A Rapid Environmental Scan of South Florida HIV Organizations’ Mpox Messaging During the August 2022 Peak of the U.S. Outbreak

Abstract

The 2022 outbreak of mpox disproportionately impacted men who have sex with men (MSM) and people living with HIV. As such, HIV organizations were uniquely situated to reach populations affected by mpox. However, the extent to which these organizations pivoted to address mpox, and what form mpox messaging took, is unknown. We conducted a rapid environmental scan of 29 HIV or sexual health organizations to assess the frequency and content of mpox messaging in August 2022, the peak of the mpox outbreak in Miami, FL. Approximately half of the organizations provided mpox messaging, most of which was accurate. Only 5% of the messages were in Spanish and 4% in Spanish and Haitian Creole. Our findings suggest HIV organizations’ pivot to mpox messaging may have been delayed overall and in reaching Spanish- and Haitian Creole-speaking communities. Results could inform modifications to mpox messaging campaigns and future outbreaks that disproportionately affect minoritized communities.

Introduction

Mpox is a viral disease caused by an Orthopoxvirus related to smallpox [1]. First discovered in cynomolgus laboratory monkeys in 1958, the first human mpox case was not reported until 1970 in the Democratic Republic of the Congo [1][2][3]. Mpox is predominately transmitted via close skin-to-skin contact; however, airborne spread is also possible and vertical transmission may occur during pregnancy [2]. People with mpox may experience symptoms including painful or itchy rashes on the genitals and mucosal surfaces, hands, feet, face, or chest as well as flu-like symptoms such as swollen lymph nodes, fever, and fatigue [1]. Although there are no FDA-approved treatments for mpox, the antiviral medication tecovirimat is available for treatment of mpox through a CDC expanded access investigational new drug protocol [4]. Additionally, two vaccines originally developed for the prevention of smallpox, ACAM2000 and JYNNEOS, are approved by the Federal Drug Administration (FDA) to prevent mpox acquisition for people with a behavioral vulnerability to mpox acquisition [5].

Historically, the incidence of mpox in humans has been low with recorded cases primarily in Central and West Africa where the virus has been endemic for the last few decades [2][6]. However, on July 23, 2022, the World Health Organization declared mpox a global pandemic for the first time [7][8]. As of June 2023, over 111 countries had recorded almost 89,581 cases of the mpox virus with most recorded cases globally occurring among gay, bisexual, or other men who have sex with men (MSM) [1]. Within the United States (U.S.) the Center for Disease Prevention and Control (CDC) declared mpox a public health emergency on August 4^th, 2022 [9]. As of June 11, 2023, there were over 30,468 cases of mpox reported in the U.S. with around 90% of cases being among men who had reported recent intimate or male-to-male sexual contact.

The U.S. mpox outbreak’s disproportionate prevalence within sexual networks of MSM [10] drew parallels to the early HIV epidemic and the stigma MSM experience(d) in relation to HIV [11]. Because mpox lesions occurring among MSM frequently occur in the anal and genital areas, mpox was mistakenly labeled as an exclusively sexually transmitted disease (STD) and/or an illness only affecting MSM communities by some media and government entities [12]. These types of messages can create additional stigma toward MSM and wrongly provide other communities a sense of security when they may have the potential to acquire mpox [10].

Like other infectious diseases epidemics (e.g., HIV, COVID-19), Black and Hispanic/Latino MSM face mpox inequities compared to their White MSM counterparts [13]. Data collected throughout the U.S., as of September 2022 (just after the study period), showed significant disparities in mpox cases, such that 35% and 30% of all recorded mpox cases were among Black and Hispanic/Latino/a/x people, respectively, despite these groups making up only 12% and 19% of the U.S. population [9]. Systematic structural inequities such as inadequate health insurance coverage, policies that perpetuate income inequality, and immigration barriers place Black and Hispanic/Latino/a/x individuals at increased susceptibility for poor health outcomes and reduced access to health services both historically and currently [14][15][16], which may have fueled these disparities.

