From COVID-19 to Monkeypox: Unlearned Lessons for Black, Latino, and Other Men With HIV Who Have Sex With Men

The past few years have demonstrated that infectious diseases remain a challenge for public health. Unfortunately, the United States is still unprepared to respond to public health emergencies. Monkeypox (MPX) is a viral zoonosis (an infection transmitted to humans from animals) with symptoms like those seen in people with smallpox, a phylogenetically related virus. However, it is clinically less severe.¹ In April 2022, MPX was identified in the United Kingdom and has been found throughout Europe and other parts of the world. The current MPX strain behaves differently from those historically found in Central and Western Africa.² The first case in the United States was confirmed in May 2022, and diagnoses have grown exponentially since that time. On July 23, 2022, after more than 23 000 cases were confirmed cases globally—including eight deaths—the World Health Organization director general declared the current MPX outbreak a public health emergency of international concern.³ During the first week of August, the United States declared MPX a public health emergency, and by then, there were more than 26 000 cases worldwide, one in four of which was diagnosed in the United States.

In the United States, most confirmed cases of MPX have been among gay, bisexual, queer, and other men who have sex with men (MSM), with New York State reporting the most, followed by California, Florida, Georgia, and Texas. Washington, DC, has the highest case rate by population, and these diagnoses potentially underestimate the actual number of cases. If the COVID-19 pandemic in the United States can serve as a guide, MPX infections could take hold first in the coastal states and then move to the interior of the United States.

Several lessons from COVID-19 have not been heeded in the current outbreak. These lessons include the need for timely and disaggregated surveillance data, free or affordable access to testing and vaccines, greater prioritization of populations at greatest risk, and tackling multiple, overlapping structural barriers.

TIMELY DISAGGREGATED DATA

Despite being three months into the outbreak of MPX in the United States, we are operating in the dark. The Centers for Disease Control and Prevention (CDC) declared MPX a notifiable disease on August 1, 2022. Before then, it was voluntary for states and territories to share the data with the CDC. A little more than 24 months ago, public health authorities were figuring out how to respond to an emergent pandemic while lacking critical data.⁴ Information about those disproportionately overrepresented among COVID-19 morbidity and mortality cases was fundamental to addressing already known health inequities.⁵ Essential public health practices have not changed despite knowing the significant adverse outcomes of insufficient information to respond to a public health crisis. The lack of disaggregated data from the states and territories is hampering the response to the MPX outbreak because data use agreements to share fundamental information, such as race/ethnicity and HIV status, are still not in place. As of July 26, 2022, the CDC had detailed information on only about half of the reported cases.⁶

After assessing publicly available data, we found that only 12 states and territories report some sociodemographic characteristics, mostly location (i.e., county, health region) and sex of those confirmed to have MPX. The most recent CDC report on the epidemiological and clinical characteristics of MPX diagnosed cases in the United States through July 22, 2022, included information from only 41% of the cases because of incomplete data. Findings from this report confirmed that most infections have been reported among Black (26%) and Latino (28%) MSM as well as MSM with HIV (41%).⁷ Using data of confirmed MPX cases from selected counties, it has been reported that up to 80% of MSM of color with MPX are also HIV positive.⁸

Although MPX has been sexually transmitted in the current outbreak, the transmission has not been limited to the skin contact common during sexual intercourse. Household clusters have been identified in Europe,⁹ and in the United States, we already have cases reported among infants.¹⁰ However, because of the lack of data, we do not have reliable information on secondary attack rates, nor can we make accurate projections of future new infections or tailor prevention strategies. This appalling scenario mimics the poor early response to the COVID-19 pandemic, in which limited data and proper interventions fueled infections and deaths among racial/ethnic minorities, people whose first language is not English, and those with low health literacy, among others.⁵

Another parallel is the challenge of addressing a public health emergency that may disproportionately affect certain groups without stigmatizing or increasing their social vulnerability. During the response to the COVID-19 pandemic, we saw an increase in racist attacks on Asians and Asian Americans.¹¹ During the MPX outbreak, we are experiencing the resurgence of historically negative connotations associated with same-sex sexual practices, HIV, sex work, and sexual and gender minorities, as evidenced by the reluctance of health workers to draw blood from men with suspected MPX cases.^12,13 Homophobia and other forms of discrimination kill. If early prevention and services fail, the impact of this virus among MSM, particularly among Black and Latino MSM, will be devastating.

