Guidelines for the Prevention and Treatment of Opportunistic Infections in Children with and Exposed to HIV

On July 23, 2022, the World Health Organization declared monkeypox a global health emergency. Monkeypox virus is a member of the Poxviridae family (genus Orthopoxvirus). The first person identified in the current outbreak in the United States was confirmed in May, and monkeypox was declared a public state of emergency in the United States on August 4, 2022. This serious emerging outbreak is currently more common among gay, bisexual, and other men who have sex with men than the general population. Sporadic cases have been reported in children and pregnant people. To date, there are no definitive data that monkeypox differentially infects people with or without HIV. However, reports do suggest monkeypox could be an opportunistic infection in people with HIV. People with advanced HIV or who are not virologically suppressed with antiretroviral therapy can be at increased risk of severe disease related to monkeypox virus infection.

Pre- and post-exposure prophylaxis and antiviral treatments are available for people who are at increased risk of severe disease and are exposed to monkeypox or diagnosed with monkeypox virus infection. The first-line antiviral treatment tecovirimat (TPOXX) is effective in animal models in treating disease caused by orthopoxviruses and is approved by the U.S. Food and Drug Administration (FDA) for the treatment of smallpox in adults and children. Tecovirimat is available through the Centers for Disease Control and Prevention (CDC) for compassionate use for monkeypox infection through an investigational drug protocol. TPOXX can affect metabolism via cytochrome P450 pathways and have some notable drug–drug interactions. Individuals on antiretrovirals and other medications may require drug dosing adjustments with concomitant TPOXX administration. More information can be found in the Adult and Adolescent Antiretroviral Guidelines, Table 24b: Drug Interactions Between Non-Nucleoside Reverse Transcriptase Inhibitors and Other Drugs. An effective, FDA-approved live attenuated, non-replicating smallpox and monkeypox vaccine (JYNNEOS) is currently available for pre- and post-exposure prophylaxis in limited settings. Pre- and post-exposure prophylaxis can be considered for people at increased risk of monkeypox infection, including gay, bisexual, and other men who have sex with men and individuals with close contact exposure to a confirmed monkeypox case. Vaccination with JYNNEOS is considered safe for people with HIV. The CDC has released interim guidance for prevention and treatment of monkeypox in people with HIV.

Currently, the best source of information about management of monkeypox can be found on the CDC’s Clinical Guidance webpage, which includes clinical considerations for monkeypox in children and adolescents, as well as considerations for breastfeeding a child who has monkeypox and for neonates born to individuals with suspected or confirmed monkeypox.