Because the 2022 mpox outbreak was an emergent pandemic, limited research had examined mpox public health messaging, or the qualities of these messages. One potentially useful tool for filling this gap in the research is rapid environmental scanning. First developed for business purposes, environmental scanning has become increasingly used in health research to understand the environmental and cultural context around a particular issue [17]. Environmental scans within public health research can explore trends, events, or relationships, and serve as needs assessments to inform future interventions and strategies. Public health researchers describe environmental scanning as a cost-effective and mobilizing tool to gather information within a community over a specific time, resulting in an initial “snapshot” of the environment [18,19]. As such, rapid environmental scanning is an ideal tool for documenting the frequency and types of mpox public health messages disseminated during the peak of the U.S. mpox outbreak. Such documentation is needed to inform decision making (e.g., whether to maintain or modify existing messaging) and improve messaging campaigns (e.g., what specific modifications to existing messaging are needed). Leveraging this tool and applying it to a new disease outbreak, the current study sought to explore a) the degree to which HIV or sexual health organizations in South Florida, which has been an epicenter for HIV and mpox, provided mpox messaging during the outbreak and b) the content of these mpox messaging campaigns [21,22].

Methods

Selection of Organizations for Rapid Environmental Scan

Organizations included in this environmental scan were selected prior to August 1^st, 2022. During this period, the CDC released communications about mpox that are summarized in Table 1. Our team developed “eligibility criteria” for selecting organizations to include in our environmental scan of mpox messaging. Eligible organizations were those that 1) were considered by our team to be an HIV or sexual health organization (operationalized as offering sexual health education or HIV prevention or treatment services); 2) had a physical presence (i.e., brick and mortar) location in South Florida, including Miami-Dade, Broward, or Palm Beach counties; and 3) maintained at least one online platform that we could scan (i.e., email listserv, website, Facebook, Instagram, Twitter, Linkedin, or Instagram).

Table 1.

Timeline of Official CDC Messaging about Mpox During and Immediately Before the Study Period (August 2022)

Date	CDC Message	Message Source
June 10, 2022	Informed the public that multiple mpox cases were documented in the U.S. and being monitored [40]	CDC Website
July 15, 2022	Informed the public about the availability of diagnostic testing for mpox and increasing testing capacity [41]	CDC Website
August 2, 2022	Shared how mpox is transmitted and displays visuals of the rash [42]	Facebook and CDC Website
August 2, 2022	Discussed the mpox vaccine and who it is recommended for [43]	Facebook
August 3, 2022	Encouraged the public to talk to healthcare providers about symptoms and how to isolate at home [44]	Facebook, Instagram
August 3, 2022	Updated the numbers of confirmed mpox cases worldwide to 25,391 [45]	Facebook
August 4, 2022	Shared information about the two mpox vaccinations: JYNNEOS and ACAM2000 [46]	Facebook and Instagram
August 5, 2022	Shared that 99% of documented mpox occurred in men and 94% overall in the U.S. occurred via male-to-male contact [47]	Facebook and CDC Website
August 5, 2022	Informed the public that people with advanced or untreated HIV might be more likely to get severely ill from mpox [48]	Facebook and CDC Website
August 5, 2022	Shared guidelines on how to lower risk of getting mpox during sex	Instagram
August 6, 2022	Recommended mpox vaccinations for people at risk	Instagram
August 8, 2022	Provided guidance on when to receive the mpox vaccine, prior to and after exposure [49]	Facebook, Instagram
August 8, 2022	Shared advice on how to reduce transmission of mpox at events	Instagram
August 9, 2022	Informed the public about the two vaccinations JYNNEOS and ACAM2000	Instagram
August 10, 2022	Shared guidance on how individuals with higher risk of mpox should take steps to protect themselves and prevent transmission [50]	Facebook, Instagram
August 10, 2022	Updated the numbers of confirmed mpox cases worldwide to 31,800 [45]	Facebook, Instagram and CDC Website
August 11, 2022	Shared 5 key facts to know about mpox including how it spreads, its symptoms and what to do if you get it	Instagram
August 12, 2022	Documented that 94% of documented mpox cases were among men with recent male-to-male sexual or close intimate contact, that racial and ethnic minority groups were disproportionately affected, and that public health practitioners should prioritize MSM in the mpox response [47]	CDC Website
August 12, 2022	Provided guidance on how to biomedically prevent (JYNNEOS vaccine) and treat (tecovirimat) mpox. CDC announced that individuals with advanced HIV may be at increased risk for severe mpox [48]	CDC Website
August 15, 2022	Recommended mpox vaccinations for people at risk [51]	Facebook, Instagram and CDC Website
August 15, 2022	Recommended the public discuss with their healthcare providers about whether to get tested for mpox [52]	Facebook, Instagram and CDC Website
August 16, 2022	Shared information on how to find where to get vaccinated for mpox [53]	Facebook, Instagram
August 16, 2022	Shared advice to the public on what to do while waiting for mpox test results	Instagram
August 17, 2022	Updated the numbers of confirmed mpox cases worldwide to 38,019 [45]	Facebook, Instagram and CDC Website
August 18, 2022	Shared the signs and symptoms of mpox [52]	Facebook, Instagram and CDC Website
August 19, 2022	Shared information about surface contamination of mpox and guidelines on how to take precautions [54]	Facebook, Instagram and CDC Website
August 19, 2022	Informed K-12 schools and childcare programs about how to take precautions for mpox [55]	Facebook and CDC Website
August 19, 2022	Informed public that the risks from getting mpox are greater than the risks from the vaccines	Instagram
August 23, 2022	Shared signs and symptoms of mpox and displayed some visual examples of the rash [52]	Facebook, Instagram and CDC Website
August 23, 2022	Announced an alternative approach to administer JYNNEOS vaccine intradermally, allowing providers to administer up to five separate doses from a single vaccine vial [56]	Facebook and CDC Website
August 24, 2022	Updated the numbers of confirmed mpox cases worldwide to 44, 503 [45]	Facebook, Instagram and CDC Website
August 26, 2022	Shared statistics that reduction of one-time sexual encounters between men can yield a 20%–31% reduction in the percentage of men who become acquire mpox [57]	Facebook and CDC Website
August 26, 2022	Provided a clarification that Chickenpox vaccination or infection does not offer protection against mpox [58]	Facebook and CDC Website
August 26, 2022	Reported that transmission of mpox via contaminated surfaces (i.e. fomites) is also possible [59]	CDC Website
August 26, 2022	Informed the public about how long mpox survives on clothing and surfaces	Instagram
August 31, 2022	Shared guidelines on Do’s and Don’t’s to prevent getting mpox [42]	Facebook and CDC Website

