During Canada’s unprecedented mpox outbreak last summer, Montreal physician Dr. Antoine Cloutier-Blais noticed a concerning trend: Patients co-infected with advanced HIV were reporting lesions across their bodies, and systemic mpox symptoms.
“It was difficult at the moment to verify that suspicion with the information we had,” he said.
Now, recent research within the Lancet medical journal backs up Cloutier-Blais’ early concerns.
The paper, a case study on mpox in individuals with advanced HIV infection, details an aggressive and serious type of the illness formerly often called monkeypox — at times involving skin cell death inside lesions, nodules within the lungs, sepsis, and a high rate of death.
This manner of mpox appears to be a “very severe skin and mucosal infection with high rates of sepsis and really severe lung complications,” said study creator Dr. Chloe Orkin, a professor of HIV/AIDS medicine at Queen Mary University of London, in an email to CBC News.
The researchers studied a cohort of nearly 400 patients from various countries, including Canada, who caught mpox while living with HIV and low CD4 cell counts. (CD4 cells are a sort of white blood cell that help fight off infections by triggering the immune system to destroy viruses and other pathogens.)
Mortality was roughly 15 per cent in individuals with advanced HIV-related disease, the researchers wrote, while the death rate for individuals with probably the most severe immunosuppression doubled to around 30 per cent, Orkin noted.
The staggering findings matter largely resulting from high rates of mpox amongst individuals living with HIV/AIDS, who account for an estimated 38 to 50 per cent of individuals diagnosed with mpox.
“I feel it’s a very important reminder of how we must not get too complacent even within the face of low case counts, because if the virus encounters an individual prone to such severe manifestations like people living with advanced HIV, then it could actually be really devastating,” said Dr. Darrell Tan, a clinician-scientist at St. Michael’s Hospital in Toronto, whose team contributed data for the Lancet paper.
Calls for more access to mpox vaccines
The takeaways of her findings, Orkin said, are that health-care staff should be trained on the high mortality rate related to mpox and HIV-related immunosuppression.
“Every one with mpox must have an HIV test and every one with HIV and mpox needs to be tested for immunosuppression,” Orkin continued, noting those with advanced HIV infection must also be monitored rigorously, given the significantly higher risk of death.
“Access to mpox vaccines and antiviral treatments are one of the best ways of reducing severity of disease and health authorities should be certain that people living with HIV are prioritized for vaccination and antivirals especially those with immunosuppression,” she added.
In Montreal, Cloutier-Blais — who was not involved with the Lancet study — agreed vaccines have to be an ongoing priority, and noted, reassuringly, that he now “rarely” encounters patients who have not had no less than one dose of the two-shot mpox vaccine.
“I actually have not seen a single [two-dose] failure and rare and mild presentations in patients who had received one dose,” he added.
Uptake and access do remain a challenge at a worldwide level, nonetheless.
“We definitely have patients in our care who’ve low CD4 counts and could possibly be prone to these types of conditions, and uptake of [second doses] in Ontario have been disappointingly low,” Tan, in Toronto, said.
“Also, there’s particular risk in the numerous parts of the world where access to protective mpox vaccines is non-existent and where the burden of HIV is high.”
Demand for second doses in lots of major cities has dwindled, data shows, while many countries — including those in Africa, and the emerging outbreak hotspot of Mexico — haven’t got vaccines available in any respect.
“It’s imperative that vaccines and antivirals turn into accessible worldwide and more global cooperation is required here,” Orkin said.