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

Appendices

Appendix E. Archived Sections

Mpox

On July 23, 2022, the World Health Organization declared mpox a global health emergency. Monkeypox virus (abbreviated as MPXV) is a member of the Poxviridae family (genus Orthopoxvirus). The first case of mpox identified in the United States as part of the recent outbreaks was confirmed in May 2022, and mpox was declared a public state of emergency in the United States from August 4, 2022, to January 31, 2023. This serious emerging outbreak is currently more common among gay, bisexual, and other men who have sex with men than among the general population. Sporadic cases have been reported in children and pregnant women. To date, no definitive data show that mpox differentially infects people with or without HIV. However, reports do suggest mpox 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 mpox 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 mpox or diagnosed with mpox. 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 mpox 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. Online resources for checking drug interactions include the Liverpool HIV Drug Interactions Checker and the Drug–Drug Interaction Guide.

JYNNEOS, an effective, FDA-approved, live attenuated, non-replicating smallpox and mpox vaccine, can be used for pre- and post-exposure prophylaxis in people with HIV. Pre- and post-exposure prophylaxis can be considered for people at increased risk of mpox infection, including gay, bisexual, and other men who have sex with men and individuals with close contact exposure to a confirmed mpox case. ACAM2000, a live replicating smallpox and mpox vaccine, is not recommended for people with HIV. Vaccinia immune globulin intravenous (or VIGIV) is available through an investigational drug protocol for infants aged under 6 months. For mpox immunization recommendations, see Figure 1. Recommended Immunization Schedule.

The Mpox and Immunization chapters of the Adult and Adolescent Opportunistic Infection Guidelines provide clinical guidance for the prevention and treatment of mpox in adults and adolescents with HIV.

The most comprehensive source of information about the prevention and treatment of mpox can be found on CDC’s Clinical Guidance webpage, which includes clinical considerations for immunocompromised people and children and adolescents, as well as mpox clinical care and treatment during pregnancy. Additional resources can be found on Infectious Diseases Society of America’s Mpox webpage.