^aThis table includes summaries of all official CDC messages that were able to be located as of July 15, 2023; some messages may have been removed or no longer available.

We identified 29 eligible organizations that were included in the rapid environmental scan. Although not part of the inclusion criteria, we also documented the type of services that each organization provided. Two organizations only provided health education related to HIV and sexual health. One organization provided biomedical prevention (e.g., pre-exposure prophylaxis) and HIV treatment services. Three organizations provided a combination of health education and biomedical prevention services. However, a majority (N=23) provided health education, biomedical prevention, and treatment services.

Research Team

The environmental scanning and coding team consisted of four people: two students (one advanced medical student and one clinical health psychology doctoral candidate) and two faculty members working in public health, psychology, and health studies. Given the disproportionate impact of mpox on Latino MSM communities in South Florida and access to an existing Latino MSM Community Advisory Board (CAB) [22], we also sought input from the CAB on the mpox messages we identified through the environmental scan, which informed guidelines for acceptable, appropriate, and affirming messaging shown in Table 2.

Table 2:

Recommendations from CAB about Future Mpox Messaging

Do:	Do Not:
Do present messages in multiple languages (tailoring to intended audience)	Do not use technical terms that are too scientific and clinical to the public
Do begin with the clear message that mpox can affect anyone and not just MSM or sexual minority men	Do not only mention MSM or sexual minority men – particularly on general platforms that the general population may see (i.e., do not give the message that mpox can only affect MSM; can state that MSM are currently disproportionately affected, but be clear that others can acquire mpox)
Do use sex positive language (e.g., encourage conversation about sexual relationships)	Do not use sex shaming language (e.g., discouraging or stigmatizing any sexual activity)
Do incorporate diverse and inclusive visuals (e.g., show individuals of multiple races and genders)	Do not use racist or stigmatizing visuals (e.g., monkeys or visuals with only men, particularly men of one specific race/ethnicity)
Do actively debunk myths and misinformation about mpox	Do not include misinformation from unreliable sources
Do collaborate with community members affected by the outbreak to design messages and ensure they will resonate and be perceived as affirming	Do not combine mpox and general STI messaging (i.e., conflates them and further confuses the public)
Do focus on communication of mpox public health information (including prevention methods and dissemination of resources for testing and treatment)	Do not promote politicizing messaging (e.g., targeting political party members, simply denouncing government without actionable items for message recipients)
Do provide additional resources to learn information about mpox (e.g., link to health department or information about vaccines)

