猴痘爆發對愛滋病毒感染者意味著什麼？
資料來源：Liz Highleyman / 2022 年 6 月 8 日 /aidsmap / 財團法人台灣紅絲帶基金會編譯
圖片來源：英國衛生安全局
新的猴痘疫情繼續在英國和世界範圍內蔓延，主要影響男男性行為者。一些罹患猴痘的男性也感染了愛滋病毒，但到目前為止，他們的結果似乎並沒有更糟。雖然任何人都可以透過密切的個人接觸感染病毒，但專家和倡議者正在敦促男同性戀和雙性戀男性，特別是在同志驕傲季節對症狀保持警惕並採取預防措施。
雖然猴痘不是一種新疾病，但目前的爆發是不尋常的。猴痘主要見於中非和西非，傳統上人們認為它不容易在人群中傳播。
英國衛生安全局 (UKHSA) 在其最新更新中報告了英格蘭 287 例確診病例，蘇格蘭 10 例，威爾斯 3 例和北愛爾蘭 2 例。 6 月 7 日，UKHSA 宣布猴痘現在是一種法定傳染病，必須向衛生當局報告。
截至 6 月 2 日，世界衛生組織 (WHO) 報告了 780 例實驗室確診的猴痘病例，這些病例發生在病毒未流行的國家。在英國之後，西班牙、葡萄牙、加拿大和德國報告的病例數量最多。 Global.health 的一項非正式統計顯示，確診或疑似病例超過 1,300 例。
迄今為止，大多數（但不是全部）病例是男性，其中大多數人認為自己是同性戀、雙性戀或其他與男性發生性關係的男性。許多男性報告了最近的國際旅行，其中一些病例與加那利群島的同性戀驕傲活動、比利時的戀物節以及西班牙和加拿大的桑拿浴室有關。在已確定性別的確診病例中，只有三例是女性。
「根據迄今為止的病例報告，這次疫情目前主要正在透過與性活動連接的社交網絡傳播，主要涉及男男性行為者。許多——但不是所有的病例——報告了短暫的和/或多個性伴侶，有時與大型活動或聚會有關」，世衛組織歐洲區域主任 Hans Henri P. Kluge 博士在一份聲明中說。「然而，我們必須記住，正如我們從之前的暴發中看到的那樣，猴痘是由一種可以感染任何人的病毒引起的，並且與任何特定人群沒有本質上的關聯」。
猴痘病毒透過密切的個人接觸傳播，包括皮膚接觸、接吻、接觸已經接觸過瘡液的衣服或床單，以及近距離的呼吸道飛沫。但人們認為它不會像導致 COVID-19 的冠狀病毒那樣透過空氣傳播更遠的距離。雖然尚不清楚猴痘是否直接通過精液傳播，但它確實透過性交時接觸到瘡口而傳播。
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猴痘背景
猴痘與天花有關，但不太嚴重。它通常會引起流感樣症狀、淋巴結腫大和皮疹，皮疹從小紅腫發展為充滿液體或膿液的水皰。皮疹可發生在面部、口腔或身體任何部位。
然而，臨床醫生報告說，當前爆發的病例並不總是遵循經典模式。有些人只有一處或幾處病變，通常在生殖器或肛門區域，這可能類似於更常見的性傳播疾病，如皰疹或梅毒。有些人沒有相關症狀，如發燒、疲勞或淋巴結腫大。
猴痘病毒的潛伏期長達三週，疾病通常持續兩到四周。當人們有症狀時最有可能傳播，並且在瘡完全癒合並且結痂脫落之前，它們可以保持傳染性。
儘管皮損可能非常痛苦，但大多數猴痘患者無需治療即可完全康復。在歐洲流行的猴痘病毒株致死率約為1%，在本次疫情爆發期間至今沒有死亡報告。
但猴痘可導致兒童、孕婦和免疫功能低下的人罹患上更嚴重的疾病。併發症可能包括肺炎、敗血症、腦炎和導致視力喪失的角膜感染。用於治療天花的抗病毒藥物也可用於治療猴痘，包括 tecovirimat (Tpoxx)、cidofovir (Vistide) 和 brincidofovir (Tembexa)。
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猴痘和愛滋病毒
關於猴痘和愛滋病病毒感染者的數據有限。此前在非洲開展的研究發現，愛滋病毒未得到控制的人預後更差，包括更大、更持久的傷口病變、更多併發症和數人死亡。
世衛組織表示：「愛滋病毒感染者的數據有限，但那些服用抗反轉錄病毒藥物且免疫系統健全的人尚未報告更嚴重的病程」。「如文獻中所述，那些未接受治療或免疫抑制的 HIV 感染者可能會有更嚴重的病程」。
「目前，除了對臨床表現和接觸史保持警惕外，我們不建議對 HIV 感染者採取任何具體行動」。
