Monkeypox and HIV: Same but Different?

Paul G. Auwaerter, MD


August 09, 2022

As a medical student in the mid-1980s in New York City, I had a firsthand experience of the tragedy and devastation wrought by HIV. Federal and local responses were underwhelming. As a medical student, I was more preoccupied with learning the basics of doctoring and understanding whether we should wear gloves when drawing blood or pulling drains after the 1985 Centers for Disease Control and Prevention (CDC) recommendation of universal precautions.

Dr Anthony Fauci was among the few leaders within the US government who, with more-than-gentle prodding by HIV activists, came to lead the scientific effort. When I came to Baltimore in 1988 for medical residency, Drs John Bartlett, Frank Polk, and others fought to get hospital resources to set up HIV clinics and inpatient services dedicated to caring for people with opportunistic infections in the pre–antiretroviral era.

In many ways, Dr Fauci's comment that these first months of the global monkeypox are reminiscent of the early HIV days is apt. The spread through social networks by intimate contact is afflicting predominantly gay, sexually active men. US government response has been slow, including only recently declaring a public health emergency. I cannot help but think that reactions would have been stronger and faster if the infection were afflicting a different population. Local health care has fallen again to public health agencies and infectious disease clinicians who remain exhausted from the ongoing COVID-19 pandemic and starved of sufficient and timely resources.

Though HIV continues to be a plague 40 years on, for several reasons monkeypox is unlikely to become as significant. HIV establishes a chronic infection with high mortality if untreated, and a practical preventive approach through vaccination has been elusive. Orthopox, on the other hand, is an acute infection with very low mortality. The transmissibility appears nowhere near SARS-CoV-2 and differs from HIV because it has a fairly short infectivity duration. Many infected with monkeypox acquired infection after participation in multiple sexual encounters. An early estimate of the 2022 outbreak places the R0 number at 1.29, with a higher rate in the United States, at 1.55. These numbers are concerning because they're greater than 1, but if they hold, they will still be nowhere near those of SARS-CoV-2 or HIV. For these reasons, the World Health Organization suggested limiting the number of sexual partners in the current environment.

A vaccine that probably will be effective is currently available, even if in short supply. Antiviral medications, like tecovirimat, are available for people with severe infections, such as proctitis, or for those who are immunosuppressed. However, we lack clear-cut evidence that these drugs are helpful in most patients.

The recently declared US public health emergency is a most welcome sign that some of the missteps and delays that occurred for those with HIV will not happen to the same degree. More vaccine supply should be available in the forthcoming months, and the US Food and Drug Administration (FDA) is considering a dose-sparing intradermal approach to increase supply. Commercial labs are offering testing, and point-of-care tests may be available soon. Hopefully, the FDA will issue an emergency use authorization to improve access to tecovirimat and reduce the barriers imposed by the CDC's expanded access investigational drug program.

The story of monkeypox is only in its infancy, but the global spread makes it unlikely that it will be contained, becoming yet another widespread human infection. One might think that the United States was ready since related smallpox prompted countermeasures to face a bioterrorism event. This real-world test points to problems that need urgent addressing, including sufficient contact tracing, testing, preparedness, and more public health resources. In 2007, Dr Fauci commented in a CNN story on AIDS fatigue when asked why you don't hear about it much in the media. He noted that "the world is a place that is so interconnected that what happens in another part of the world will impact us." We have a different version of fatigue nowadays and have no comfort we'll handle the next differently.

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