Note: These recommendations are from a Community Advisory Board comprised of Latino sexual minority men in South Florida.

Data Collection

Authors used a rapid environmental scan to a) identify the frequency with which HIV and sexual health organizations in South Florida pivoted to provide mpox messaging and b) characterize the content of these messaging campaigns during a time in which mpox cases were peaking across U.S. metropolitan areas, including South Florida [23]. We carried out our rapid environmental scan by documenting all mpox-related messaging that appeared on each included organizations’ email listserv, website, Facebook page, Instagram, Twitter, LinkedIn, Grindr, and Scruff. To be included in the scan, the mpox message needed to be provided directly on one of these online platforms by one of the 29 organizations that were eligible and included in our scan. Organizations were scanned by the first two authors two times per week from August 1^st–31^st, 2022, yielding 9 total data collection dates. On each scanning date, team members reviewed every online platform that the organization had and collected screenshots of every mpox-related message (e.g., image, text, article) that the organization posted, regardless of whether the organization was the original developer of the content or not. We did not scan general websites or online resources that were not linked to a specific HIV or sexual health organization in South Florida, as described in our inclusion criteria.

Each screenshot of an mpox message was considered a “data point” in our scan. Screenshots were saved, assigned a unique ID number, and tracked with the following information: (1) the content of the message, (2) the organization that posted the message, and (3) the date the message was posted by the organization and collected by our research team. If an identical message (e.g., the same flyer about mpox vaccination) was posted on multiple platforms within the same organization or across multiple organizations, the data points were linked by a common data point (i.e., ID number) to allow us to track unique messages across organizations and platforms. Additionally, we documented the presence of the same content if it was still present on the online platform across scan dates. For example, if an organization’s website had the same information about mpox transmission at three consecutive scan dates, we documented its presence on all three dates.

Data Analysis

Research Question 1: Frequency of Mpox Messaging.

To answer our first research question about the degree to which HIV-focused organizations in South Florida pivoted to provide mpox messaging, we examined the proportion of organizations that did versus did not provide any mpox messaging during the month of August 2022. Next, within those organizations that did provide mpox messaging, we identified the number of total and unique posts that each organization provided during the scan period. Based on the empirical distribution and frequency of posts, we divided organizations into low (1–5 posts), medium (6–10 posts), and high frequency (10+ posts) of mpox messages together with input from the first two and last two authors. To assess the frequency of mpox messaging across each social media platform, we tabulated the number of posts on each platform including organizations’ websites, emails, Facebook pages, Instagram, Twitter, LinkedIn, Grindr, and Scruff across all organizations. If an identical message (i.e., the same flyer) was shared across multiple platforms, it was counted in the frequency for each, as our goal was to document all mpox messaging, across platforms, that took place during the study period. For example, if an organization posted the same flyer about mpox on their Facebook and Instagram pages, we counted this as a total of two messages.

Research Question 2: Content of Mpox Messaging

To determine the content of the observed mpox messaging, we created rating forms which evaluated characteristics of each post including the post’s accuracy, purpose, language, region of origin, and intended recipients (see Table 3). We operationalized “factually accurate” messages as those that made statements that were consistent with the current state of published scientific research and facts (at the time of the review). The raters consulted the published scientific literature to evaluate the accuracy of the statements. The rating form was completed by two raters (first and second authors), who had 95% agreement in their ratings. The last two authors resolved any disagreements between the two raters via consensus meetings. During those meetings, we discussed the 5% of instances in which there was disagreement between the raters and arrived at a consensus rating. To evaluate data from the rating form, we used descriptive statistics and data visualizations to summarize the relevant features of the data set. All analyses were performed using SPSS analytical software.

