Monkeypox Virus Infection in Humans Across 16 Countries - April-June 2022
Monkeypox Virus Infection in Humans Across 16 Countries - April-June 2022
Original Article
A BS T R AC T
BACKGROUND
Before April 2022, monkeypox virus infection in humans was seldom reported out- The authors’ full names, academic de-
side African regions where it is endemic. Currently, cases are occurring worldwide. grees, and affiliations are listed in the Ap-
pendix. Prof. Orkin can be contacted at
Transmission, risk factors, clinical presentation, and outcomes of infection are c.m.orkin@qmul.ac.uk, or at the SHARE
poorly defined. Collaborative, Centre for Immunobiolo-
gy, Blizard Institute, Queen Mary Univer-
METHODS sity of London, 4 Newark St., London E1
2AT, United Kingdom.
We formed an international collaborative group of clinicians who contributed to an
international case series to describe the presentation, clinical course, and outcomes *The investigators in the SHARE-net clin-
ical group are listed in the Supplemen-
of polymerase-chain-reaction–confirmed monkeypox virus infections. tary Appendix, available at NEJM.org.
in 16 countries. Overall, 98% of the persons with infection were gay or bisexual men, This article was published on July 21, 2022,
75% were White, and 41% had human immunodeficiency virus infection; the median at NEJM.org.
age was 38 years. Transmission was suspected to have occurred through sexual DOI: 10.1056/NEJMoa2207323
activity in 95% of the persons with infection. In this case series, 95% of the per- Copyright © 2022 Massachusetts Medical Society.
sons presented with a rash (with 64% having <10 lesions), 73% had anogenital
lesions, and 41% had mucosal lesions (with 54 having a single genital lesion).
Common systemic features preceding the rash included fever (62%), lethargy (41%),
myalgia (31%), and headache (27%); lymphadenopathy was also common (reported
in 56%). Concomitant sexually transmitted infections were reported in 109 of 377
persons (29%) who were tested. Among the 23 persons with a clear exposure his-
tory, the median incubation period was 7 days (range, 3 to 20). Monkeypox virus
DNA was detected in 29 of the 32 persons in whom seminal fluid was analyzed.
Antiviral treatment was given to 5% of the persons overall, and 70 (13%) were
hospitalized; the reasons for hospitalization were pain management, mostly for
severe anorectal pain (21 persons); soft-tissue superinfection (18); pharyngitis
limiting oral intake (5); eye lesions (2); acute kidney injury (2); myocarditis (2); and
infection-control purposes (13). No deaths were reported.
CONCLUSIONS
In this case series, monkeypox manifested with a variety of dermatologic and sys-
temic clinical findings. The simultaneous identification of cases outside areas where
monkeypox has traditionally been endemic highlights the need for rapid identifica-
tion and diagnosis of cases to contain further community spread.
M
onkeypox virus, a zoonotic ortho- tionately affected men who are gay or bisexual and
pox DNA virus related to the virus that other men who have sex with men, which suggests
causes smallpox, was first described in amplification of transmission through sexual
humans in 1970 in the Democratic Republic of networks.
Congo (formerly Zaire).1 Sporadic outbreaks of Phylogenetic analyses suggest that the virus
infection have been reported in Africa, typically has circulated undetected for some time outside
originating from contact with wildlife reservoirs areas where it has been endemic, possibly mas-
(particularly rodents).2 Such outbreaks and travel- querading as other sexually transmitted infections
associated cases outside Africa have had limited (STIs).17 The current international case definitions
secondary spread, and therefore human-to-human (Table S1 and Fig. S1 in the Supplementary Ap-
transmission has been deemed inefficient.3-9 De- pendix, available with the full text of this article
spite the fact that monkeypox virus has circulated at NEJM.org) may not be adequate to reflect the
for decades in regions where it has traditionally changing spectrum of clinical presentations, al-
been endemic, research into monkeypox has been low early identification, clarify transmission routes,
neglected and underfunded. Since early May 2022, and inform international public health policies and
more than 3000 monkeypox virus infections have clinical trials. The case series we report here may
been reported in more than 50 countries across help to inform the response.
