HIV and Sexually Transmitted Infections Among Persons with Monkeypox — Eight U.S. Jurisdictions, May 17–July 22, 2022

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High prevalences of HIV and other sexually transmitted infections (STIs) have been reported in the current global monkeypox outbreak, which has affected primarily gay, bisexual, and other men who have sex with men (MSM) (1–5). In previous monkeypox outbreaks in Nigeria, concurrent HIV infection was associated with poor monkeypox clinical outcomes (6,7). Monkeypox, HIV, and STI surveillance data from eight U.S. jurisdictions* were matched and analyzed to examine HIV and STI diagnoses among persons with monkeypox and assess differences in monkeypox clinical features according to HIV infection status. Among 1,969 persons with monkeypox during May 17–July 22, 2022, HIV prevalence was 38%, and 41% had received a diagnosis of one or more other reportable STIs in the preceding year. Among persons with monkeypox and diagnosed HIV infection, 94% had received HIV care in the preceding year, and 82% had an HIV viral load of <200 copies/mL, indicating HIV viral suppression. Compared with persons without HIV infection, a higher proportion of persons with HIV infection were hospitalized (8% versus 3%). Persons with HIV infection or STIs are disproportionately represented among persons with monkeypox. It is important that public health officials leverage systems for delivering HIV and STI care and prevention to reduce monkeypox incidence in this population. Consideration should be given to prioritizing persons with HIV infection and STIs for vaccination against monkeypox. HIV and STI screening and other recommended preventive care should be routinely offered to persons evaluated for monkeypox, with linkage to HIV care or HIV preexposure prophylaxis (PrEP) as appropriate.

Eight health departments matched probable and confirmed cases of monkeypox^† diagnosed through July 22, 2022, and occurring among persons aged ≥18 years, to local HIV and STI surveillance data using individually established methods that included various personal identifiers (e.g., name, soundex,^§ date of birth, address, and telephone number). Matched data were deidentified and securely transmitted to CDC for analysis.

Among persons with monkeypox, prevalence of diagnosed HIV infection, determined through local HIV surveillance matches,^¶ was calculated. HIV surveillance data were used to assess receipt of HIV care,** HIV viral suppression (an indication of antiretroviral therapy use),^†† most recent CD4 count,^§§ and time since HIV diagnosis (8). STI surveillance data were used to assess chlamydia, gonorrhea, and syphilis diagnoses. Monkeypox signs, symptoms, and outcomes were compared according to HIV infection status. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.^¶¶

Among 1,969 persons aged ≥18 years with monkeypox diagnosed during May 17–July 22, 2022, in eight participating jurisdictions, 755 (38%) had received an HIV diagnosis, 816 (41%) had another reportable STI diagnosed in the preceding year, and 363 (18%) had both; 1,208 (61%) persons had either (Table 1) (Table 2).*** Since May 1, 2022, 19 (1%) persons with monkeypox had received an HIV diagnosis, and 297 (15%) had received an STI diagnosis. Persons with monkeypox and HIV infection more commonly had received an STI diagnosis in the preceding year (48%) than had those without HIV infection (37%).

Among persons with monkeypox, the weekly percentage with concurrent HIV infection increased over time (31%–44% by July). The percentage of persons with monkeypox who had HIV infection was higher in older age groups: among persons aged 18–24 years, HIV prevalence was 21%, and among those aged ≥55 years, was 59%. HIV prevalence among persons with monkeypox also varied by race and ethnicity, ranging from a high of 63% among non-Hispanic Black or African American (Black) persons, to 41% among Hispanic or Latino (Hispanic) persons, 28% among non-Hispanic White persons, and 22% among non-Hispanic Asian persons.

Among 755 persons with monkeypox and HIV infection, 713 (94%) received HIV care in the preceding year, 618 (82%) were virally suppressed, and 586 (78%) had CD4 count ≥350/μL. The median interval since HIV diagnosis was 10 years (IQR = 6–15 years). Data on HIV PrEP use were available for 172 (14%) persons without HIV infection, 115 (67%) of whom reported current PrEP use.

Compared with persons with monkeypox who did not have HIV infection, those with HIV infection were more likely to report rectal pain (34% versus 26%), tenesmus (20% versus 12%), rectal bleeding (19% versus 12%), purulent or bloody stools (15% versus 8%), and proctitis (13% versus 7%), but were less likely to report lymphadenopathy (48% versus 53%) (Figure). The prevalence of other signs and symptoms was similar among persons with monkeypox with and without HIV infection. Among 564 persons with monkeypox, HIV, known HIV viral load values, and signs and symptoms data, the 51 persons with unsuppressed HIV viral load were more likely than were the 513 with suppressed viral load to have lymphadenopathy (59% versus 46%), generalized pruritis (59% versus 42%), rectal bleeding (25% versus 18%), and purulent or bloody stools (22% versus 14%). Compared with persons with CD4 counts ≥350/μL, those with CD4 counts <350/μL more commonly experienced fever (69% versus 59%) and generalized pruritis (53% versus 42%).