Table 3.

Mpox Messaging Rating Form

Accuracy	__ Misinformation: the statements in the post are not based on available scientific research and facts
	__ Accurate information: the statements in the post are based on available scientific research and facts
	__ Unable to rate: No claims about scientific research or facts were made, therefore unable to rate the accuracy of the post
Purpose *	__ Immediate Informational: directly provides the audience facts about mpox (e.g., current events, symptoms, etc.)
	__ Community Educational Event: provides information about upcoming meeting in community about mpox
	__ Vaccination Outreach: advertises available mpox vaccines or vaccination events
	__ Testing Outreach: advertises available mpox testing locations or events
	__ Risk Reduction: provides methods to directly decrease the probability of contracting virus
	__ Political Call to Action: encourages an immediate action from public, government, or specific organization, or for message recipient to take political action
Intended Audience (who the intended audience is for the post)	__ General: message appeared to be directed toward a broad audience of the public (i.e., not specific subpopulation)
	__ Sexual Minority: message appeared to be specifically directed toward sexual minorities (e.g., gay, bisexual, men who have sex with men)
	__ Racial or Ethnic Minority: message appeared to be specifically directed toward a racial or ethnic minority group (e.g., Black, Latino/a/x)
	__ Both: message appeared to be specifically directed toward both a sexual minority group and racial/ethnic minority group (e.g., Latino MSM, Black MSM)
Language of Post	__ English
	__ Spanish
	__ Haitian Creole
	__ English and Spanish
	__ English, Spanish, and Haitian Creole
Region (the area of focus of the organization from which the post originated)	__ South Florida specific (Palm Beach, Miami, Broward, Keys)
	__ Florida
	__ US South: includes Alabama, Arkansas, Delaware, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia
	__ National
	__ Other Specific region listed

^*Could check all that apply

Results:

Between August 1^st and August 31^st, 2022, the environmental scan identified a total of 77 posts, 58 unique, across all the organizations within the scan.

Frequency of Mpox Messaging.

Over the course of the 9 different scan dates in August 2022, the number of posts increased from 9 (first scan) to 77 (final scan). The bar chart shown in Figure 1 demonstrates that this was a steady increase throughout the month. Although 29 organizations were scanned, only 14 (48%) organizations posted any mpox related messaging during the study period. Most organizations either posted no mpox messages (N=15, 52%) or posted within the low (1–5 messages) or medium (6–10 messages) frequency range (N= 12, 31%). Only two (7%) organizations were in the high frequency category, with 10 or more posts throughout the scan period (Figure 2).

Fig. 1.

Bar Chart of Overall Mpox Messaging Frequency During August 2022 Environmental Scan

Fig. 2.

Bar Chart of Mpox Messaging Frequency Category (By Organization)

We also assessed the most frequent online platforms through which organizations disseminated their mpox messaging. Most organizations (80%) disseminated their mpox messaging through 3 or fewer platforms. Figure 3 displays the frequency with which each platform was used for mpox messaging, across all organizations that posted mpox messages. Facebook was the most frequent messaging platform (N=21, 27%), followed by email listserv (N=17, 22%), Instagram (N=14, 18%), and organizational websites (N=13, 16%). Twitter (N=9, 13%) and LinkedIn (N=3, 4%) were less frequently used. Although we observed general mpox information on Grindr and Scruff during the scan, we did not identify any organization-specific messaging.

Fig. 3.

Bar Chart of Mpox Messaging Platform Frequency (Across all Organizations)

Content of Mpox Messaging

Table 4 presents findings related to the content of posts (i.e., messaging purpose, intended audience, language, and region) observed during the scan. Only unique posts (N=58) were included in this analysis. Most posts presented factually accurate information (N=54, 93%). We did not identify any messages that were inconsistent with the published scientific literature regarding mpox during the study period. In terms of purpose, we found that most of the messages were immediate informational and provided the public with evolving facts about mpox (N=39, 67%). Many posts promoted vaccination outreach (N=18, 31%) or risk reduction by providing behavioral strategies to decrease the probability of acquiring mpox (N=17, 29%).

Table 4.

