Clinical Characteristics of Monkeypox Virus Infections Among Men With and Without HIV

A Large Outbreak Cohort in Germany

Christian Hoffmann; Heiko Jessen; Christoph Wyen; Stephan Grunwald; Sebastian Noe; Jörn Teichmann; Anja-Sophie Krauss; Henning Kolarikal; Stefan Scholten; Christoph Schuler; Markus Bickel; Clemens Roll; Peter Kreckel; Siegfried Köppe; Matthias Straub; Gerd Klausen; Johannes Lenz; tefan Esser; Björn Jensen; Michael Rausch; Stefan Unger; Ramona Pauli; Georg Härter; Matthias Müller; Anja Masuhr; Guido Schäfer; Ulrich Seybold; Sven Schellberg; Jochen Schneider; Malte Benedikt Monin; Eva Wolf; Christoph D. Spinner; Christoph Boesecke


HIV Medicine. 2023;24(4):389-397. 

In This Article

Abstract and Introduction


Background: Since May 2022, increasing numbers of monkeypox virus (MPXV) infections have been reported from across Europe and North America. Studies, mainly from Africa, have suggested a higher risk for severe MPXV cases in people living with HIV.

Methods: This was a retrospective study of all confirmed MPXV infections observed in the participating centres since 19 May 2022. We conducted a chart review to evaluate clinical characteristics, comorbidities, and coinfections, including HIV, viral hepatitis, and sexually transmitted infections (STIs).

Results: By 30 June 2022, a total of 546 MPXV infections were reported from 42 German centres. All patients were men who have sex with men (MSM), of whom 256 (46.9%) were living with HIV, mostly with a preserved immune system and with viral suppression. In total, 232 (42.5%) MSM were also taking HIV pre-exposure prophylaxis (PrEP) and 58 (10.6%) MSM had no known HIV infection or PrEP use. The median age was 39 years (range 20–67), and comorbidities were rare. However, 52.4% and 29.4% of all patients had been diagnosed with at least one STI within the last 6 months or within the last 4 weeks, respectively. The most frequent localizations of MPXV infection were genital (49.9%) and anal (47.9%), whereas fever (53.2%) and lymphadenopathy (42.6%) were the most frequent general symptoms. The hospitalization rate was low (4.0%), and no fatal course was observed. The clinical picture showed no apparent differences between MSM with or without HIV.

Conclusions: In this preliminary cohort analysis from a current large outbreak among MSM in Germany, the clinical picture of MPXV infection did not differ between MSM with and without HIV infection. Severe courses were rare and hospitalization rates were low. However, most patients were relatively healthy, and only a few people living with HIV were viremic or severely immunosuppressed.


Monkeypox virus (MPXV) belongs to the orthopoxvirus genus, which also includes variola virus (which causes smallpox), vaccinia virus (used in the smallpox vaccine), and cowpox virus. The first human case of MPXV infection was observed in 1970 in a 9-year-old boy in the Democratic Republic of Congo.[1] Since then, sporadic outbreaks outside Central and West African countries have been limited to a few cases in recent years and were based on zoonotic transmission or exported cases from endemic countries.[2] In 2022, this changed dramatically. Since 7 May 2022, when the UK Department of Health reported an initial case in a traveller returning from Nigeria, unusually high and increasing numbers of cases are now being reported across Europe and other regions. Initial publications suggest that, to date, the disease has almost exclusively affected men who have sex with men (MSM).[3–5] In Munich, Germany, the first case was published on 20 May 2022.[6] By 17 June 2022, 338 confirmed cases were known to the Robert Koch Institute; 1 week later, the number had doubled to 676, making Germany one of the most affected countries worldwide.[7]

Person-to-person transmission of MPXV mainly occurs through close physical contact. The reasons for the current increase in case numbers are still unclear, and questions remain about the dynamics of transmission. Preliminary genome sequence data suggest a close relationship with the MPXV clade circulating in West Africa.[8,9] It has been suggested that this clade may cause milder disease and have a lower mortality than the clade first described in Central Africa.[10,11] However, a 2017–2018 Nigerian outbreak was associated with a case fatality rate of 6%. Four of the seven patients who died had concomitant HIV/AIDS, suggesting a need to further explore the potential connection between the two diseases.[12] Little is known about other risk factors for severe courses, but children and pregnant women are probably at increased risk.[13,14] The aim of the present work was to compare the clinical picture in patients with MPXV with or without HIV.