TESTING AND VACCINES

As with the COVID-19 pandemic, MPX testing began very slowly and was limited to only a subset of authorized laboratories. Testing capacity has ramped up, from being limited to CDC and other public health laboratories to being expanded to commercial laboratories. Combining the public health laboratories and commercial sector, the total MPX testing capacity in the United States is 80 000 tests per week,¹⁴ but we are not reaching this capacity. Data on the number of tests performed also are not being publicly released. It is imperative to remove barriers to testing and provide culturally congruent services, considering the negative experiences of Black and Latino MSM when seeking testing for other infections.^15,16 Health care providers must recognize the clinical manifestations of MPX, which sometimes are similar to syphilis and other sexually transmitted infections, and provide testing when necessary. Testing also must be provided free in community settings (e.g., clubs, bars), community-based organizations, and sexual health clinics trusted by MSM populations. With an efficient testing infrastructure, better surveillance can be conducted and sentinel studies can be implemented in collaboration with health departments, community partners, and academia.

Unlike in the early stages of the COVID-19 pandemic, when we lacked an efficacious vaccine, we have vaccines that offer protection against MPX, but they are in limited supply. The MPX vaccines are being made available through the Strategic National Stockpile. As of August 12, 2022, the US Department of Health and Human Services (HHS) has shipped 634 213 vials of Bavarian Nordic’s JYNNEOS, a US Food and Drug Administration–licensed vaccine to prevent smallpox and monkeypox in adults 18 years and older.¹⁷ The ACAM2000 vaccine is also available and in much greater supply, but because of significant side effects is not recommended for everyone. The HHS reports allocating the JYNNEOS vaccine to “meet the needs of at-risk individuals and prioritize the hardest-hit jurisdictions, which have high case burden and transmission rates.”¹⁷ This vaccine allocation strategy will likely adapt as the outbreak evolves. However, there is undoubtedly an inequitable distribution of the vaccines and not enough information to optimize the distribution of limited supplies. Most doses have been allocated thus far to New York State, California, and Florida, where most MPX cases have been identified; however, concentrations of Black and Latino MSM, as described later, inhabit other jurisdictions.

As with COVID-19 testing and vaccines, slots for MPX vaccines have been made available primarily online. We need vaccines in the arms of the most vulnerable, including Black and Latino MSM. They are negatively affected by social factors, such as access to technology and employment, which can challenge their vaccine uptake. Eligible people who do not have fast Internet access or the ability to leave work to get a vaccine have been left behind. Similarly, without knowing the HIV status of confirmed cases, the HHS is blinded to providing vaccines to locations where sexual networks with people with HIV could be at increased risk for infection and disease progression. As documented in a Kaiser Family Foundation report,¹⁸ the current distribution of MPX vaccines is very limited in jurisdictions with high concentrations of Black and Latino MSM and MSM with HIV, including several states in the South (e.g., AL, MS) and Puerto Rico. Furthermore, most are going to White recipients even where the vaccines are available. In North Carolina, 70% of the cases are in Black men, but only 24% of vaccines have gone to Black recipients (67% have gone to White recipients).¹⁹

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) people are more likely to engage in vaccination efforts, as evidenced by their uptake of the COVID-19 vaccine, than are heterosexuals. Using data from the National Immunization Survey–Adult COVID Module, the CDC found that gay men reported high COVID-19 vaccination coverage and vaccine confidence compared with other sexual minority groups. It is worth noting that COVID-19 vaccination coverage was lower among non-Hispanic Black sexual minorities but still close to 75%.²⁰ MSM and other LGBTQ populations are receptive to public health innovations during public health emergencies. There may be more of them with a high willingness for MPX vaccination than there are vaccines available, which may contribute to the shortage of vaccines.

PRIORITIZING POPULATIONS

The response to the MPX outbreak needs to be bolstered. A greater focus should be placed on containing the outbreak in MSM and other populations at elevated risk for HIV. Early evidence also suggests that special attention should be placed on vaccinating and treating people with HIV. As shown in Figure 1, communities of color are disproportionately affected by HIV. Consequently, this public health emergency should prioritize Black and Latino MSM, transgender people, sex workers, and people who use drugs.

FIGURE 1—

Cumulative Monkeypox (MPX; 2022) and New HIV (2020) Diagnoses Among Black and Latino Men Who Have Sex With Men (MSM) vs White MSM: United States

Source. Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report Epidemiologic and Clinical Characteristics of Monkeypox Cases (August 5, 2022) and CDC HIV Special Focus Profile (2020 data).