Characteristics of Mpox Messages Identified in the Environmental Scan

Scan Variable	Mpox Posts (N= 58 unique posts)
Accuracy
Misinformation	0 (0%)
Accurate information	54 (93%)
Unable to rate	4 (7%)
Purpose of Message *
Immediate Informational	39 (67%)
Community Education Event	6 (10%)
Vaccine Outreach	18 (31%)
Testing Outreach	3 (5%)
Risk Reaction	17 (29%)
Political Call to Action	6 (10%)
Target Audience
General	47 (81%)
Sexual Minority	7 (12%)
Racial or Ethnic Minority	2 (3.5%)
Both Sexual Minority and Racial/Ethnic Minority	2 (3.5%)
Language
English	53 (91%)
Spanish	0 (0%)
Haitian Creole	0 (0%)
English and Spanish	3 (5%)
English, Spanish and Haitian Creole	2 (4%)
Region
South Florida	24 (41%)
Florida	8 (14%)
South US	0 (0%)
National	16 (28%)
Other Specific Region	10 (17%)

^*Options are not mutually exclusive

Figure 4 illustrates how the message content changed across the study period. At the beginning of the study period, most of the messages were immediate informational, which continued to be the most common type of message throughout the study period. However, as the study period progressed, messages about vaccine outreach and risk reduction strategies increased, whereas messages focused on testing outreach, political calls to action, and community educational events remained relatively uncommon throughout the study period. These trends are largely consistent with the CDC messaging shown in Figure 1.

Fig. 4:

Line Graph of Change in Mpox Message Content Over the Study

Figure 5 breaks down the frequency of message type even further within organizations with medium and high messaging frequency. We did not examine low frequency due to limited available data. Immediate informational messages were most common, and increased throughout the study period, although to a greater extent in Organization 1 compared to the others. Organization 3 showed substantial increases in immediate informational, community educational event, and vaccine outreach messages over time. The other organizations in Figure 5 showed more moderate increases over time in their mpox messages.

Fig. 5.

Line Graphs of Change in Mpox Messaging Content within High and Medium Communication Organizations Over the Study Period

^bThis figure only depicts organizations that were medium (6–10 messages) or high (10+ messages) communicators of mpox messages during the study period.

Most of the mpox messages documented in the scan were intended for the general public (N = 47, 81%). Fewer were focused on sexual minority (N = 7, 12%) or racial and ethnic minority communities (N = 2, 3.5%). Two posts (2.5%) were rated as specifically intended for racial/ethnic minority and sexual minority communities. Most posts were solely in English (N=53, 91%). Only 3 posts were written in both English and Spanish and 2 posts written in English, Spanish, and Haitian Creole.

Nearly half of the mpox messages identified in the scan were directed towards South Florida specifically (N=24, 41%). Other posts were directed towards the general U.S. population (N=16, 28%) or other regions in the U.S. (N=10, 17%) including Chicago or Los Angeles but disseminated on South Florida HIV organization’ online platforms.

Discussion

Overall, our findings demonstrate a mix of strengths and limitations in terms of HIV and sexual health organizations’ dissemination of mpox messages to communities affected by the mpox outbreak within South Florida. Although some organizations did pivot to provide mpox messaging, more than half did not provide any mpox messaging via their online platforms during the outbreak. Five organizations (out of total of 29) contributed to more than half of the mpox messages observed during the study period. Organizations providing HIV and sexual health services often have not only longstanding connections with MSM and people living with HIV (who have been disproportionately impacted by mpox), but also established programs to disseminate health promotion information to multiple marginalized groups underscores the need to support these organizations in rapidly disseminating health promotion messages directly relevant to the communities they serve [24].

In addition to the low frequency of mpox posts in general, only a few were specifically designed to reach groups disproportionately affected by the mpox pandemic over the course of the scan. Since Black and Latino MSM are disproportionately affected by the mpox [25], the fact that only three posts were communicated in Spanish and/or Haitian Creole suggests that key populations may have been underreached. Some organizations’ messaging may have been limited to English due to the linguistic needs of their populations served; however, up to 70% of Miami-Dade’s population is known to speak Spanish, therefore additional messaging in Spanish or Haitian Creole may have facilitated greater reach [26], [27].