five regions, prompting the World Health Orga-
nization to declare monkeypox an “evolving threat Me thods
of moderate public health concern” on June 23,
2022.10,11 Case Definition and Identification
Transmission of monkeypox virus occurs We used the U.K. Health Security Agency (UKH-
through large respiratory droplets, close or direct SA) definition of a confirmed case: a laboratory-
contact with skin lesions, and possibly through confirmed monkeypox virus infection defined
contaminated fomites.12 There is no clear evidence by a positive result on monkeypox virus poly-
of sexual transmission through seminal or vaginal merase-chain-reaction (PCR) assay in a specimen
fluids. Vertical transmission and fetal deaths have from any anatomical site.18 The type of clinically
been described.13 qualified PCR assay used for the identification
Endemic monkeypox is generally self-limited, of monkeypox virus infections was locally deter-
with clade-dependent case fatality rates of 1 to mined on the basis of availability and guide-
10%.9 Illness typically begins with fever, followed lines.
by the development of multiple papular, vesiculo- In response to the worldwide outbreaks, aca-
pustular, and ulcerative lesions on the face and demic researchers within the London-based Sex-
body and prominent lymphadenopathy.9,14 Com- ual Health and HIV All East Research (SHARE)
plications include pneumonitis, encephalitis, Collaborative contacted peers in affected coun-
keratitis, and secondary bacterial infections.14 tries through informal clinical and research net-
Young children and immunocompromised per- works and formed a global collaborative group
sons, including persons living with human im- (SHARE-net). Members of this group contribut-
munodeficiency virus (HIV) infection, have been ed to a convenience-sample case series in the
reported to be at increased risk for severe out- interests of improving case identification. The
comes, but whether effective antiretroviral ther- geographic distribution of SHARE-net contribut-
apy (ART) for HIV infection modifies this risk is ing sites is shown in Figure 1.
unknown.15
The current global outbreak of monkeypox Data Collection
virus infection in humans suggests changes in Each contributing center completed a deidentified
biologic aspects of the virus, changes in human structured case-report spreadsheet developed on
behavior, or both; such changes might be driven May 31, 2022 (Fig. S2). Drop-down menus and
by waning smallpox immunity, relaxation of free-text fields were used. The case-report spread-
coronavirus disease 2019 (Covid-19) prevention sheet captured clinical data and was not part of
measures, resumption of international travel, and a research protocol. Variables of interest were
sexual interactions associated with large gather- derived from case definitions that preceded this
ings.16 To date, the current spread has dispropor- outbreak and from evolving international case
Europe Netherlands
1
Belgium 2
United Kingdom
10
Denmark
2 5 1
Portugal
Canada 5
Germany
2
1
2
United States 1 5
France 2
Spain Switzerland Italy
2
Israel
Mexico 1
1
Australia
* Percentages may not total 100 because of rounding. HIV denotes human immunodeficiency virus, IQR interquartile
range, and STI sexually transmitted infection.
† Sexual orientation and race or ethnic group were reported by the persons.
‡ Travel from the country of residence in the month before the positive monkeypox virus polymerase-chain-reaction
(PCR) result is shown.
persons who were not known to have HIV in- Table 2. Demographic and Clinical Characteristics of Persons with HIV
fection. Infection in the Case Series.*
All Persons
Characteristic (N = 528)
Medical setting of presentation — no. (%)
Sexual health clinic 120 (23)
Emergency department 106 (20)
Primary care 20 (4)
Dermatology clinic 38 (7)
HIV clinic 154 (29)
Other hospital clinic 30 (6)
Private clinics or other 60 (11)
Suspected route of transmission — no. (%)
Sexual close contact 504 (95)
Nonsexual close contact 4 (1)
Other or unknown 17 (3)
Household contact 3 (1)
Contact with person known to have monkeypox — no. (%) 135 (26)
Reported clinical features — no. (%)
Rash or skin lesions 500 (95)
Fever 330 (62)
Lymphadenopathy 295 (56)
Pharyngitis 113 (21)
Headache 145 (27)
Lethargy or exhaustion 216 (41)
Myalgia 165 (31)
Low mood 54 (10)
Proctitis or anorectal pain 75 (14)
Site of positive monkeypox viral PCR — no. (%)†
Skin or anogenital lesion 512 (97)
Nose or throat swab 138 (26)
Blood 35 (7)
Urine 14 (3)
Semen 29 (5)
Site of skin lesions — no. (%)‡
Anogenital area 383 (73)
