heightened vulnerability underscores the importance of following prevention strategies, including vaccination, to safeguard health. Understanding how mpox spreads and the available preventive measures is essential for managing this dual health challenge effectively.¹

Leo Moore, MD, MSHPM, an internal medicine, HIV medicine, and lifestyle medicine physician based in Los Angeles, California, emphasizes the varying risks for people with HIV. He explains,

“I think about those who are either living with HIV on treatment, have low viral loads or suppressed viral loads, and have strong immune systems, versus those who are not on medication, who have high viral loads and low white blood cell counts. Those patients are at increased risk for severe cases of mpox. So those are the patients that I’m particularly concerned about when I think about this new mpox strain.”

Mpox is caused by different strains, each with varying levels of severity and transmission. Clade I is associated with more severe disease and higher fatality rates compared to clade II. As a result, clade I necessitates more extensive public health measures, such as widespread vaccination and strict isolation, particularly for vulnerable populations like those with advanced HIV. Clade II generally leads to milder disease, lower fatality rates, and less transmission, which allows for more targeted public health responses, including surveillance and localized containment.²

Moore comments, “The potential for clade I to spread to the United States increases the risk for those who have uncontrolled HIV.” Understanding these differences is important for effective resource allocation and response strategies.

Our discussion also touched on the commercialization of the Jynneos vaccine and its impact on vaccine accessibility. According to the CDC’s updated mpox guidance, Jynneos is recommended for immunocompromised individuals, including those with HIV or primary immunodeficiency.

Moore raises concerns about the commercialization of vaccines, particularly following the period of federal government provision at no cost. “It decreases availability for those who are uninsured or underinsured. I’m particularly concerned about that in states where Medicaid has not been expanded because we know that patients without Medicaid or other health insurance are unlikely to access the medication. It’s going to be much more difficult for them to find it for free or on a sliding scale,” he said.

Fortunately, individuals with HIV will still have access to Jynneos after its commercialization. The updated guidance confirms that Jynneos will remain available for individuals with HIV and other immunocompromised conditions, with provisions to ensure accessibility.³

For HIV-positive patients with mpox, initiating antiretroviral therapy (ART) alongside mpox treatment is essential. Jynneos, as well as post-exposure prophylaxis and antiviral treatments, have minimal interactions with ART and immunosuppressive medications.³

Bavarian Nordic is scaling up manufacturing to meet anticipated orders and ensure surge capacity. The majority of mpox cases in Africa have been reported in individuals under 18 years old. Bavarian Nordic is working to expand vaccine access to adolescents and younger children through clinical studies and regulatory approvals.⁴

Moore comments on international efforts: “Providing vaccines to countries in Africa is important and needs to be done. I also want to ensure that in our country there is an opportunity and an access point for those who are uninsured and underinsured because we know that as this has spread to Sweden, it’s likely in other countries, and it’s only a matter of time before it reaches the US.”

To continue, there is an HIV stigma that circulates negative beliefs about people with HIV, including assumptions about who can contract the virus and judgments about prevention actions. Discrimination is behaviors based on these beliefs, such as refusing to provide healthcare, avoiding social interaction, or using derogatory terms.⁵

Addressing stigmas, Moore shares effective ways that patients can form their own safe space to communicate their concerns or symptoms to their clinician without judgment, “Tell us what you’re experiencing and show us if you have any lesions. I also think it’s important for patients to be empowered to pull up an article on their phone if they need to or show pictures of what they’re seeing that they think is similar to what’s on their body as well.” Effective patient-clinician communication is vital for optimal care.

Moore concludes, “For those who are indicated for this vaccine (Jynneos), those who are men who have sex with men, transgender or non-binary persons who’ve had at least one STI or have multiple sex partners, or if they’re the partners of people who fall into those categories, they should get two doses of the Jynneos vaccine, and they should get it as soon as possible.”

References

1. Mpox and HIV. CDC. Updated April 22, 2024. Accessed August 20, 2024. https://www.cdc.gov/poxvirus/mpox/prevention/hiv.html#:~:text=We%20do%20not%20know%20if,death%20if%20they%20get%20mpox.

2. Shafaati M, Zandi M. State-of-the-art on monkeypox virus: an emerging zoonotic disease. Infection. 2022 Dec;50(6):1425-30

3. Clinical Considerations for Treatment and Prophylaxis of Mpox in People Who are Immunocompromised. CDC. Updated June 13, 2024. Accessed August 20, 2024. https://www.cdc.gov/poxvirus/mpox/clinicians/people-with-HIV.html

4. Bavarian Nordic Provides Statement on Mpox Vaccine Supply and Collaboration with African and Global Stakeholders. Bavarian Nordic news statement. August 17, 2024. Accessed August 20, 2024. https://www.bavarian-nordic.com/investor/news/news.aspx?news=6970

5. Let’s Stop HIV Together. CDC. Last reviewed February 7, 2024. Accessed August 20, 2024. https://www.cdc.gov/stophivtogether/hiv-stigma/index.html#:~:text=HIV%20stigma%20is%20negative%20attitudes,believed%20to%20be%20socially%20unacceptable.