Classifying necrotising mpox as an AIDS- defining condition

We are grateful for the opportunity to respond to Oriol Mitjà and colleagues regarding the potential usefulness of labelling fulminant mpox (formerly known as monkeypox) as an AIDS-defining condition.1Mitjà O Alemany A Marks M et al.Mpox in people with advanced HIV infection: a global case series.Lancet. 2023; 401: 939-949Summary Full Text Full Text PDF PubMed Scopus (89) Google Scholar, 2Núñez I Valdés-Ferrer SI Fulminant mpox as an AIDS-defining condition: useful or stigmatising?.Lancet. 2023; 401: 881-884Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar In this Correspondence we will provide counterpoints to the main issues. We agree that people with advanced HIV can be severely afflicted by mpox.1Mitjà O Alemany A Marks M et al.Mpox in people with advanced HIV infection: a global case series.Lancet. 2023; 401: 939-949Summary Full Text Full Text PDF PubMed Scopus (89) Google Scholar, 3Núñez I García-Grimshaw M Ceballos-Liceaga SE et al.Epidemiological and clinical characteristics of patients with human monkeypox infection in Mexico: a nationwide observational study.Lancet Reg Health Am. 2023; 17100392 PubMed Google Scholar However, given that the outbreak has mainly affected this group, it is difficult to know if the immunosuppression derived from advanced HIV conveys a higher risk than other types of immunosuppression. In our Comment, we did not suggest that having any AIDS-defining condition is stigmatising to people living with HIV.2Núñez I Valdés-Ferrer SI Fulminant mpox as an AIDS-defining condition: useful or stigmatising?.Lancet. 2023; 401: 881-884Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar Rather, we state that people with mpox have suffered from stigma due to public commentary and untold reactions. This stigma has concerned organisations such as WHO, the UNAIDS, and the US Centers for Disease Control and Prevention (CDC), who have issued statements addressing the issue of stigma and went as far as to change the name of the disease (monkeypox became mpox), which underlines the pervasiveness of the problem that stigma presents.4WHOWHO recommends new name for monkeypox disease.https://www.who.int/news/item/28-11-2022-who-recommends-new-name-for-monkeypox-diseaseDate: Nov 28, 2022Date accessed: June 6, 2023Google Scholar, 5UNAIDSUNAIDS warns that stigmatizing language on monkeypox jeopardises public health.https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2022/may/20220522_PR_MonkeypoxDate: May 22, 2022Date accessed: June 6, 2023Google Scholar, 6CDCCDC mpox equity and anti-stigma toolkit.https://www.cdc.gov/poxvirus/mpox/resources/toolkits/equity.htmlDate: March 16, 2023Date accessed: June 6, 2023Google Scholar We do not consider labelling mpox as an AIDS-defining condition useful for two primary reasons. First, if a label is to be used to describe a disease (such as AIDS-defining condition) that will inexorably link two diseases that bring (even by themselves) unjustified and unfair stigma to the people who have them, a clear, tangible, and incontestable benefit must be derived from such a label. With current HIV guidelines and practice, such robust benefits remain unclear. Second, such a label could be misleading to physicians regarding the uncertain exclusivity of fulminant mpox with advanced HIV. As we stated previously, it is not known if only people living with advanced HIV are at an increased risk of death from mpox, or if we have not seen this happen in other forms of immunosuppression because the prevalence of other immunosuppressive states is very low in the population primarily affected by mpox. The CDC errs on the side of caution and considers people with a wide range of immunosuppressive states as being at risk for severe mpox. Thus, a more useful label would be opportunistic infection, which would still guide clinicians to consider the disease as potentially more severe in those who are immunosuppressed and intensify management, as suggested by the CDC. We declare no competing interests. We thank Pablo Belaunzarán-Zamudio for the helpful feedback. Fulminant mpox as an AIDS-defining condition: useful or stigmatising?The 2022 mpox outbreak was declared a public health emergency of international concern in July, 2022, by WHO within 2 months of the initial reports.1 With over 85 000 confirmed cases and 86 deaths, the outbreak has mainly affected men, many of whom identify as men who have sex with men (MSM).2–6 In the current outbreak, a high proportion of people with mpox are people living with HIV.3–6 These findings have raised the concern that advanced HIV could predispose to more severe mpox.3–6 However, although mpox outcomes are similar regardless of HIV status, current evidence indicates that mpox deaths—to the best of our knowledge—have occurred only in people living with HIV. Full-Text PDF