英國性健康和愛滋病毒協會主席克萊爾·杜斯納普博士在 5 月 23 日的aidsmap的聊天版中發表談話表示，接受抗反轉錄病毒治療且 CD4 計數超過 200 的愛滋病毒陽性者「沒有任何特別的風險變得更加不適」。
英國 HIV 協會 (BHIVA) 同意 HIV 本身可能不會增加對猴痘感染的易感性或導致更嚴重的疾病。
「目前，除了對臨床表現和接觸史保持警惕之外，我們不建議對 HIV 感染者採取任何具體行動」，BHIVA 在一份快速聲明中說。然而，該組織建議，CD4 計數低於 200、持續可檢測到的病毒載量或最近患有 HIV 相關疾病的人應被視為處於較高風險之中。
歐盟疾病監測(Eurosurveillance) 最近的一份報告描述了意大利男同性戀中的四例猴痘病例。兩人為 HIV 陽性並接受了有效的抗反轉錄病毒治療，兩人為 HIV 陰性並接受了 PrEP。其中三名男子參加了加那利群島的活動，一名男子說他是為了性工作而旅行；所有的人都報告說在旅行時與不同的男性伴侶發生了不安全的性行為。
其中三名男性有全身症狀。均報告了身體不同部位的病變，包括 3 例生殖器和 2 例肛門區域。但與經典的猴痘表現不同的是，它們都有不同步的病變，這意味著所有的瘡都不是同時處於同一階段。所有男性都在沒有治療的情況下康復。測試顯示，三人精液中的猴痘病毒 DNA 水平非常低，兩人糞便樣本呈陽性，一名唾液樣本呈陽性。
同一期 Eurosurveillance 的另一份報告描述了葡萄牙的 96 例猴痘病例，其中包含 27 例病例的更詳細信息。所有人都是男性，其中大多數是二三十歲的人。十四人是愛滋病毒陽性。只有四人報告了最近的國際旅行，只有一人知道與有類似症狀的人有過接觸，但大多數人報告了最近與多個伴侶發生性關係，還有幾個人去過桑拿浴室。大約一半報告了全身症狀，包括發燒和淋巴結腫大。六人患有生殖器潰瘍，五人患有肛門潰瘍。
英國的調查人員也在這個問題上發表了一份報告。儘管他們確實向患有猴痘的人詢問了愛滋病毒和其他先前存在的健康狀況，但他們決定報告中不包括這些信息，因為數據仍然是初步的。
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猴痘預防
天花疫苗也可以預防猴痘，但大多數 50 歲以下的人沒有接種疫苗，因為 1980 年天花在全球範圍內被根除。
BASHH 主席 Claire Dewsnap 博士於 5 月 23 日在aidsmap 聊天中分享了有關猴痘的新聞。
較舊的活痘苗病毒疫苗 (ACAM2000) 可能會導致不良事件，尤其是在免疫功能低下的人和皮膚病患者中。但最近批准的非複制型天花和猴痘疫苗（Imvanex 或 Jynneos）已經過測試，發現對 HIV 感染者是安全的。 Dewsnap 建議，對於 CD4 計數較高的接愛抗反轉錄病毒藥物治療患者，「如果您被提供了天花疫苗，就您就應該接種」。
猴痘的傳播可以透過環形疫苗接種或針對以感染者的密切接觸者為目標的疫苗接種來控制。由於猴痘的潛伏期較長，接觸後數日內接種疫苗可作為暴露後預防。一些國家現在正在向接觸已知病例的高風險者和醫療保健提供者接種疫苗。加拿大最近宣布將為過去 14 天內有兩個以上男性性伴侶的男性提供疫苗。但專家表示，目前不建議對普通人群進行普遍的天花疫苗接種。
衛生官員敦促身體任何部位，尤其是生殖器出現異常皮疹或病變的人，應聯繫他們的醫療保健提供者或性健康診所。但是，人們應該在訪問前提前打電話尋求建議。
猴痘檢測呈陽性的人應該隔離，直到他們完全康復並且皮疹完全癒合。建議那些認為自己可能接觸過病毒的人自我監測症狀，避免發生性行為，並避免在三週內進行密切接觸的聚會。儘管尚不清楚該病毒是否透過生殖器分泌物傳播，但 UKHSA 建議猴痘患者在感染後八週內應使用保險套作為預防措施。
此外，對於猴痘檢測呈陽性的人和認為自己可能接觸過病毒的人來說，配合接觸者追踪工作也很重要。幸運的是，男男性行為者及其健康照護提供者擁有可用於遏制猴痘的性傳播疾病爆發的管理經驗。
「當涉及到他們和他們所在社區的性健康時，同性戀和雙性戀社區具有高度的意識和快速的尋求健康的行為」，克魯格博士說。「事實上，我們應該為他們早期向醫療保健服務機構呈現疾病而鼓掌」。
What does the monkeypox outbreak mean for people living with HIV?
