News & Media > BHIVA rapid statement on monkeypox virus

BHIVA rapid statement on monkeypox virus

Tuesday 31 May 2022 (update to original 17 May 2022 statement)

As of 31 May 2022, 190 cases of monkey pox virus (MPV) have been reported in the UK. Men who had sex with men (MSM) are disproportionately impacted and most cases report no travel to an endemic area. UKHSA are working closely with stakeholders across the NHS, including BASHH, BHIVA and Terrence Higgins Trust to ensure appropriate information is disseminated as broadly as possible and services are supported to provide appropriate screening and management.

The UK Health Security Agency (UKHSA) press release is here:
https://www.gov.uk/government/news/monkeypox-cases-confirmed-in-england-latest-updates

Latest information on case definitions, vaccination and principles of infection control are here:
https://www.gov.uk/government/collections/monkeypox-guidance


Impact of HIV on MPV

There is limited evidence as to how HIV impacts risk of MPV acquisition or its disease course:

  • 118 MPV cases in Nigeria: 6% mortality rate, 4/7 deaths in people with HIV, at least 3 with advanced HIV and not on ART; total number of people with HIV not described [1]

  • 40 MPV cases in Nigeria (9 with HIV; at least 7 with high viraemia and/or low CD4 counts): people with HIV experienced more prolonged illness, larger lesions, and higher rates of both secondary bacterial skin infections and genital ulcers [2]

  • 34 MPV cases identified in the US: HIV status was not reported; there were no deaths [3]

Currently we do not recommend any specific actions for people with HIV beyond vigilance about clinical presentations and history of exposure. If UKHSA develop guidance for immunocompromised individuals, we suggest the following to be at higher risk and prioritised for specialist review:

  • CD4 cell count <200 cells/mm3

  • Recent HIV-related illness (e.g. AIDS diagnosis in the prior six months)

  • Persistent HIV viraemia (e.g. >200 copies/mL)


Vaccine considerations

There are two smallpox vaccines which also confer protection against MPV:

1. one prepared with live vaccinia virus, which is no longer available in the UK

2. a largely attenuated non-replicating one e.g. the MVA-BN (Imvanex) vaccine recommended in some circumstances by UKHSA [4]

Non-replicating smallpox vaccines can be used in line with existing BHIVA vaccine guidance [5]. The MVA-BN vaccine has been studied in people with HIV and a CD4 greater than 100 cells/mm3. The vaccine can be used at CD4 counts <100 although like to be less effective (particularly if CD4 <50); patients should receive specialist advice about protection from exposure.


Treatment: pharmacokinetic & renal considerations

There are three antivirals available to treat MPV:

1. Tecovirimat potential for drug-drug interactions (DDI), see Liverpool website [6]

2. Brincidofovir (oral pro-drug of cidofovir), potential for DDI, see Liverpool website [6]

3. Cidofovir high nephrotoxic potential; avoid nephrotoxic antiretrovirals (e.g. tenofovir-disoproxil) and lack of data with tenofovir-alafenamide warrants caution


References

1. Yinka-Ogunleye A et al; CDC Monkeypox Outbreak Team. Lancet Infect Dis. 2019 Aug;19(8):872-879.

2. Ogoina D et al. Clin Infect Dis. 2020 Nov 5;71(8):e210-e214.

3. Huhn GD et al. Clin Infect Dis. 2005 Dec 15;41(12):1742-51.

4. UKHSA Monkeypox vaccination guidance 2022 https://www.gov.uk/government/publications/monkeypox-vaccination

5. BHIVA vaccine guidelines 2015 https://www.bhiva.org/file/NriBJHDVKGwzZ/2015-Vaccination-Guidelines.pdf (page 70)

6. https://www.hiv-druginteractions.org/checker


For further information, please contact bhiva@bhiva.org or for media enquiries, please contact Jo Josh at jo@commsbiz.com or +44 (0)7306 391875.