Monkeypox vaccination-an opportunity for HIV prevention.

As the world copes with the ongoing COVID-19 pandemic, WHO declared the outbreak of monkeypox virus a global public health emergency on July 23, 2022. This zoonotic orthopox DNA virus, related to the virus that causes smallpox, has been described in humans since 1970. In the past 50 years, cases were described in sporadic outbreaks in Africa, typically originating from contact with wildlife reservoirs (particularly rodents). However, in 2022, the near-simultaneous global outbreaks are affecting sexually active gay, bisexual, and other men who have sex with men almost exclusively. Contrary to the COVID-19 pandemic, a vaccine that could be used for monkeypox was already available, but the key challenge has been deploying the vaccine according to global demand that substantially exceeds supply. Given the scarcity, good public health dictates that the vaccines are offered to those at the highest risk—ie, in the current outbreak, sexually active gay, bisexual, and other men who have sex with men who have multiple partners, and who participate in group sex or attend sex on premises venues. It is clear that monkeypox shares the same risk behaviours with other sexually transmitted diseases, most notably HIV. In fact, 41% of monkeypox infections in a large global case series were in people with HIV, and almost 60% of those without HIV were on pre-exposure prophylaxis (PrEP).

Antiretroviral therapy has fundamentally changed the natural history of HIV infection in terms of morbidity, mortality, and rate of transmission. Nevertheless, all treatment cascades show that late diagnosis remains a major obstacle. Indeed, people with HIV who present late (ie, with a CD4 count below 350 cells per μL, or even less than 200 cells per μL) represent more than 40% of the new diagnoses in Europe annually with no improvement in the past 2 decades. Late diagnosis, with a mortality rate of around 5%, not only represents a clinical challenge for the individual but is also the main obstacle for HIV elimination. Important reasons driving late presentation include poor understanding of personal risk, and social, interpersonal, and internalised stigma. The intense media attention surrounding the monkeypox emergency, and the access to large vaccination events for people who might be at risk of acquiring HIV infection or might be unaware of their HIV status, represents a golden opportunity. Each vaccination event offers a unique opportunity, either to increase HIV and other sexually transmitted disease testing, or to prevent new infections. Indeed, the approach of public health agencies to the vaccination effort should not merely replicate the vaccination events for SARS-CoV-2 but should offer an integrated sexual health clinic.

This person-centred, holistic approach to sexual health could entail HIV testing and promotion of rapid antiretroviral therapy for people with HIV or evaluation for PrEP in case of a negative HIV test. This could also be an opportunity to spark further activism around PrEP in countries such as Italy where PrEP is still not reimbursed.

Unfortunately, this person-centred approach to sexual health has not been adopted as standard of care. Thornhill and colleagues described that among the 310 cases of unknown or negative previous HIV tests, only 122 (39%) patients underwent a HIV test after monkeypox diagnosis, and two (2%) of those had positive results. The WHO declaration of public health emergency for monkeypox reflects the growing number of infections, which fortunately have not been associated with severe outcomes or death. Amid the media attention around COVID-19 and now monkeypox, it should not be forgotten that the HIV pandemic is ongoing, with more than 50 million people living with HIV globally and thousands of deaths, not only in low-income and middle-income countries, but also in high-income countries, especially among late presenters. In the attempt to decrease late presentation, many approaches have been tried; for example, the HIV in Europe initiative has provided a list of indicator diseases to identify people who should be tested for HIV, including sexually transmitted diseases, lymphomas, and thrombocytopenia. Other approaches have included testing people in emergency departments. In our opinion, not only should monkeypox itself be included in this list of indicator diseases for HIV testing, but also, everyone undergoing vaccination should be tested for HIV and, if they are negative, counselled about PrEP.

CM reports grants and travel support from Gilead, personal fees from ViiV Healthcare, and participation on advisory boards from CORIMUNO, ViiV Healthcare, ROCHE, Janssen, Gilead Sciences, and Merck Sharp & Dohme. GG reports grants, personal fees, travel support, and participation on advisory boards from Gilead Sciences, ViiV Healthcare, and Merck Sharp & Dohme, and personal fees from Janssen. CO reports grants, personal fees, and travel sponsorship from ViiV Healthcare, and grants and personal fees from GlaxoSmithKline, Gilead Sciences, Merck Sharp & Dohme, Janssen, and AstraZeneca.