Liz Highleyman / 8 June 2022 / aidsmap /
Image: UK Health Security Agency
The new monkeypox outbreak continues to spread in the UK and worldwide, mainly affecting men who have sex with men. Several of the men who developed monkeypox are living with HIV, but so far they do not appear to have worse outcomes. While anyone can contract the virus through close personal contact, experts and advocates are urging gay and bisexual men, in particular, to be alert for symptoms and take precautions during Pride season.
While monkeypox is not a new disease, the current outbreak is unusual. Monkeypox is primarily seen in Central and West Africa, and traditionally it was thought that it did not spread easily among people.
In its latest update, the UK Health Security Agency (UKHSA) reported 287 confirmed cases in England, 10 in Scotland, three in Wales and two in Northern Ireland. On 7 June, UKHSA announced that monkeypox is now a notifiable infectious disease that must be reported to health authorities.
As of 2 June, the World Health Organization (WHO) reported 780 laboratory confirmed monkeypox cases in countries where the virus is not endemic. After the UK, the largest number of cases have been reported in Spain, Portugal, Canada and Germany. An informal tally by Global.health puts the number of confirmed or suspected cases at more than 1300.
Most, but not all, cases so far are men, a majority of whom identify as gay, bisexual or other men who have sex with men. Many of the men reported recent international travel, and some of the cases have been linked to a gay Pride event in the Canary Islands, a fetish festival in Belgium and saunas in Spain and Canada. Of the confirmed cases with an identified gender, only three are women.
“Based on the case reports to date, this outbreak is currently being transmitted through social networks connected largely through sexual activity, primarily involving men who have sex with men. Many—but not all cases—report fleeting and/or multiple sexual partners, sometimes associated with large events or parties,” Dr Hans Henri P. Kluge, WHO Regional Director for Europe, said in a statement. “We must remember, however, as we have seen from previous outbreaks, that monkeypox is caused by a virus that can infect anyone and is not intrinsically associated with any specific group of people.”
The monkeypox virus is transmitted through close personal contact, including skin-to-skin contact, kissing, contact with clothing or linens that have been in contact with from fluid from sores, and respiratory droplets at close range. But it is not thought to spread through the air at longer distances like the coronavirus that causes COVID-19. Although it is still unclear whether monkeypox is directly transmitted through semen, it does spread through contact with sores during sex.
Monkeypox background
Monkeypox is related to smallpox but is less severe. It typically causes flu-like symptoms, swollen lymph nodes and a rash that progresses from small red bumps to fluid- or pus-filled blisters. The rash can occur on the face, in the mouth or anywhere on the body.
However, clinicians report that cases in the current outbreak do not always follow the classic pattern. Some people have only one or a few lesions, often on the genitals or in the anal area, which may resemble more common sexually transmitted diseases such as herpes or syphilis. Some individuals have not had associated symptoms like fever, fatigue or swollen lymph nodes.
The monkeypox virus has an incubation period of up to three weeks, and the illness typically lasts two to four weeks. Transmission is most likely when people have symptoms, and they can remain infectious until the sores are completely healed and the scabs fall off.
Although the lesions can be quite painful, most people with monkeypox fully recover without treatment. The monkeypox strain circulating in Europe has a fatality rate of around 1%, and there have been no deaths reported so far during the current outbreak.
But monkeypox can cause more severe illness in children, pregnant women and immunocompromised people. Complications may include pneumonia, sepsis, encephalitis and corneal infection leading to vision loss. Antiviral medications used to treat smallpox can also be used for monkeypox, including tecovirimat (Tpoxx), cidofovir (Vistide) and brincidofovir (Tembexa).
Monkeypox and HIV
There is limited data on monkeypox and people living with HIV. Previous studies in Africa found that people with uncontrolled HIV had worse outcomes, including larger and longer-lasting lesions, more complications and several deaths.
