ABSTRACT
Background: Late presentation to care remains a major public health problem in Brazil, despite the countrys longstanding commitment to universal access to ART to all PLWH. The COVID-19 pandemic severely hit the country and further impacted the HIV care continuum, with worse disparities observed by gender and sexual orientation. By December 28th 2022, Brazil reported 10,493 and 14 mpox cases and deaths ranking second globall. Although mpox lethality is low, HIV-related immunosuppression may negatively impact mpox outcomes, increasing hospitalizations and fatalities. We aim to describe mpox hospitalization rates and explore the impact of HIV-infection on mpox-related hospitalizations and clinical outcomes. Method(s): Prospective, observational cohort study of individuals with confirmed mpox infection followed at the major mpox referral center in Rio de Janeiro, Brazil. Demographic and clinical data including reasons for hospitalization were systematically collected. Chi-squared or Fisher's exact tests for qualitative variables and the Moods median test for quantitative variables were used. Result(s): From June 12 to December 12, 2022, 402 participants had a laboratory-confirmed mpox diagnosis. Median age was 34 years, 365 (91%) were cisgender men, and 197 (49%) were PLWH. Overall, 39 (10%) participants were hospitalized due to mpox-related causes;20 (51%) were PLWH. All PLWH with CD4 counts< 200 cells/mm3 required hospitalization. Compared to nonhospitalized PLWH, a higher proportion of hospitalized PLWH had concomitant opportunistic infections (4/20 [20%] vs. 1/177 [0.6%];p< 0.001), were not virologically suppressed (7/20 [35.0%] vs. 22/177 [15.3%];p=0.1) and were not on ART (4/20 [20%] vs. 15/177 [7.6%];p=0.03). Among all hospitalized participants, PLWH were more frequently hospitalized due to severe proctitis than HIV-negative participants (12/20 [60%] vs. 5/19 [26.3%];p=0.03), with no differences regarding hospitalizations for pain control (Table). PLWH accounted for all cases of hospitalized individuals who required intensive care support (n=4), had deep tissue involvement (n=3) and had a mpox related death (n=2). Conclusion(s): Our findings suggest an association between worse outcomes in the HIV care continuum and mpox-related hospitalizations. Advanced immunosuppression (CD4< 200) contributed to more severe clinical presentations and death. Public health strategies to mitigate HIV late presentation and the negative impact of the COVID-19 pandemic to the HIV care continuum are urgently needed. Sociodemographic and clinical characteristics of mpox cases according to HIV and hospitalization status.
ABSTRACT
Background: Although cisgender MSM (cis-MSM) and transgender women (TGW) suffer the highest burden due to the HIV epidemic in Latin America (LA), PrEP implementation is limited. ImPrEP was an implementation study to assess safety and feasibility of same-day PrEP initiation (daily-oral TDF/FTC) for cis-MSM and TGW vulnerable to HIV infection in Brazil, Peru and Mexico;results on factors associated with long-term PrEP engagement (LTPE) and HIV incidence are reported here. Methods: Eligible cis-MSM and TWG (HIV-negative, ≥18 years-old, reporting 1+ risk criteria) were screened and enrolled on the same-day, receiving a 30-day PrEP supply. Follow-up visits were scheduled at week 4 after enrollment and quarterly thereafter. Main outcomes were LTPE (3+ follow-up visits within 52 weeks of enrollment) and HIV incidence. A multivariable model controlling for country, education, gender, substance use, STIs, and self-reported adherence is presented. Results: From March 2018-June 2021, 9522 participants were enrolled (Brazil: 3928, Mexico: 3301, Peru: 2293), with 12348.92 person-years (PY) follow-up;follow-up time accrued for LTPE analysis affected by Covid-19 restrictions was shorter in Brazil than in Mexico and Peru. Overall, 26% were aged 18-24, 94.3% cis-MSM, 5.7% TGW, 73.2% non-white and 76.0% >secondary education;92.8% reported condomless anal sex (CAS), 17.3% sex-work, 57.8% had >5 sex partners. Overall, 8.8% attended only the enrollment visit and 68.2% showed LTPE (Brazil:80.1%;Mexico:67.2%;Peru:45.0%). Participants aged 18-24 years (aOR 0.53[95%CI:0.46-0.62]), 10 sex partners (aOR 1.48[95%CI:1.28-1.70]), reporting receptive CAS (aOR 1.24[95%CI:1.12-1.39]), complete adherence at week-4 (aOR:3.11[95%CI:2.79-3.45]) and CAS with HIV+ partner (aOR:1.48[95%CI:1.28-1.71]) were more likely. HIV incidence was 0.84/100 PY (95% CI:0.69-1.02), higher in Peru, among TGW and 18-24 years-old participants. Conclusion: Same-day PrEP is feasible and safe among cis-MSM and TGW in LA. Overall LTPE was high;COVID-19 restrictive measures may partially explain the differences across countries. Social and structural levels of HIV risk need to be addressed for full PrEP benefits realization.