The CDC has already issued recommendations for treatment and prophylaxis for MPX among people with HIV and has recognized the increasing severity of MPX infection among people who have advanced HIV or are not virologically suppressed. The CDC also has documented the safety of the JYNNEOS vaccine for people with HIV and the considerations for MPX treatment in this group.²¹ The JYNNEOS vaccine provides a significant immune response after the first dose. Data from the United Kingdom based on ELISA (enzyme-linked immunoassay) testing shows that the immune response 28 days after the first dose is up to 83% among people without HIV and 67% among people with HIV. At 42 days or 14 days after the second shot, the immune response per HIV status was 98% and 96%, respectively.²²

However, these data are from a group of people with HIV who were virally suppressed. Because Black and Latino MSM are less likely to be virally suppressed than are White MSM— possibly leading to worse MPX outcomes—MSM of color living with HIV should be among the groups prioritized for the second dose of the JYNNEOS vaccine. Moreover, the US transition to one fifth of the recommended vaccine dose will raise questions of equity, given that communities of color have been less likely to be vaccinated with the standard 0.05 milliliter dose. In addition, the lower vaccine dose must be administered intradermally, increasing the likelihood of scarring and keloids among people of color and the possibility of underdosing if injections are administered too deeply.

As in the early days of the HIV epidemic and the COVID-19 pandemic, community-based organizations are responding to the needs of MSM. It is no surprise to witness these communities’ resourcefulness and resilience again. However, many organizations operate in constant public health emergency mode while resources are limited. Any resources that are made available in response to the MPX outbreak must be provided to organizations working with Black and Latino MSM and MSM with HIV. These organizations know their communities and, over time, have gained the trust of those often underserved by the broader health care system. Funding should support the work of Black- and Latino-led organizations; LGBTQ organizations; ballroom communities; leather and other groups serving gay, bisexual, and transgender populations; and networks of people with HIV, sex workers, and people who use drugs. These groups can work with other stakeholders and community clinical providers to educate, promote harm reduction practices among, screen, vaccinate and treat people with a diagnosis or at heightened risk for MPX. They can do so with a stigma- and shame-free approach to sexual health and consistently with the values of different MSM and people with HIV.

Resources should also be allocated to addressing syndemics. For example, meningococcal disease vaccination should be expanded to all MSM, not only those in or traveling to Florida. Public sexually transmitted infection clinics and primary health care centers providing comprehensive sexual health, HIV, and sexually transmitted infection services must receive funding for their crucial services. Social support should be contemplated for those who may lose their jobs, reduce their income, or lack the resources to isolate during care or prevent the virus’s transmission.

TACKLING BARRIERS

As with COVID-19, structural barriers remain challenging to health equity in the fight against MPX. However, we have lessons learned from the response to previous and current public health emergencies, on such topics as community engagement and research, that certainly should help reduce the disparities during this outbreak. The engagement with the LGBTQ community and racial and ethnic minorities must be supported at all stages of the response, from crafting and delivering prevention messages to developing national guidelines. This community engagement will be effective only if we create conditions in which communities are empowered to make decisions, provide recommendations, and manage resources. Their safety is fundamental, and the stress and vulnerability caused by recent legal decisions about sexual health, sexuality education, and inclusion of transgender people in different social contexts should be acknowledged as these communities engage in the public health response. Likewise, the National Institutes of Health should provide funding for research to understand the impact of the current MPX outbreak and its overlap with HIV and explore whether prevention fatigue may affect MPX prevention and care practices among people at risk for or with HIV.²³

Several lessons from the response to the COVID-19 pandemic seem to have been unlearned. The CDC needs more information to face the public health emergency, but the agency depends on voluntary information sharing from the states. Under the US Constitution, states have primary responsibility for public health. But this presumes that states finance public health. Today, however, the federal government is the primary payer for public health through grants to states and territories (and to cities to a limited extent). There may need to be a renewed negotiation over the terms of collaboration between the federal government and the states for the federal government to have a more comprehensive national picture of public health threats and to be able to mobilize all federal, state, and local resources more quickly in the face of significant threats to the public. Congress needs to consider these issues and to work with the executive branch. Legislation may be required for a comprehensive system to manage epidemiological data in the United States and to develop an updated and stronger collaborative relationship between federal and state agencies that allows more nimble responses and that fosters public trust. Creating more bureaucracy is not the solution to public health problems.

The LGBTQ communities, including MSM, have learned from decades of response to the HIV epidemic. More recently, we have faced an unprecedented pandemic. In the United States and globally, we have the resources to contain this MPX outbreak and avoid the resurgence of health inequities. We must collectively do everything we can to keep our broader communities healthy. Otherwise, we will be perpetuating health inequities by choice.