Conclusion
The rapid global expansion of mpox cases during the 2022 outbreak demonstrated how a zoonotic infection effectively transformed into a sexually transmitted disease in the modern era. It is now clear that PLWH who are poorly controlled are at significantly increased risk of severe disease and death. Sporadic case clusters suggest ongoing community transmission, though it remains to be seen if mpox will ultimately become truly endemic. The natural progression of disease in these severe cases, to include possible IRIS and risk factors for progression other than low CD4 T Cell count, must be further clarified, and optimal management remains undefined. While the STOMP trial and VIRISMAP are actively attempting to answer these questions, low case counts have slowed enrollment.
Therefore, until further data are available, we advise that the most severe cases should be treated in consultation with the CDC, with combination antiviral therapy, rapid initiation of ART and followed by a multidisciplinary team to include a wound care specialist over the prolonged course of the recovery. Those at risk should be vaccinated with Jynneos. We also strongly encourage providers to enroll patients into the STOMP trial and VIRISMAP to further define the natural course of this disease and clarify optimal management strategies.