Men who have sex with men (MSM) living with HIV experience more severe symptoms and are significantly more likely to require hospitalization if they contract mpox, according to a retrospective study conducted in Hangzhou, China. The findings, published in 2026, underscore the importance of considering HIV status and immune function when evaluating and managing mpox cases.
Mpox Severity Increased with HIV Coinfection
Researchers analyzed data from 104 laboratory-confirmed mpox cases among MSM, comparing those with HIV coinfection to those with mpox alone. The study revealed a substantial difference in symptom burden between the two groups. Specifically, 67.39% of patients with both mpox and HIV reported lesion pain, compared to 39.66% of those with mpox alone. Critically, all 27 hospitalizations within the entire cohort occurred among individuals with mpox-HIV coinfection, including one admission to intensive care.
The study also included a comparison group of individuals with HIV monoinfection, matched one-to-one with the mpox-HIV coinfected patients. This allowed investigators to isolate the impact of mpox coinfection on clinical outcomes.
Immune Suppression a Key Factor
While the vast majority (97.83%) of coinfected patients were already receiving antiretroviral therapy (ART) for HIV, a significant proportion still exhibited signs of immune suppression. Over a quarter (28.26%) had CD4 positive T cell counts at or below 350 cells per microliter. Lower CD4 counts were directly correlated with more severe clinical manifestations and a higher risk of hospitalization. This suggests that even with ART, incomplete immune recovery can leave individuals vulnerable to more serious mpox illness.
Sexual Behavior and Risk
The study also identified behavioral factors associated with mpox-HIV coinfection. High-risk sexual behaviors, including having multiple sexual partners and frequent sexual activity, were more common among those with both infections. The authors suggest these patterns highlight the need for integrated surveillance and prevention strategies targeting both HIV and mpox within higher-risk populations.
Implications for Clinical Practice
These findings have important implications for clinicians in the United States and elsewhere. The data suggest that mpox may present and progress differently in patients living with HIV, particularly those with incomplete immune recovery. Documenting a patient’s HIV status and recent CD4 count is therefore crucial when evaluating suspected mpox cases. Careful assessment of pain levels and lesion distribution is also warranted.
While mpox is often a self-limiting illness, the presence of underlying immunocompromise can significantly alter its course. The study reinforces the call for coordinated public health strategies that address both HIV and mpox in populations at overlapping risk. This includes promoting HIV testing and treatment, encouraging adherence to ART, and implementing targeted prevention measures for mpox, such as vaccination, within high-risk groups.
A recent case report further illustrates the potential for severe outcomes in individuals with multiple infections. Researchers in Beijing described a patient with mpox, advanced HIV-1, and extensively drug-resistant tuberculosis (XDR-TB) who had been previously vaccinated against smallpox. Despite prior vaccination, the confluence of these infections, coupled with a very low CD4 count (less than 200 cells/μL) and unprotected sexual contact, resulted in a severe mpox infection. This case underscores the importance of addressing underlying immune deficiencies to mitigate the risk of severe mpox illness.
As noted in a systematic review published in 2023, the current mpox outbreak disproportionately affects MSM engaging in high-risk sexual behaviors. This highlights the need for targeted prevention efforts and ongoing surveillance to monitor the evolving epidemiology of the disease.
Reference: Jin X et al. Retrospective Study of Epidemiological and Clinical Characteristics of Mpox-HIV Coinfection in Men Who Have Sex with Men in Hangzhou, China. AIDS Behav. 2026. doi:10.1007/s10461-026-05068-8.
