Mpox severity and associated hospitalizations among people with HIV and related immunosuppression in Brazil

Abstract

Objectives: This study aimed to analyze characteristics of mpox hospitalization in a Brazilian cohort, further exploring the impact of HIV on mpox-related outcomes and hospitalization. Design: We conducted a descriptive analysis, comparing characteristics of individuals diagnosed with mpox according to hospitalization and HIV status, and described the mpox cases among those living with HIV. Methods: This was a single-center, prospective cohort study conducted at a major infectious diseases referral center in Rio de Janeiro, Brazil, that enrolled participants older than 18 years of age diagnosed with mpox. Information was collected on standardized forms, including data on sociodemographic, behavioral, clinical and laboratory characteristics. For comparisons we used chi-squared, Fisher's exact and the Moods median tests when appropriate. Results: From June to December, 2022, we enrolled 418 individuals diagnosed with mpox, of whom 52% were people living with HIV (PLHIV). PLHIV presented more frequently with fever, anogenital lesions and proctitis. The overall hospitalization rate was 10.5% (n = 43), especially for pain control. Among hospitalized participants, PLHIV had more proctitis and required invasive support. Mpox severity was related to poor HIV continuum of care outcomes and low CD4+ cell counts. All deaths (n = 2) occurred in PLHIV with CD4+<50 cells/mm3. Conclusions: HIV-related immunossupression likely impacts mpox clinical outcomes. This is of special concern in settings of poor adherence and late presentation to care related to socioeconomic inequalities, such as Brazil. The HIV continuum of care must be taken into account when responding to the mpox outbreak.

Long or complicated mpox in patients with uncontrolled HIV infection

“…More recent published works, suggest that PLWH with either immunodeficiency or lack of control of viremia may develop more complications or might be at a greater risk of hospitalization. [13][14][15][16][17][18][19] Nevertheless, several issues should be highlighted in these studies. Some of them only provided descriptive data.…”

“…13,17 Others were performed at a smaller-scale and the number of PLWH included was low. 14,18,19 Finally, hospitalization may have been the result of greater clinician concern instead of more severe disease. It is worth mentioning that, in the present study, the 26 unsuppressed individuals with HIV infection…”

“…[13][14][15][16] More specifically, severe forms of mpox with high mortality have been related to poor HIV control (i.e., advanced immunosuppression, nonsuppressed HIV viral loads). [17][18][19] However, the latter studies had a limited sample size 18,19 or did not conduct a statistical analysis of association between mpox severity and control of HIV infection.…”

“…Conversely, other works suggested that PLWH have higher rates of mpox‐related clinical complications and they are hospitalized more frequently than individuals without HIV infection 13–16 . More specifically, severe forms of mpox with high mortality have been related to poor HIV control (i.e., advanced immunosuppression, nonsuppressed HIV viral loads) 17–19 . However, the latter studies had a limited sample size 18,19 or did not conduct a statistical analysis of association between mpox severity and control of HIV infection.…”

“…More specifically, severe forms of mpox with high mortality have been related to poor HIV control (i.e., advanced immunosuppression, nonsuppressed HIV viral loads) 17–19 . However, the latter studies had a limited sample size 18,19 or did not conduct a statistical analysis of association between mpox severity and control of HIV infection. Given the shortage of vaccines and targeted therapeutic options, it is of the greatest interest to identify populations at risk of developing severe disease, in which early therapeutic/preventive measures could be promptly implemented to avoid adverse outcomes.…”