Face 134 (25)
Trunk or limbs 292 (55)
Palms or soles 51 (10)
Description of rash — no./total no. with rash reported (%)
Vesiculopustular 291/500 (58)
Macular 19/500 (4)
Single ulcer 54/500 (11)
Multiple ulcers 95/500 (19)
Other 41/500 (8)
No rash 28
Table 3. (Continued)
All Persons
Characteristic (N = 528)
No. of skin lesions — no. (%)
<5 207 (39)
5–10 131 (25)
11–20 112 (21)
>20 56 (11)
No lesions or missing data 22 (4)
Mucosal lesions present — no. (%) 217 (41)
Site of mucosal lesions — no./total no. (%)
Anogenital only 148/217 (68)
Oropharyngeal only 50/217 (23)
Anogenital and oral 16/217 (7)
Nasal and eye 3/217 (1)
Medical care setting — no. (%)
Inpatient 70 (13)
Outpatient 458 (87)
Received monkeypox-specific treatment — no. (%) 25 (5)
Treatment used — no. (%)
Cidofovir 12 (2)
Tecovirimat 8 (2)
Vaccinia immune globulin 1 (<1)
Other 2 (<1)
remained positive was 21 days after symptom partners in the previous 3 months was 5 part-
onset. ners, 147 (28%) reported travel abroad in the
The clinical presentation was similar among month before diagnosis, and 103 (20%) had at-
persons with HIV infection and those without tended large gatherings (>30 persons), such as
HIV infection. The clinical characteristics of the Pride events. Overall, 169 (32%) were known to
persons with HIV infection are shown in Table 2. have visited sex-on-site venues within the previ-
Concomitant STIs were reported in 109 of the ous month, and 106 (20%) reported engaging in
377 persons (29%) who were tested, with gonor- “chemsex” (i.e., sex associated with drugs such
rhea, chlamydia, and syphilis found in 8%, 5%, as mephedrone and crystal methamphetamine)
and 9%, respectively, of the those who underwent in the same period.
testing. A total of 70 persons (13%) were admitted to
a hospital. The most common reasons for ad-
Transmission mission were pain management (21 persons),
The suspected means of monkeypox virus trans- mostly for severe anorectal pain, and treatment
mission as reported by the clinician was sexual of soft-tissue superinfection (18). Other reasons
close contact in 95% of the persons. It was not included severe pharyngitis limiting oral intake
possible to confirm sexual transmission. A sexual (5 persons), treatment of eye lesions (2), acute
history was recorded in 406 of 528 persons; among kidney injury (2), myocarditis (2), and infection-
these 406 persons, the median number of sex control purposes (13). There was no difference
e f g h
d e f g h
Figure 2 (facing page). Lesions in Persons with Con- ed percentages of positive PCR results were 26%
firmed Human Monkeypox Virus Infection. for nasopharyngeal specimens, 3% for urine spec-
Panel A shows the evolution of cutaneous lesions in a imens, and 7% for blood specimens. Semen was
person with monkeypox; images a1 and a2 show facial tested in 32 persons from five clinical sites and
lesions, images b1 through b3 show a penile lesion, was PCR positive in 29 persons (4 of these in-
and images c1 and c2 show a lesion on the forehead.
stances have previously been reported19) (Table 4).
The polymerase-chain-reaction (PCR) status is indicat-
ed if available. IM denotes intramuscular, and MSM
man who has sex with men. Panel B shows oral and Discussion
perioral lesions (image a, perioral umbilicated lesions;
image b, perioral vesicular lesion on day 8, PCR posi- We describe a human monkeypox case series that
tive; image c, ulcer on the left corner of the mouth on
includes 528 infections from four WHO regions
day 7, PCR positive; image d, tongue ulcer; image e,
tongue lesion on day 5, PCR positive; and images f, g, (Europe, Americas, Western Pacific, and Eastern
and h, pharyngeal lesions on day 0, 3, and 21, respec- Mediterranean) and 16 countries reported over a
tively, PCR positive on day 0 and 3 and negative on day 2-month period. Sexual activity, largely among gay
21). Panel C shows perianal, anal, and rectal lesions or bisexual men, was by far the most frequently
(image a, anal and perianal lesions on day 6, PCR posi-
suspected route of transmission. The strong like-
tive; images b and c, rectal and anal lesions in a single
person, PCR positive; image d, perianal ulcers, PCR lihood of sexual transmission was supported by
positive; image e, anal lesions; image f, umbilicated the findings of primary genital, anal, and oral
perianal lesion on day 3, PCR positive; image g, umbili- mucosal lesions, which may represent the inocu-
cated perianal lesions on day 3, PCR positive; and im- lation site. Monkeypox virus DNA that was de-
age h, perianal ulcer on day 2, PCR positive).
