Richard Amenyah| Mpox and HIV: Should regional policymakers be concerned?

For the second time in two years, the World Health Organization (WHO) declared mpox a public-health emergency of international concern (PHEIC) on August 14. This highlights the growing global concern over the resurgence of mpox, including its impact on people living with or at risk of HIV.

Evidence shows that people with advanced HIV, who are severely immunocompromised, are at an increased risk of severe mpox, a more severe clinical course, or even death if not prevented or treated early. Consequently, during the mpox outbreak of 2022, people living with HIV (PLHIV) accounted for 38-50 per cent of those affected.

The mpox multicountry outbreak response for the Americas, by PAHO, reveals that as of August 26, there were 68,728 cases of mpox, including 142 deaths in 32 countries. Most cases in the Americas were from HIV care services, sexual health services, or primary and/or secondary healthcare facilities, involving mainly, but not exclusively, men who have sex with men (MSM). The highest proportion of cases was recorded in 2022 (61,477 cases, 90 per cent), with a progressive downward trend in 2023 (4,261 cases, 6.2 per cent) and 2024 (2,990 cases, 4.4 per cent). The North American subregion reported the highest burden of mpox cases, with 39,416 cases and 94 deaths up to August. The South American subregion has the next highest proportion of cases (24,162 cases and 44 deaths), followed by the Caribbean and Atlantic Ocean Islands (4,129 cases and two deaths), and Central America (1,021 cases and two deaths).

There were 12,749 cases of concurrent HIV infection reported in the Americas. This underscores the importance of educating all people living with HIV about mpox. Individuals with HIV and mpox should continue taking their antiretroviral medicines for sustained viral suppression. They should seek early medical advice if they come into contact with someone who has mpox or develop symptoms of the disease. Medical professionals will check for symptoms such as a high-grade fever, swollen lymph nodes, or skin rashes and monitor individuals for 21 days after their last contact with an infected person and take appropriate action.

SIMILAR VULNERABILITIES

It is crucial to note that mpox and HIV share similar vulnerabilities that drive both diseases, especially among marginalised key populations. Mpox is transmitted through close physical contact, including kissing, hugging, and sexual activities (vaginal or anal), as well as through respiratory droplets, contaminated bedding, or towels. There is also evidence of vertical transmission from mother to child, like HIV, syphilis, and hepatitis B.

Given these similarities, there is need for a well-coordinated, multisectoral, and people-centred response for the two diseases. Lessons from COVID-19, where communities played an essential role in mitigating the impact of the pandemic, should be applied.

Three approved vaccines provide effective protection against mpox. Health policymakers should, therefore, prioritise making vaccines available to vulnerable populations, especially close contacts of people with mpox and key populations at substantial risk of HIV as was supported by PAHO via the Revolving Fund during the mpox response two years ago. Vaccination and contact-tracing efforts should be integrated with existing HIV prevention programmes.

Although no cases of the new mpox variant have been reported in the Americas yet, PAHO has strongly advised countries to remain vigilant and continue surveillance through laboratory testing and timely reporting of confirmed and probable cases. This presents a valuable opportunity for the Caribbean to enhance its response to both HIV and mpox and for governments to increase domestic financing for health as this should be treated as an important public good. Governments must increase their vigilance by activating their contingency plans for mpox, apply lessons learned from previous outbreaks and utilise evidence-based strategies from HIV and COVID-19 responses to address this new global-health alert. For a collective response, a whole-of-government and whole-of-society approach is essential, with communities actively involved in decision-making and central to the implementation of a truly multisectoral, human rights-based, and people-centred mpox response.

RECOMMENDATIONS

Governments should, therefore,

1. Sharpen surveillance systems to strengthen their integrated surveillance systems to detect outbreaks early and monitor trends using standard PCR or GeneXperts. Governments should seize the opportunity to build human-resource capacities in surveillance, including gene sequencing. This will also support public-health research, contributing to global scientific knowledge and informed policymaking.

2. Enhance risk communication and community engagement to effectively reduce the risks of mpox and HIV and mobilise community action, public-awareness campaigns and community sensitisation efforts to increase knowledge about both diseases. Collaboration with community leaders and civil society is crucial for pandemic response efforts as it helps to reduce fear, panic, and stigma associated with mpox and HIV. Community-based initiatives should promote safe practices, personal hygiene, and offer social support to affected individuals, including community surveillance, contact tracing, and mobilising vulnerable populations for vaccination. Combating misinformation, disinformation, and the misconception that mpox is a “gay disease” is vital to ensure that gay men and sex workers are not unfairly blamed or shamed for the outbreak.

3. Enhance case finding and clinical management to ensure that anyone presenting with potential mpox symptoms is offered an HIV test to facilitate access to early initiation of antiretroviral therapy. Therefore, governments in the Caribbean should enhance case-finding efforts through joint testing and diagnosis opportunities among at-risk populations and close contacts of mpox cases. Healthcare workers need to be trained in recognising early symptoms and diagnosing both diseases while also adopting integrated-care approaches, including vaccinations. Training healthcare providers allied staff will also contribute to reducing stigma in medical settings and ensure equitable access and non-discriminatory care as well as the prevention of occupational transmission of mpox to frontline healthcare workers.

4. Strengthen regional and international partnerships to fortify partnerships, particularly through CARPHA and PAHO, for real-time data sharing and knowledge exchange via webinars. Regional cross-border collaborations will enable Caribbean countries to build capacities in surveillance, diagnostic challenges, and clinical management practices, harmonise health policies, and mobilise additional financial resources to tackle mpox and HIV effectively.

It is crucial for Caribbean countries to leverage the declaration of mpox as a Public Health Emergency of International Concern to focus on prevention, preparedness, and strengthening the mpox response, including HIV and sexually transmitted infection programmes.

All people living with HIV should be aware of their status, getting treatment, and adhering to therapy for sustained viral load suppression, with special attention to re-engaging those who have experienced treatment interruptions. This will require Caribbean governments to prioritise the protection of the front-line health workforce and other community health-service providers responding to mpox, increase domestic investments in health to build resilient systems, engage communities, and effectively address the public-health challenges posed by the mpox outbreak while also reinforcing their HIV response efforts, particularly at the primary healthcare level.

Dr Richard Amenyah is a medical doctor and public health specialist. He is the director for the UNAIDS multicountry office for the Caribbean. Follow him on X (formerly Twitter) at @RichardAmenyah or @UNAIDSCaribbean. Send feedback to jamaica@unaids.org.