HIV Status Not Linked to Tecovirimat Treatment Outcomes for Mpox

When comparing patients with and without HIV who were treated with tecovirimat for severe mpox, researchers found that HIV did not affect treatment outcomes.

However, it is important to note that patients with mpox who did not receive tecovirimat were not routinely followed, leading to a lack of comparable outcome data and limiting how much treatment efficacy could be assessed in this study.

The retrospective cohort study, which was published in Annals of Internal Medicine, included 196 individuals who were treated with tecovirimat for mpox between June 20 and August 29, 2022, at New York Presbyterian’s Weill Cornell Medical Center or New York Presbyterian’s Columbia University Medical Center. Of this group, 154 tested positive for mpox and remained in the study, and of this cohort, 72 had HIV and 82 did not. By the end of the study, 33 people with HIV (PWH) and 55 people without HIV had completed both at least 1 follow-up visit and a posttreatment visit.

All 152 participants in the study were male. PWH were more likely to be Black and those without HIV were more likely to be White, but overall, the proportions of White (33%), Black (26%), and Hispanic or Latino (25%) men in the study were not starkly different. Additionally, 70% of men without HIV were taking preexposure prophylaxis (PrEP).

While PWH were more likely to have skin lesions, fever, or diarrhea on day 1 of mpox illness, those without HIV were more likely to experience a prodrome and develop additional symptoms. Rates of sexually transmitted infections were higher among patients without HIV, and while bacterial superinfection rates were high overall, they were slightly greater among patients without HIV.

Treatment outcomes were similar between participants with and without HIV, and tecovirimat was well tolerated, with 4 patients experiencing serious adverse events that the study investigators and treating clinicians deemed unlikely to be related to tecovirimat.

PWH started treatment earlier than patients without HIV, but both groups reported improvement at similar rates. Specialty consultations were most frequently requested from dermatology, colorectal surgery, and urology, with no difference between groups.

“Those who started treatment earlier in the course of disease may have had faster symptom resolution—extrapolating from what is known about antiviral treatment of other acute infections—but those who started later could also have had shorter times to full symptom resolution if their symptoms had already begun to improve,” the authors noted. “Additional studies to show the effect of tecovirimat on disease progression and to more closely track the timeline of symptom resolution are needed.”

Aside from the lack of a control group that did not receive tecovirimat and the high rates of patients lost to follow-up, there were other limitations to the study that should be addressed in future research.

The authors noted that the study may have been affected by selection bias, as some PWH may have been included due to their HIV status rather than their mpox infection. Additionally, most PWH in the study had well-controlled disease, with viral loads lower than 1000 copies/mL and CD4 counts above 0.20×10⁹ cells/L, which limited insight into the effect of advanced HIV infection on mpox infection outcomes.

“Although it remains unclear how the incidence and demographic features of the current mpox outbreak will develop going forward, the current scenario requires better understanding of both disease and treatment in those persons who bear the greatest burden of disease to date—primarily MSM [men who have sex with men] and PWH,” the authors said. “Tecovirimat is a promising treatment whose efficacy will hopefully be borne out in future rigorous studies.

Reference

McLean J, Stoeckle K, Huang S, et al. Tecovirimat treatment of people with HIV during the 2022 mpox outbreak: a retrospective cohort study. Ann Intern Med. Published online May 2, 2023. doi:10.7326/M22-3132