“There is limited data among people living with HIV, but those who take antiretrovirals and have a robust immune system have not reported a more severe course,” according to WHO. “Those people living with HIV who are not on treatment or remain immunosuppressed may have a more severe course, as documented in the literature.”
“Currently we do not recommend any specific actions for people with HIV beyond vigilance about clinical presentations and history of exposure.”
Speaking during a 23 May aidsmapCHAT, Dr Claire Dewsnap, president of the British Association for Sexual Health and HIV, said that HIV-positive people who are on antiretroviral therapy with viral suppression and a CD4 count above 200 “are not at any particular risk of becoming significantly more unwell.”
The British HIV Association (BHIVA) concurs that HIV itself likely does not increase susceptibility to monkeypox infection or lead to more severe disease.
“Currently we do not recommend any specific actions for people with HIV beyond vigilance about clinical presentations and history of exposure,” BHIVA said in a rapid statement. However, the organization suggests that people with a CD4 count below 200, persistent detectable viral load or a recent HIV-related illness should be considered at higher risk.
A recent report in Eurosurveillance described four monkeypox cases among gay men in Italy. Two were HIV-positive and on effective antiretroviral therapy and two were HIV-negative and on PrEP. Three of the men attended the Canary Islands event and one said he travelled for sex work; all reported condomless sex with different male partners while travelling.
Three of the men had systemic symptoms. All reported lesions on different parts of the body, including the genitals in three cases and the anal region in two cases. But unlike the classic monkeypox presentation, all had asynchronous lesions, meaning all the sores were not at the same stage at the same time. All of the men recovered without treatment. Testing revealed that three had very low levels of monkeypox virus DNA in their semen, two had positive faecal samples and one had a positive saliva sample.
Another report in the same issue of Eurosurveillance described 96 monkeypox cases in Portugal, with more detailed information on a subset of 27 cases. All were men, most of them in their twenties or thirties. Fourteen were HIV positive. Only four reported recent international travel, and just one had known contact with people with similar symptoms, but most reported recent sex with multiple partners and several had visited saunas. About half reported systemic symptoms including fever and swollen lymph nodes. Six had genital ulcers and five had anal ulcers.
Investigators in the UK also published a report in the issue. Although they did ask people with monkeypox about HIV and other pre-existing health conditions, they decided not to include this information as the data were still preliminary.
Monkeypox prevention
Smallpox vaccination prevents monkeypox as well, but most people younger than age 50 or so have not been vaccinated, as smallpox was eradicated worldwide in 1980.
Dr Claire Dewsnap, Chair of BASHH, shares news on monkeypox in aidsmapCHAT on 23 May.
An older live vaccinia virus vaccine (ACAM2000) can cause adverse events, especially in immunocompromised people and those with skin conditions. But a recently approved non-replicating smallpox and monkeypox vaccine (Imvanex or Jynneos) has been tested and found to be safe for people with HIV. For people on antiretrovirals with a high CD4 count, “If you’re offered a smallpox vaccine, you should take it,” Dewsnap advised.
Monkeypox transmission can be contained through ring vaccination, or targeted vaccines for close contacts of an infected individual. Because monkeypox has a long incubation period, vaccination within several days after exposure works as post-exposure prophylaxis. Several countries are now administering vaccines to high-risk contacts of known cases and health care providers. Canada recently announced it would offer vaccines to men who have had more than two male sex partners in the past 14 days. But experts say universal smallpox vaccination for the general population is not indicated at this time.
Health officials are urging anyone with an unusual rash or lesions on any part of their body, especially the genitals, to contact their health care provider or a sexual health clinic. However, people should call ahead for advice before visiting.
People who test positive for monkeypox should isolate until they are fully recovered and the rash heals completely. Those who think they might have been exposed are advised to self-monitor for symptoms, refrain from sex and avoid gatherings that involve close contact for three weeks. Although it is not known whether the virus is transmitted in genital secretions, UKHSA recommends that people with monkeypox use condoms for eight weeks after infection as a precaution.
In addition, it is important for people who test positive for monkeypox and those who think they might have been exposed to cooperate with contact tracing efforts. Fortunately, men who have sex with men and their providers have experience managing sexually transmitted disease outbreaks that can be applied to monkeypox containment.
“The gay and bisexual communities have high awareness and rapid health-seeking behaviour when it comes to their and their communities’ sexual health,” Dr Kluge said. “Indeed, we should applaud them for their early presentation to health care services.”