tectable by PCR in seminal fluid in 29 of the 32
cases in which seminal fluid was tested further
supports this hypothesis. However, whether se-
in the frequency of admission according to HIV men is capable of transmitting infection remains
status. Three new cases of HIV infection were to be investigated, since it is unknown whether
identified. the viral DNA detected in these specimens was
Two types of serious complications were re- replication competent. Reports of clusters asso-
ported: one case of epiglottitis and two cases of ciated with sex parties or saunas further under-
myocarditis. The epiglottitis occurred in a per- score the potential role of sexual contact as a
son with HIV infection who had a CD4 cell promoter of transmission. International travel and
count of less than 200 per cubic millimeter; the attendance at large gatherings linked to sex-on-
person was treated with tecovirimat and recov- site activities may explain the global spread of
ered completely. The myocarditis cases were monkeypox infections amplified through sexual
self-limiting (<7 days) and resolved without anti- networks.
viral therapy. One occurred in a person with HIV The clinical presentation we describe has
infection who had a CD4 cell count of 780 per some distinct features not included in the inter-
cubic millimeter, and one occurred in a person nationally accepted case definitions.20 Although
without HIV infection. No deaths were reported. these definitions recently expanded to include
In total, 5% of the 528 persons received gay or bisexual men and other men who have sex
monkeypox-specific treatment. The drugs ad- with men as a risk group, they do not specifi-
ministered included intravenous or topical cidof cally highlight mucosal or rectal presentations,
ovir (in 2% of persons), tecovirimat (2%), and nor do they caution about the possibility of ini-
vaccinia immune globulin (<1%). tial single-lesion manifestations. Existing defi-
nitions do recommend consideration of monkey-
Diagnosis pox in the context of any “unusual” rash but do
The health setting of initial presentation reflected not cover the full range of possible manifesta-
referral patterns and included sexual health or tions. Solitary genital skin lesions and lesions
HIV clinics, emergency departments, and derma- involving the palms and soles may easily lead to
tology clinics and, less commonly, primary care. misdiagnosis as syphilis and other STIs, which
A positive PCR result was most commonly ob- may in turn delay detection. Concomitant labo-
tained from skin or anogenital lesions (97%); other ratory-confirmed STIs were also reported in 29%
sites were less frequently sampled. The report- of the persons tested. Consequently, we recom-
Seminal Fluid
PCR Result No. of Sex
and Person Sexual Partners in Concomitant HIV Presenting Location of Skin or Mucosal Lesions PCR Positivity for
No. Orientation Past 3 Mo STI (Site) Status Symptoms† Rash (No. of Lesions) Monkeypox Virus
Skin Throat
Lesion Swab
The
Positive
1 Homosexual <5 None Positive 1, 2, 3, 5, 6 MU Genitals and face (<5) Yes Yes
2 Bisexual >20 None Negative 1, 2, 4, 5, 6 VP Genitals, trunk, limbs, and lip (>20) Yes No
3 Homosexual 11 to 20 None Positive 1, 2, 3, 4, 5, 6 VP Genitals, palms, soles, rectum, mouth, and tongue Yes Yes
(11–20)
4 Homosexual 11 to 20 Chlamydia Negative 1, 2, 3, 4, 5 VP Perianal area, rectum, penis, face, head, arm, and Yes Yes
(rectum) mouth (11–20)
5 Homosexual <5 None Negative 1, 5 MU Trunk and limbs (<5) Yes No
6 Homosexual >10 Gonorrhea Positive 1, 5 VP Perianal area, trunk, limbs, and tongue (>20) Yes ND
(penis)
n e w e ng l a n d j o u r na l
7 Homosexual >10 Unknown Positive 5 VP Perianal area, trunk, and limbs (11–20) Yes Yes
8 Homosexual >10 Unknown Negative 1, 5 VP Perianal area, trunk, limbs, and tongue (>20) Yes ND
9 Homosexual >10 Syphilis Positive 5 VP Genitals, trunk, and limbs (>20) Yes Yes
10 Bisexual 3 Unknown Negative 1, 5 VP Perianal area, trunk, limbs, eyelid, and nasal mucosa Yes No
(<5)
11 Homosexual <10 Unknown Positive None VP Penis, groin, and arms (<5) Yes Yes
12 Homosexual >10 Unknown Positive 1 VP Perianal area, penis, scrotum, and hand (<5) Yes Yes
13 Homosexual <10 None Negative 1, 6 VP Perianal area, wrist, and chest (11–20) Yes Yes
14 Homosexual <10 None Negative 1, 5 VP Penis, chest, and arms (11–20) Yes Yes
15 Homosexual <10 Unknown Negative 1, 3, 6 VP Penis, lip, face, and arm (11–20) Yes Yes
16 Homosexual <10 Syphilis Positive 5, 6 VP Penis, scrotum, arms, and wrist (11–20) Yes Yes
Downloaded from nejm.org by Priscila Nader on July 24, 2022. For personal use only. No other uses without permission.