It is important to consider the resource constraints that many HIV-focused organizations face when tasked with responding to an emerging public health situation while continuing previously provided services. Prior research, both locally and across the U.S., suggests that HIV organizations are already resource-limited in general, with most staff, funding, and time allocated to services and messaging about HIV prevention and treatment [28]. Further adding to these resource limitations, prior to mpox, HIV and sexual health organizations in South Florida were already having to pivot to address other emergent public health issues of COVID-19, as well as a meningococcal outbreak that occurred in South Florida immediately before the mpox outbreak [27] [29]. Our environmental scan only documented HIV and sexual health organizations’ online messages about mpox. Therefore, it is possible that these same organizations were pivoting to deliver mpox related healthcare services (e.g., mpox assessment, testing, acquiring tecovirimat treatment through the CDC expanded access program, and follow-up) which further limited their resources to simultaneously provide mpox related messaging to the community. To prepare and disseminate mpox messaging in addition to the daily functions HIV and sexual health organizations perform would be resource intensive, underscoring the need to provide additional resources to HIV organizations for this expanded scope of work. HIV and sexual health organizations need to be equipped with adequate resources (e.g., personnel, scalable prevention messaging in multiple languages, rapid response grants to fund public health messaging efforts regarding mpox) to support implementation and dissemination of equitable and accessible mpox messaging in addition to their other responsibilities.

Despite some of these challenges, we also found that there was a rapid increase in overall mpox messaging, with the number of organizations that provided any mpox messaging doubling during the one-month study period. The content of observed mpox messages also shifted throughout the month, suggesting that organizations might have been adapting to new information and resources. Early messages were primarily information focused (e.g., increase mpox symptom and transmission awareness), and although informational messages prevailed as most common throughout the study period, more messages toward the end of the month (compared to the beginning) addressed other topics, such as facilitating community events, advertising vaccination locations, or encouraging message recipients to take political action. Further, many of the messages we observed mirrored information released from the CDC over the period. In particular, CDC’s earlier messages in the month were more informational, whereas they began to release information about vaccines and behavioral risk reduction during the month of August 2022; local organizations’ messaging corresponded to this through local dissemination of vaccine outreach and risk reduction content. As a national organization, the CDC did not distribute messaging with content on local community events or encouraging political action; these were types of messages that we only observed locally.

Organizations that posted mpox messaging during our environmental scan used established web-based platforms (e.g., Facebook, emails, organization’s websites) more often than newer social media apps (e.g., Twitter) to disseminate mpox messaging. Several organizations included in the scan did not have Instagram or Twitter accounts potentially due to resource limitations or unfamiliarity with newer platforms [30]. However, social media use among key populations affected by mpox and HIV is increasing, including MSM and racial and ethnic minorities [31]; therefore, this scan reveals the need for organizations to diversify their online outreach efforts to ensure the broadest possible reach and to communicate with different demographic groups [32]. For example, individuals between the ages of 31–35 have been most impacted by mpox [33], and this age group is well represented among users of social media platforms other than Facebook including TikTok, Youtube and Instagram [34]. Further, sexual networking and hookup apps that cater to MSM may be ideal places for mpox messaging due to their emphasis on sexual relationships and wide reach among MSM experiencing greater risk for mpox. Although these apps created their own mpox messaging, no organizations in our scan disseminated mpox messaging directly on these apps, which could be intentional depending on the populations served by these organizations or might reflect structural limitations (e.g., high cost of advertising on these platforms) in the degree to which organizations can provide their own outreach messaging within these apps.

