According to the Centers for Disease Control and Prevention (CDC), since May 2022, “more than 25,000 monkeypox cases have been identified in the United States.” More than 38 percent of people diagnosed with monkeypox also had HIV. In fact, the most severe monkeypox infections have been among people living with untreated HIV. Given this data, it is essential that health care providers understand the details of this connection and that providers consistently screen patients who have monkeypox for possible untreated HIV.
What are the correlations?
The CDC has determined that as the monkeypox outbreak in the US has progressed, an increasing number of cases have been identified among Black and Hispanic/Latino people, who are also disproportionately affected by HIV. Severe virus manifestations occur among both immunocompromised and immunocompetent individuals, but most people diagnosed have had mild-to-moderate clinical courses.
The most severe manifestations include symptoms such as necrotic lesions that require amputation of an extremity, lesions associated with a secondary infection or other complications, lesions in sensitive areas that interfere with daily living, lesions that cause obstructions, and lesions that cause scarring, increasing their morbidity.
What can providers do?
Health care providers should know the risk factors for severe manifestations of monkeypox and practice prevention methods by testing every patient with confirmed or suspected monkeypox for HIV. According to the CDC, “In prior outbreaks in Nigeria, co-infection with HIV was associated with worse clinical outcomes, including severe manifestations of monkeypox, hospitalization, and death.” Providers should also be aware of other immunocompromising conditions and medications that increase the severity of monkeypox.
Some FDA-approved medications used to treat human smallpox disease should not be used to treat monkeypox. The FDA does not approve treatment of monkeypox with these types of medications. Because the monkeypox virus directly affects the immune system, providers should pay careful attention should their patients with immunocompromising illnesses or other autoimmune diseases contract monkeypox. Health care providers should also limit their prescribing of immunosuppressants, as they tend to cause more severe monkeypox manifestations.
Worsening, non-healing skin lesions while receiving antiviral treatment have been observed among immunocompromised people with severe manifestations of monkeypox. The CDC suggests that providers obtain “repeat lesion swabs to assess for persistent monkeypox DNA.” Clinicians may also consider continuing treatment with medication (tecovirimat) beyond 14 days until there is an improvement (no more than 90 days). Any provider with questions regarding dosing adjustments can contact the CDC Emergency Operations Center (EOC) at 770-488-7100 or email
What should a provider do if they contract monkeypox?
Providers who treat people with monkeypox who believe they are at risk or have severe manifestations of the disease should reach out to their local public health jurisdictions or the CDC for appropriate treatment. People with severe manifestations may also benefit from seeing a specialist in infectious disease, ophthalmology, dermatology, urology, or critical care medicine.
The CDC also offers consultations via email (
What studies are being conducted for monkeypox?
The CDC is currently conducting surveillance to monitor the development of resistance to medications used to treat monkeypox. They are doing this primarily from samples sent to the CDC for monkeypox testing. To promote public health surveillance, the CDC encourages providers to continue sending samples for monkeypox virus testing in order to determine mutations that could result in resistance to treatments and therapy. Currently, after over 600 evaluations, the CDC has not observed any specimens related to medication resistance. Still, it is unclear if any of the submitted samples came from people with worsening symptoms while taking prescribed medications.
Other Recommendations for Providers
Upon the first presentation of symptoms of monkeypox, providers should test all sexually active adults and adolescents for HIV, STIs, and other immunocompromising conditions. Providers must also be familiar with severe manifestations of monkeypox and risk factors for severe disease. For patients with a high risk of severe manifestations or those already experiencing severe manifestations, providers should have various countermeasures determined. If any medication is progressing the disease or making lesions worse, the provider must have other treatment alternatives at their disposal.
When applicable, health care providers should encourage people with monkeypox to be assessed for enrollment in the ACTG STOMP trial, which evaluates the efficacy of monkeypox treatment medications. For those patients who are HIV-negative and at risk for HIV, discuss putting them on HIV pre-exposure prophylaxis (PrEP).
Finally, providers should consider consulting with the CDC Monkeypox Response Clinical Escalations Team via the email and phone number listed above, as well as partnering with specialists in their provider group.