17 Homosexual 1 Unknown Negative None VP Face (<5) Yes Yes
18 Homosexual 1 Unknown Positive None VP Face (<5) No Yes
Seminal Fluid
PCR Result No. of Sex
and Person Sexual Partners in Concomitant HIV Presenting Location of Skin or Mucosal Lesions PCR Positivity for
No. Orientation Past 3 Mo STI (Site) Status Symptoms† Rash (No. of Lesions) Monkeypox Virus
Skin Throat
Lesion Swab
19 Homosexual <10 None Positive 1 MU Trunk and limbs (<5) ND Yes
20 Homosexual 2 Syphilis Positive 1, 5 VP Genitals (11–20) Yes Yes
21 Homosexual <10 Unknown Positive 1 VP Arm, thigh, buttocks, and face (5–10) Yes Yes
22 Homosexual Unknown None Negative 1, 3, 5 VP Perianal area, penis, palms, soles, trunk, and limbs Yes No
(11–20)
23 Homosexual Unknown None Positive 1, 2, 3, 4, 5, 6 VP Face, trunk, arms, and tonsil (5–10) Yes Yes
24 Homosexual Unknown Unknown Negative 1, 4, 5 VP Perianal area, rectum, penis, head, face, hand, and No No
soles (5–10)
25 Homosexual Unknown None Negative 1 MU Perianal area (<5) No No
26 Homosexual Unknown None Positive 1, 3, 4, 5, 6 VP Perianal area (5–10) No No
27 Homosexual Unknown Unknown Negative 1, 2, 3, 5, 6 Ma Perianal area, rectum, penis, face, palm, and soles No No
(>20)
28 Homosexual Unknown None Positive 1, 2, 4, 5 Ma Perianal area, rectum, penis, and face (11–20) No Yes
29 Homosexual Unknown Unknown Negative 5 VP Rectum, trunk, limbs, face, palms, soles, pharynx, No No
and mouth (5–10)
Negative
30 Homosexual <10 None Positive 1, 2, 3 VP Penis and perianal area (5–10) Yes Yes
31 Homosexual 2 Unknown Positive 1, 4, 5, 6 VP Genitals (5–10) ND ND
32 Homosexual 3 Unknown Positive 1, 3, 4 VP Trunk and limbs (5–10) No Yes
mend consideration of monkeypox in at-risk per- role of vaccines in preexposure prophylaxis also
sons presenting with traditional STI symptoms. requires study; vaccines are currently being of-
In our series, the diagnosis of monkeypox fered to persons who are at high risk for infec-
was most commonly confirmed from swab tion in the United Kingdom, New York City, and
specimens taken from skin or genital lesions, Canada.
with throat or nasopharyngeal swab specimens Although the current outbreak is dispropor-
and blood less commonly tested. Anal or rectal tionately affecting gay or bisexual men and other
swabs should be considered for those presenting men who have sex with men, monkeypox is no
with anal pain or proctitis. more a “gay disease” than it is an “African dis-
Clinical outcomes in this case series were ease.” It can affect anyone. We identified nine
reassuring. Most cases were mild and self-limit- heterosexual men with monkeypox. We urge
ed, and there were no deaths. Although 13% of vigilance when examining unusual acute rashes
the persons were admitted to a hospital, no seri- in any person, especially when rashes are com-
ous complications were reported in the majority bined with systemic symptoms, to avoid missing
of those admitted. Common reasons for admis- diagnoses in heterosexual persons.