As an adjunct to our rapid environmental scan, we consulted with a community advisory board (CAB) comprised of Latino sexual minority men to solicit their impressions of the mpox messages that we identified within our scan, and their recommendations for improving mpox messaging in the future. This consultation involved viewing the mpox messages captured in our scan and discussing across two, two-hour meetings the CAB’s reactions and recommendations for modifying these messages. Table 2 outlines a series of recommendations for future mpox messaging generated by the CAB. Future studies could examine the degree to which other MSM agree with these recommendations. CAB members highlighted that mpox messaging should focus on shared responsibility for mpox prevention among the general population rather than politicizing or specifically targeting sexual minority men, men who have sex with men, and/or racial/ethnic minority groups. They expressed the need to balance “tailored” with “targeted” messaging. This is consistent with prior data suggesting that sexual minority men preferred broad advertisements over targeted messaging to reduce stigma in HIV-related health campaigns [35]. CAB members indicated that messaging directed to MSM might inadvertently cause more stigmatization and discrimination against MSM if presented on a broad platform. In contrast, the same message might feel tailored and affirming if delivered in an LGBTQ-specific context because it would reduce the potential for stigmatization by the general population. To improve access to the information, CAB members also indicated that health promotion messaging in South Florida should be disseminated in multiple languages, particularly Spanish and Haitian Creole, reflecting local linguistic diversity. Finally, CAB members recommended that health messaging should incorporate more visuals and simple text to accommodate community members with varying levels of education.

To incorporate CAB’s feedback, a potential solution is for local HIV and sexual health organizations to increase collaboration with central public health organizations, which could develop community-reviewed public health messages for all groups including those disproportionately impacted by mpox. Through centralizing development of critical information in various formats and languages, a network of participating HIV and sexual health organizations might be able to more rapidly disseminate information to a wider audience while decreasing burden on each individual organization.

Despite the contributions of this study, it also has limitations. Although we were guided by a definition of accurate information vs. misinformation and used the published scientific literature to guide our ratings, the scientific literature on mpox was rapidly evolving during the study period [36]. Another limitation of our study is that we were focused on online communication about mpox, which may not be reflective of other forms of health communication. Organizations may have also provided in-person and word-of-mouth messaging about mpox, which may be particularly relevant to populations that are not as active on social media. Additionally, our study was conducted in South Florida, so it is unknown the degree to which our findings generalize beyond the geographical region.

Given the high case count of mpox during the study period, this was an optimal time to conduct a rapid environmental scan. However, given that mpox was and continues to be an evolving public health problem, it would be valuable to understand how messaging has shifted over a longer period of time. As discussed, organizations that provided mpox messages doubled in just one month. It may be that since that first month, messaging rapidly scaled up across organizations, or not; knowing what the pattern after this peak in mpox cases was could inform the degree to which our findings reflect an initial delay versus a gap in messaging altogether.

It is also important to acknowledge that our method of study, a rapid environmental scan, has its own set of advantages and disadvantages. Rapid environmental scans allow for an expedient examination of an evolving public health situation and can help to inform strategies to respond to these situations [19]. Some experts also argue that it is difficult for rapid environmental scans to provide researchers with an in-depth analysis of each community or environment, but can be used as an initial assessment to inform future studies and action, which we recommend as well [37]. Given the rapid nature of this method, opportunities could be missed that might not be in a project with longer lead time before implementation. For example, we did not collect consumer engagement data with the observed posts, which was not possible to collect accurately in retrospect. We recommend that future scans capture user engagement data proactively. Additionally, we conducted our rapid environmental scan online and at random time intervals throughout the month. It is possible that this resulted in missed data points (e.g., messages that were only posted for 24 hours as is done in Instagram “stories” or messages disseminated on other platforms not included in this protocol).

Despite the limitations, our study is among the first to evaluate the degree to which HIV and sexual health organizations that serve MSM and people living with HIV pivoted to disseminate mpox messaging and the nature of these messages. Our findings highlight potential ways that online platforms can be used to engage the public and spread accurate, actionable information during the peak of a disease outbreak, such as mpox. Our findings underscore the role and importance HIV and sexual health organizations have in mpox awareness and messaging, particularly to MSM and people living with HIV, communities with whom they have established relationships. Leveraging these established networks in the context of new disease outbreaks affecting minoritized communities may be complex and challenging, but critical to preventing ongoing transmission and disparities.

Although, the U.S. controlled the initial mpox outbreak [38], there have been resurgences across the globe, and as such, our findings are valuable for informing new messaging campaigns in this context [39]. Our findings also have implications for any other disease outbreaks that might disproportionately impact MSM, people living with HIV, or other minoritized communities. We hope that our findings can be used to enhance public health preparedness for any epidemic threat and facilitate accurate, rapid, and accessible communication in future public health emergencies.