Of the 38 people who have died of mpox (formerly monkeypox) in the United States, most were Black cisgender gay men, and among those with a known HIV status, all had AIDS and only two were on antiretroviral treatment, according to an analysis by the Centers for Disease Control and Prevention (CDC).

Mpox cases have declined dramatically since the outbreak peaked late last summer, but it remains a risk for people living with HIV, who have accounted for around half of all U.S. cases.

HIV-positive people on antiretroviral therapy with an undetectable viral load and an adequate CD4 T-cell count do not fare worse with mpox than their HIV-negative peers, but it’s a different story for those with advanced immune suppression.

A previous CDC analysis found that more than 80% of people hospitalized with severe mpox in the United States were living with HIV. Most of them were Black men who were not on antiretroviral treatment. The good news is that no one with well-controlled HIV died, suggesting that antiretrovirals can prevent severe outcomes.

In the latest analysis, Aspen Riser, MPH, of the CDC’s Mpox Emergency Response Team, and collaborators from more than a dozen city and state health departments looked at the epidemiological and clinical features of mpox-associated deaths in the United States from May 10, 2022—at the start of the global outbreak—to March 7, 2023. During this period, the CDC tallied 30,235 confirmed and probable mpox cases. Throughout the outbreak, most people with mpox were gay and bisexual men.

During the same period, the CDC received reports of 52 deaths among people with confirmed or probable mpox. Of these, 38 had mpox as a cause or contributing factor, for a rate of 1.3 mpox-associated deaths per 1,000 cases. Three people died of other causes (including one suicide), and 11 deaths were still under investigation.

“These findings highlight the importance of integrating prevention, testing and treatment for multiple sexually associated infections,” the study authors wrote. “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.”