Among 1,308 (66%) persons with information on hospitalization, the proportion of persons hospitalized with monkeypox was lower among those without HIV infection (3%, 26 of 798) than among those with HIV infection (8%, 42 of 510). Among 45 persons with monkeypox and HIV infection who were not virally suppressed, 12 (27%) were hospitalized, and among 61 with a CD4 count <350 cells/μL, nine (15%) were hospitalized.

Corresponding author: Kathryn G. Curran, ydh9@cdc.gov.

¹CDC Monkeypox Emergency Response Team; ²DLH Corporation, Atlanta, Georgia; ³California Department of Public Health; ⁴San Francisco Department of Public Health, San Francisco, California; ⁵Los Angeles County Department of Public Health, Los Angeles, California; ⁶District of Columbia Department of Health; ⁷Georgia Department of Public Health; ⁸Illinois Department of Public Health; ⁹Epidemic Intelligence Service, CDC; ¹⁰Chicago Department of Public Health, Chicago, Illinois; ¹¹New York State Department of Health.

References

1. European Centre for Disease Prevention and Control; World Health Organization Regional Office for Europe. Joint ECDC-WHO Regional Office for Europe monkeypox surveillance bulletin. Stockholm, Sweden: European Centre for Disease Prevention and Control; 2022. https://monkeypoxreport.ecdc.europa.eu
2. Thornhill JP, Barkati S, Walmsley S, et al.; SHARE-net Clinical Group. Monkeypox virus infection in humans across 16 countries—April–June 2022. N Engl J Med 2022;387:679–91. https://doi.org/10.1056/NEJMoa2207323 PMID:35866746
3. Tarín-Vicente EJ, Alemany A, Agud-Dios M, et al. Clinical presentation and virological assessment of confirmed human monkeypox virus cases in Spain: a prospective observational cohort study. Lancet 2022;400:661–9. https://doi.org/10.1016/S0140-6736(22)01436-2 PMID:35952705
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6. Ogoina D, Iroezindu M, James HI, et al. Clinical course and outcome of human monkeypox in Nigeria. Clin Infect Dis 2020;71:e210–4. https://doi.org/10.1093/cid/ciaa143 PMID:32052029
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* Persons with self-reported HIV infection who did not match to local HIV surveillance data (39) were excluded from the analysis.
^† Eight state and city or county jurisdictions independently funded for HIV surveillance: California (including Los Angeles County and San Francisco), District of Columbia, Georgia, Illinois (including Chicago), and New York (excluding New York City).
^§ Hispanic or Latino persons can be of any race.
^¶ Other includes persons who identify as Native Hawaiian and other Pacific Islander, American Indian or Alaska Native, or multiracial, and persons who declined to report.
** Report date includes either date of specimen collection, Orthopoxvirus test, monkeypox diagnosis by clinician, illness onset, or rash onset. Report date shown by epidemiologic week; the first 3 weeks of the outbreak are combined because of small numbers.

Abbreviations: NA = not applicable; PrEP = preexposure prophylaxis; STI = sexually transmitted infection.
* Persons with self-reported HIV infection who did not match to local HIV surveillance data (39) were excluded from the analysis.
^† Eight state and city or county jurisdictions independently funded for HIV surveillance: California (including Los Angeles County and San Francisco), District of Columbia, Georgia, Illinois (including Chicago), and New York (excluding New York City).
^§ Row percentages calculated using nonmissing data.
^¶ Overall, 1,308 persons had data available for hospitalization, including 798 persons without diagnosed HIV infection and 510 persons with diagnosed HIV infection.
** Overall, 48 hospitalized persons had data available for hospitalization duration, including 18 persons without diagnosed HIV infection and 30 persons with diagnosed HIV infection.
^†† Receipt of HIV care was defined as at least one HIV viral load or CD4 test since May 1, 2021; tests conducted during evaluation for monkeypox might have been included.
^§§ HIV viral suppression was defined as the most recent HIV viral load <200 copies/mL since May 1, 2021.
^¶¶ Recent CD4 count was defined as the most recent CD4 count since May 1, 2021.
*** Among persons without diagnosed HIV infection, 172 persons had data available for current HIV PrEP use.

FIGURE. Signs and symptoms of monkeypox,*^,† by HIV infection status^§ — eight U.S. jurisdictions,^¶ May 17–July 22, 2022

* Persons with self-reported HIV infection who did not match to local HIV surveillance data (39) were excluded from the analysis.

^† Signs and symptoms were not mutually exclusive.

^§ Percentages calculated using nonmissing data. Overall, 1,707 persons had data available for signs and symptoms except proctitis, including 1,082 persons without diagnosed HIV infection and 625 persons with diagnosed HIV infection. For proctitis, data were available for 393 persons without diagnosed HIV infection and 304 persons with diagnosed HIV infection.

^¶ Eight state and city or county jurisdictions independently funded for HIV surveillance: California (including Los Angeles County and San Francisco), District of Columbia, Georgia, Illinois (including Chicago), and New York (excluding New York City).