Thread by @profchloeorkin

📣 📣 Our global case series on MPOX in people with advanced HIV infection is at #CROI2023 and in @TheLancet today: 382 cases of human MPOX infection in PLWH with CD4 counts <350 cells/mm3 in 19 countries
**We found MPOX is an opportunistic pathogen** /1
thelancet.com/journals/lance…

BACKGROUND: Limited evidence on MPOX outcomes in advanced HIV disease. Two Nigerian reports suggested more severe/prolonged symptoms. Two @CDC reports showed worse rectal disease, complications & some deaths #CROI2023 /2

SITES: We collaborated with sites from the global SHARE-Net & Skin NTDS and STI HUGTiP networks with high numbers of MPOX diagnoses. 44 contributing sites from 19 different countries. #CROI2023 /3

METHODS: Each centre completed a de-identified case report sheet to capture routinely collected data from medical records. All statistical analyses were descriptive #CROI2023 /4

RESULTS: Baseline demographics – most were from the Americas, most cisgender men, 91.4% had known HIV, 59.7% on ARV, 50.5% had a suppressed HIV viral load, ~9% were newly diagnosed HIV at time of MPOX. #CROI2023 /5

RESULTS: We describe a severe disseminated necrotising form of MPOX & a relationship between ⬇️CD4 count and hospitalisations, ICU admissions & deaths. Detectable viral load also impacted outcomes. No deaths with CD4 count >200. Mortality rate 15% CD4 <200; 27%<100 #CROI2023 /6

RESULTS: Nearly all complications were more common in individuals with CD4 <100 cells/mm3 compared to individuals with CD4 counts >300 cells/mm3 #CROI2023 /7

RESULTS: Skin - rash was prolonged. The hallmark feature of this severe disseminated form of MPOX was large coalescing and necrotising lesions which occurred in 93% of those who died. Sepsis occurred in 89% of those who died and respiratory symptoms in 85%
#CROI2023 /8

RESULTS: 3.1% neurological involvement – these were nearly exclusively described in persons with HIV CD4 counts <100 cells/mm3. There was only one case of encephalitis. #CROI2023 /9

TREATMENT: 62 people received Tecovirimat. 3 people developed resistance to Tecovirimat.

There were huge inequities: all patients receiving antivirals were treated in Europe or the USA, except two that received Tecovirimat in Brazil  
#CROI2023 /10

RESULTS: 27 (7.15%) died. Of these, the median CD4 count was 35 cells/mm3 (IQR 24-100), & the median HIV viral load was 5 log copies/ml (IQR 4-5). Only one patient was virally suppressed. Nobody who died had received MPOX vaccination prior to, or during 2022 #CROI2023 /11

RESULTS: Of 85 people who started/restarted on ART, IRIS was suspected as the cause of clinical deterioration in 25%. All had a CD4 count <200 and 57% of those with suspected IRIS, died. #CROI2023 /12

CONCLUSION: Based on our findings we believe that severe necrotising MPOX with systemic disease is an AIDS-defining condition caused by an opportunistic pathogen in those with advanced HIV disease – it should be added to HIV disease classifications #CROI2023 /13

IMPLICATIONS: Clinical vigilance required in individuals with low CD4 counts & consider possibility of IRIS. Those with HIV infection & at risk of MPOX infection should be prioritised for preventative vaccines.
Access to MPOX antivirals/vaccine is urgent globally! #CROI2023 /14

We would like to acknowledge the teams at our contributing sites & all individuals with MPOX and families of deceased individuals who graciously consented to contribute data to further knowledge of this disease #CROI2023 /15

Our @TheLancet paper has a clinical photo directory. #CROI2023 / 16

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thelancet.com/journals/lance…