sion were pain and bacterial superinfection. How- Several limitations of our study need to be
ever, rare serious complications (myocarditis and highlighted. Our case series is an observational
epiglottitis) were observed, and therefore the full convenience case series in which infection was
spectrum of the disease and complications confirmed with various (locally approved) PCR
needs further study, particularly over the long platforms. Persons in this case series had symp-
term, given the short duration of our follow-up. toms that led them to seek medical care, which
The clinical presentation and severity of mon- implies that persons who were asymptomatic, had
keypox appeared similar among persons with or milder symptoms, or were paucisymptomatic
without HIV infection, but in almost all those in could have been missed. Established links be-
our series who had HIV infection, HIV was well tween persons receiving preexposure HIV pro-
controlled, with a median CD4 cell count of 680 phylaxis and sexual health clinics and between
cells per cubic millimeter. persons living with HIV infection and HIV clin-
A small percentage of persons (5%) received ics could have led to a referral bias, especially
antiviral therapy, most often with cidofovir or given the potential for early care seeking in
tecovirimat. Data on the effectiveness of these these groups. Spread to other populations is
compounds in humans are limited, although anticipated, and vigilance is required. Symptoms
studies in animals and case reports suggest that were recorded from the time of presentation,
they may be active.21 In this case series, 56 per- and therefore early symptoms may have been un-
sons were older than 50 years of age, and over- derreported, limiting information on the incuba-
all, 9% reported having previously received a tion period.
smallpox vaccination, so we cannot comment on Because viruses know no borders, the world
its effect. needs to move cohesively and quickly to close
Health care professionals need to be educated knowledge gaps and to contain the outbreak.
to recognize and manage cases of monkeypox. Without widely available treatment or prophylaxis,
Targeted health promotion that sensitively sup- rapid case identification is vital to containment.
ports enhanced testing and education in popula- As is common in clinical medicine, there is a di-
tions at risk is needed. Involving communities versity in how illnesses may manifest — and mon-
from the outset in shaping the implementation keypox is no different.
of public health interventions is essential to en-
Disclosure forms provided by the authors are available at
sure that they are appropriate and nonstigmatiz- NEJM.org.
ing and to avoid messaging that will drive the A data sharing statement provided by the authors is available
outbreak underground. The duration of potential with the full text of this article at NEJM.org.
We thank everyone who volunteered to be included in this
infectious viral shedding after lesions have cleared descriptive case series and those who provided additional con-
remains unclear. UKHSA guidelines have advised sent for their deidentified images to be shown, the many col-
condom use for 8 weeks after infection, but the laborating investigators for their dedication and their diligent
review of the data provided, and Ms. Sadna Ullah of the SHARE
potential duration and infectiousness of viral Collaborative at Queen Mary University of London for adminis-
shedding in semen requires study. The potential trative support.
Appendix
The authors’ full names and academic degrees are as follows: John P. Thornhill, M.D., Ph.D., Sapha Barkati, M.D., Sharon Walmsley,
M.D., Juergen Rockstroh, M.D., Andrea Antinori, M.D., Luke B. Harrison, M.D., Ph.D., Romain Palich, M.D., Ph.D., Achyuta Nori,
M.D., Iain Reeves, M.D., Maximillian S. Habibi, M.D., Ph.D., Vanessa Apea, M.D., M.P.H., Christoph Boesecke, M.D., Linos Vande-
kerckhove, M.D., Ph.D., Michal Yakubovsky, M.D., Elena Sendagorta, M.D., Ph.D., Jose L. Blanco, M.D., Ph.D., Eric Florence, M.D.,
Ph.D., Davide Moschese, M.D., Fernando M. Maltez, M.D., Ph.D., Abraham Goorhuis, M.D., Ph.D., Valerie Pourcher, M.D., Ph.D.,
Pascal Migaud, M.D., Sebastian Noe, M.D., Claire Pintado, M.D., Fabrizio Maggi, M.D., Ph.D., Ann‑Brit E. Hansen, M.D., Ph.D., Chris-
tian Hoffmann, M.D., Ph.D., Jezer I. Lezama, M.D., Ph.D., Cristina Mussini, M.D., AnnaMaria Cattelan, M.D., Keletso Makofane,
M.P.H., Ph.D., Darrell Tan, M.D., Ph.D., Silvia Nozza, M.D., Ph.D., Johannes Nemeth, M.D., Marina B. Klein, M.D., and Chloe M.
