Study indicates that HIV-infected and uninfected patients have similar monkeypox illness outcomes

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In a recent study published in the journal HIV MedicineGerman researchers evaluated the clinical characteristics of monkeypox virus (MPXV) infections in people with and without human immunodeficiency virus (HIV) infection.

Study: Clinical characteristics of monkeypox virus infections in HIV-infected and HIV-uninfected men: A large outbreak cohort in Germany.  Image credit: Kateryna Kon / Shutterstockthe study: Clinical characteristics of monkeypox virus infections in men with and without HIV: A large outbreak cohort in Germany. Image credit: Kateryna Kon / Shutterstock


Nigeria’s 2017-2018 MPXV outbreak had a case fatality rate of 6%. Four of the seven patients who died during this outbreak had acquired immunodeficiency syndrome (AIDS) or HIV infection. Accordingly, several studies, particularly from Africa, have raised concerns that HIV-infected individuals are at increased risk for MPXV infection.

During the 2022 MPXV outbreak, the number of cases increased sharply in Europe and North America. For example, in Germany, 338 confirmed cases of MPXV have been reported to the Robert Koch Institute by June 17, 2022. Within a week, cases almost doubled, making Germany one of the most MPXV-affected countries in the world. However, scientists are not sure what factors put people at risk for severe MPXV infection. In addition, the reason for the current outbreak, the sharp increase in the number of cases, and the kinetics of the MPXV transmission remain unclear.

About the study

This study investigated the possible association between HIV and MPXV infections. Therefore, the German AIDS Society and the German Association of Outpatient Physicians for Infectious Diseases and HIV Medicine asked all German health centers to participate in the current study. They were further asked to retrospectively document all confirmed cases of MPXV between 19 May 2022 and 30 June 2022.

All participating care centers used an anonymized questionnaire to collect study data. These data included patient demographics, comorbidities including HIV infection, current use of HIV pre-exposure prophylaxis (PrEP), previous or current viral hepatitis B and C, and sexually transmitted infections (STIs) in the past six months.

The researchers evaluated the date of confirmed diagnosis of MPXV infection and onset of symptoms, probable country of MPXV infection, disease severity, location and number of lesions, previous smallpox vaccination and general symptoms such as fever, night sweats, swollen lymph nodes. , specific therapies and reason for hospitalization, if any.

The study observation period was short, with a median of three days from MPXV diagnosis. Also, the average duration between the onset of symptoms and the diagnosis of MPXV was four days. A total of 298 patients were followed for at least seven days from the onset of symptoms. In addition, the investigators performed all diagnostic procedures, including MPXV polymerase chain reaction (PCR), at the local German laboratories of the participating centers or at another laboratory of the German National Robert Koch Institute in Berlin.

Results of the study

This large retrospective study evaluated data on 546 PCR-confirmed MPXV cases from 42 participating medical centers. Data from the study covered almost 50% of all MPXV cases in 2022 reported in Germany. The German cities worst affected by MPXV were Berlin, Cologne and Hamburg, with the majority of cases among men having sex with men (MSM) who are either living with HIV or taking PrEP. The authors noted an overall hospitalization rate of around 4%, with no significant difference observed between MSM with and without HIV. Most cases were predominantly mild to moderate, with no deaths.

Interestingly, the HIV-infected individuals identified in this study had good immunity, lower viral loads (less than 200 copies/ml), and appeared healthy despite having acquired MPXV infection. In addition, studies indicate that children and pregnant women may be at increased risk of contracting MPXV infection. However, these populations do not appear to be present in the current outbreak.

Almost 2/3 of MPXV patients were diagnosed with at least one STI within the past six months and 1/3 within one month or at the same time. This finding is critical and suggests that acutely diagnosed MPXV or STI should prompt a diagnostic test for another disease. Also, 32.4% of all patients and 38.9% of PrEP users had gonorrhea in the past six months. Notably, STI rates were lower among MSM without HIV or PrEP, with 47.6% of all patients having no STI in the past six months. Two other cohort studies from Madrid and London found similarly high STI rates among MSM with MPXV infections.

Vaccination against smallpox provides some protection against MPXV. Thus, vaccinated individuals in the study cohort had a relatively milder clinical course of MPXV. However, only four of 22 patients hospitalized for severe MPXV infection (18.2%) were vaccinated against smallpox.

Interestingly, the localization of disease in the study cohort appeared different from that seen during the 2017-2018 MPXV outbreak in Nigeria. The manifestation of MPVX infection in the current cohort affected the face and trunk, but the limbs to a lesser extent. Accordingly, 82.7% of patients had a maximum of 10 lesions, with only a few having more than 50 lesions. Additionally, MSM without HIV or PrEP had a higher incidence of genital lesions and a lower incidence of anal lesions.


All 546 study participants with MPXV in the current study were MSM with or without HIV. The authors observed no clinical differences in MPXV infections between HIV-positive and HIV-negative MSM. As most of the participating centers focused on HIV infection and PrEP, other affected groups were probably not diagnosed or diagnosed in centers that did not participate in this study. In addition, most cases were mild. However, based on the current outbreak kinetics, the study findings suggest that MPXV is emerging as a new and serious STI.

Therefore, sexually active MSM with skin lesions, especially those with anogenital location and a history of other STIs, should be promptly tested for MPXV. In addition, education and information campaigns should urgently address this issue among MSM and all population subgroups at high risk of MPXV infection.

Link to the journal:

  • Clinical Characteristics of Monkeypox Virus Infections in HIV- and HIV-Non-Male Men: A Large Outbreak Cohort in Germany, Christian Hoffmann, Heiko Jessen, Christoph Wyen, Stephan Grunwald, Sebastian Noe, Jörn Teichmann, Anja-Sophie Krauss, Henning Kolarikal, Stefan Scholten, Christoph Schuler, Markus Bickel, Clemens Roll, Peter Kreckel, Siegfried Köppe, Matthias Straub, Gerd Klausen, Johannes Lenz, Stefan Esser, Björn Jensen, Michael Rausch, Stefan Unger, Ramona Pauli, Georg Härä Müller, Anja Mast, Matthias Ulrich Seybold, Sven Schellberg, Jochen Schneider, Malte Benedikt Monin, Eva Wolf, Christoph D. Spinner, Christoph Boesecke, HIV Medicine 2022, DOI:,

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