Most US Mpox Deaths Occurred Among Black Men With Advanced HIV

Most mpox-associated deaths occurred among Black, cisgender men with advanced HIV or AIDS who reported recent sexual contact with another man, according to the CDC’s latest Morbidity and Mortality Weekly Report.

Between May 10, 2022, and March 7, 2023, a total of 30,235 confirmed and probable mpox cases have been reported in the United States. During this time, 38 mpox-associated deaths were recorded in the country, equating to 1.3 mpox-associated deaths per 1000 cases.

The number of deaths in the United States alone makes up nearly a third of mpox-related deaths worldwide, with more than 87,000 cases across 110 countries, and 120 deaths at the time of reporting, according to the World Health Organization.

The CDC received reports of 52 total US deaths among individuals with confirmed or probable mpox, with 38 classified as mpox-associated. Three deaths were confirmed to not be mpox-associated, and 11 deaths are still being investigated.

Among the 38 who died of mpox in the United States, 87% were Black—followed by White (8%) and Latino (5%)—compared with 33% of those who survived and recovered from mpox. All but 2 decedents were cisgender men, with 1 being a cisgender woman and 1 a transgender woman. The CDC also reported that nearly half (47%) of decedents resided in Southern states, compared with 39.4% of survivors in the region.

“The gender and racial disparities in mpox-associated deaths align with previous reports, in which most patients hospitalized for severe manifestations of mpox were Black men with uncontrolled HIV and parallel racial and ethnic disparities in HIV infection and mortality,” the authors said. “In 2020, 75% of all-cause deaths among adults with HIV occurred in males, 39% of whom were Black males. Disparities and barriers are apparent at all levels of HIV care including recognition of HIV risk, access to testing, and access to and receipt of preexposure prophylaxis and ART [antiretroviral therapy].”

Of the 10 decedents for whom recent sexual or intimate contact information was available, 9 had sexual or intimate contact with cisgender men within 3 weeks prior to symptom onset. Additionally, 2 decedents had been in close contact with individuals with mpox, but not through sexual activity, rather through sharing a bed or caring for a family member, and 5 of 11 decedents with available housing data experienced homelessness.

HIV infection was more common among decedents than survivors, as indicated by information available for 87% of decedents and 45% of survivors, with an HIV prevalence of 93.9% and 38.3%, respectively. Among 24 decedents with HIV with available information, all had very advanced HIV or AIDS, with all but one individual having a CD4 count <50. Two other decedents were immunocompromised for other reasons, with one experiencing diabetic ketoacidosis and the other recently undergoing a kidney transplant that was complicated by acute rejection.

Of 25 individuals with HIV, only 2 had reported taking ART before receiving an mpox diagnosis, and HIV was not well-controlled in one of these decedents. ART was started for 19 of the 20 decedents who were not already receiving it, including 1 who received an HIV diagnosis just 5 days after receiving an mpox diagnosis.

One decedent declined treatment for advanced HIV, and ART treatment status was unknown for three of the 25 decedents with HIV. ART was either delayed or interrupted for 7 decedents due to clinician concerns regarding immune reconstitution inflammatory syndrome (IRIS), a hyperinflammatory response that can occur in patients with HIV during the first 6 months of receiving ART.

Current mpox death prevention methods include integrated testing, diagnosis, and early treatment for mpox and HIV, and ensuring equitable access to both mpox and HIV prevention and treatments like ART.

Clinicians chose not to administer mpox therapeutics to 2 of the decedents. In one instance, this was due to concerns regarding contraindication linked to other comorbidities, and in the other, the decedent was already undergoing ART for HIV with an undetectable viral load at the time of the initial assessment for mpox care. One month later, the latter decedent was found deceased during a wellness check, showing diffuse lesions indicative of mpox. Additionally, 7 of 27 decedents refused therapeutic or intravenous medications or left the hospital against medical advice during their clinical treatment.

The median (IQR) age at death was 34 (22-58) years, and the median time from symptom onset to death was 68 (50-86) days, as mpox cases peaked in summer 2022 while deaths peaked in fall to early winter 2022. Among the 38 mpox-associated deaths in the CDC report, 25 (65.8%) occurred between October and November 2022. The number of both cases and deaths have greatly declined since then.

According to the authors, the findings in this report further highlight the importance of combining prevention, testing, and treatment for sexually associated infections like mpox and HIV.

“Equitable access to prevention, treatment, and engagement and retention in care for both mpox and HIV should be prioritized, particularly among Black men and other persons at risk for sexually associated infections,” the authors emphasized. “These results underscore previous recommendations that providers offer HIV testing to all patients with probable or confirmed mpox and consider early mpox-directed treatment in highly immunocompromised patients. Further, combining therapies for mpox and boosting immune function might also reduce mortality from severe mpox.”

Reference

Riser AP, Hanley A, Cima M, et al. Epidemiologic and clinical features of mpox-associated deaths — United States, May 10, 2022–March 7, 2023. MMWR Morb Mortal Wkly Rep. 2023;72:404–410. doi:10.15585/mmwr.mm7215a5