Orkin, M.D.
The authors’ affiliations are as follows: the Blizard Institute and the SHARE Collaborative, Queen Mary University of London, and the
Department of Infection and Immunity, Barts Health NHS Trust (J.P.T., V.A., C.M.O.), the Department of Genitourinary Medicine and
Infectious Disease, Guys and St. Thomas’ NHS Trust (A.N.), the Department of Sexual Health, Homerton University Hospital (I.R.), and
the Clinical Infection Unit, St. George’s University Hospitals NHS Foundation Trust (M.S.H.) — all in London; the Department of
Medicine, Division of Infectious Diseases (S.B., L.B.H., M.B.K.), the J.D. MacLean Centre for Tropical Diseases (S.B.), the Research
Institute of the McGill University Health Centre (S.B., M.B.K.), and the Chronic Viral Illness Service, Department of Medicine (M.B.K.),
McGill University Health Centre, Montreal, and the Department of Medicine, University Health Network, University of Toronto (S.W.),
the Division of Infectious Diseases and the MAP Centre for Urban Health Solutions, St. Michael’s Hospital (D.T.), and the Department
of Medicine, University of Toronto (D.T.), Toronto — all in Canada; University Hospital Bonn, Department of Medicine I, Bonn (J.R.,
C.B.), the Department of Infectious Diseases, St. Joseph Hospital, Berlin (P.M.), Medizinisches Versorgungszentrum (MVZ) München
am Goetheplatz, Munich (S. Noe), and the Infektionsmedizinisches Centrum Hamburg (ICH) Study Center, Hamburg MVZ ICH Stad-
mitte, Hamburg (C.H.) — all in Germany; the National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome (A.A., F.M.),
the Division of Infectious Disease, Luigi Sacco Hospital, Azienda Socio-Sanitaria Territoriale Fatebenefratelli Sacco (D.M.), and the
Department of Infectious and Tropical Diseases, IRCCS–Ospedale San Raffaele (S. Nozza), Milan, the Clinic of Infectious Diseases,
University of Modena, Modena (C.M.), and the Infectious Diseases Division, Department of Medical Sciences, Azienda Ospedale Uni-
versita, Padua (A.C.) — all in Italy; the Department of Infectious Diseases, Sorbonne University, Assistance Publique–Hôpitaux de
Paris (AP-HP), Pitié–Salpêtrière Hospital (R.P., V.P.), and the Department of Infectious Diseases, Saint Louis Lariboisière Hospital,
AP-HP, University of Paris Cité (C.P.), Paris, and the Department of Prevention and Community Health, Créteil Intercommunal Hospital,
Créteil (C.P.) — all in France; the HIV Cure Research Center, Department of Internal Medicine and Pediatrics, Faculty of Medicine and
Health Sciences, Ghent University and Ghent University Hospital, Ghent (L.V.), and the HIV/STI Clinic, Institute of Tropical Medicine,
Antwerp (E.F.) — both in Belgium; the Sackler Faculty of Medicine, Tel Aviv University, and the Israel Department of Infectious Dis-
eases and Infection Control, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel (M.Y.); the Department of Dermatology, University
Hospital La Paz, Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Investigación
Hospital Universitario La Paz (E.S.), and CIBERINFEC, Instituto de Salud Carlos III (J.L.B.), Madrid, and the Infectious Diseases Service,
Hospital Clinic–IDIBAPS (Instituto de Investigaciones Biomédicas August Pi i Sunyer), University of Barcelona, Barcelona (J.L.B.) — all
in Spain; Hospital de Curry Cabral–Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (F.M.M.); Amsterdam Univer-
sity Medical Centers, University of Amsterdam, Amsterdam (A.G.); the Department of Infectious Diseases, University Hospital of Co-
penhagen, Hvidovre, Denmark (A.-B.E.H.); the Condesa Specialized Clinic, Mexico City (J.I.L.); the François-Xavier Bagnoud Center for
Health and Human Rights at Harvard University, Boston (K.M.); and the Department of Infectious Diseases and Hospital Epidemiology,
University Hospital Zurich, Zurich, Switzerland (J.N.).
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