The new monkeypox outbreak continues to spread in the UK and worldwide, mainly affecting men who have sex with men. Several of the men who developed monkeypox are living with HIV, but so far they do not appear to have worse outcomes. While anyone can contract the virus through close personal contact, experts and advocates are urging gay and bisexual men, in particular, to be alert for symptoms and take precautions during Pride season.
While monkeypox is not a new disease, the current outbreak is unusual. Monkeypox is primarily seen in Central and West Africa, and traditionally it was thought that it did not spread easily among people.
In its latest update, the UK Health Security Agency (UKHSA) reported 287 confirmed cases in England, 10 in Scotland, three in Wales and two in Northern Ireland. On 7 June, UKHSA announced that monkeypox is now a notifiable infectious disease that must be reported to health authorities.
As of 2 June, the World Health Organization (WHO) reported 780 laboratory confirmed monkeypox cases in countries where the virus is not endemic. After the UK, the largest number of cases have been reported in Spain, Portugal, Canada and Germany. An informal tally by Global.health puts the number of confirmed or suspected cases at more than 1300.
Most, but not all, cases so far are men, a majority of whom identify as gay, bisexual or other men who have sex with men. Many of the men reported recent international travel, and some of the cases have been linked to a gay Pride event in the Canary Islands, a fetish festival in Belgium and saunas in Spain and Canada. Of the confirmed cases with an identified gender, only three are women.
“Based on the case reports to date, this outbreak is currently being transmitted through social networks connected largely through sexual activity, primarily involving men who have sex with men. Many—but not all cases—report fleeting and/or multiple sexual partners, sometimes associated with large events or parties,” Dr Hans Henri P. Kluge, WHO Regional Director for Europe, said in a statement. “We must remember, however, as we have seen from previous outbreaks, that monkeypox is caused by a virus that can infect anyone and is not intrinsically associated with any specific group of people.”
The monkeypox virus is transmitted through close personal contact, including skin-to-skin contact, kissing, contact with clothing or linens that have been in contact with from fluid from sores, and respiratory droplets at close range. But it is not thought to spread through the air at longer distances like the coronavirus that causes COVID-19. Although it is still unclear whether monkeypox is directly transmitted through semen, it does spread through contact with sores during sex.
Monkeypox background
Monkeypox is related to smallpox but is less severe. It typically causes flu-like symptoms, swollen lymph nodes and a rash that progresses from small red bumps to fluid- or pus-filled blisters. The rash can occur on the face, in the mouth or anywhere on the body.
However, clinicians report that cases in the current outbreak do not always follow the classic pattern. Some people have only one or a few lesions, often on the genitals or in the anal area, which may resemble more common sexually transmitted diseases such as herpes or syphilis. Some individuals have not had associated symptoms like fever, fatigue or swollen lymph nodes.
The monkeypox virus has an incubation period of up to three weeks, and the illness typically lasts two to four weeks. Transmission is most likely when people have symptoms, and they can remain infectious until the sores are completely healed and the scabs fall off.
Although the lesions can be quite painful, most people with monkeypox fully recover without treatment. The monkeypox strain circulating in Europe has a fatality rate of around 1%, and there have been no deaths reported so far during the current outbreak.
But monkeypox can cause more severe illness in children, pregnant women and immunocompromised people. Complications may include pneumonia, sepsis, encephalitis and corneal infection leading to vision loss. Antiviral medications used to treat smallpox can also be used for monkeypox, including tecovirimat (Tpoxx), cidofovir (Vistide) and brincidofovir (Tembexa).
Monkeypox and HIV
There is limited data on monkeypox and people living with HIV. Previous studies in Africa found that people with uncontrolled HIV had worse outcomes, including larger and longer-lasting lesions, more complications and several deaths.
“There is limited data among people living with HIV, but those who take antiretrovirals and have a robust immune system have not reported a more severe course,” according to WHO. “Those people living with HIV who are not on treatment or remain immunosuppressed may have a more severe course, as documented in the literature.”
"Currently we do not recommend any specific actions for people with HIV beyond vigilance about clinical presentations and history of exposure."
Speaking during a 23 May aidsmapCHAT, Dr Claire Dewsnap, president of the British Association for Sexual Health and HIV, said that HIV-positive people who are on antiretroviral therapy with viral suppression and a CD4 count above 200 “are not at any particular risk of becoming significantly more unwell.”
The British HIV Association (BHIVA) concurs that HIV itself likely does not increase susceptibility to monkeypox infection or lead to more severe disease.
“Currently we do not recommend any specific actions for people with HIV beyond vigilance about clinical presentations and history of exposure,” BHIVA said in a rapid statement. However, the organization suggests that people with a CD4 count below 200, persistent detectable viral load or a recent HIV-related illness should be considered at higher risk.
A recent report in Eurosurveillance described four monkeypox cases among gay men in Italy. Two were HIV-positive and on effective antiretroviral therapy and two were HIV-negative and on PrEP. Three of the men attended the Canary Islands event and one said he travelled for sex work; all reported condomless sex with different male partners while travelling.
Three of the men had systemic symptoms. All reported lesions on different parts of the body, including the genitals in three cases and the anal region in two cases. But unlike the classic monkeypox presentation, all had asynchronous lesions, meaning all the sores were not at the same stage at the same time. All of the men recovered without treatment. Testing revealed that three had very low levels of monkeypox virus DNA in their semen, two had positive faecal samples and one had a positive saliva sample.
Another report in the same issue of Eurosurveillance described 96 monkeypox cases in Portugal, with more detailed information on a subset of 27 cases. All were men, most of them in their twenties or thirties. Fourteen were HIV positive. Only four reported recent international travel, and just one had known contact with people with similar symptoms, but most reported recent sex with multiple partners and several had visited saunas. About half reported systemic symptoms including fever and swollen lymph nodes. Six had genital ulcers and five had anal ulcers.
Investigators in the UK also published a report in the issue. Although they did ask people with monkeypox about HIV and other pre-existing health conditions, they decided not to include this information as the data were still preliminary.
Monkeypox prevention
Smallpox vaccination prevents monkeypox as well, but most people younger than age 50 or so have not been vaccinated, as smallpox was eradicated worldwide in 1980.
An older live vaccinia virus vaccine (ACAM2000) can cause adverse events, especially in immunocompromised people and those with skin conditions. But a recently approved non-replicating smallpox and monkeypox vaccine (Imvanex or Jynneos) has been tested and found to be safe for people with HIV. For people on antiretrovirals with a high CD4 count, “If you’re offered a smallpox vaccine, you should take it,” Dewsnap advised.
Monkeypox transmission can be contained through ring vaccination, or targeted vaccines for close contacts of an infected individual. Because monkeypox has a long incubation period, vaccination within several days after exposure works as post-exposure prophylaxis. Several countries are now administering vaccines to high-risk contacts of known cases and health care providers. Canada recently announced it would offer vaccines to men who have had more than two male sex partners in the past 14 days. But experts say universal smallpox vaccination for the general population is not indicated at this time.
Health officials are urging anyone with an unusual rash or lesions on any part of their body, especially the genitals, to contact their health care provider or a sexual health clinic. However, people should call ahead for advice before visiting.
People who test positive for monkeypox should isolate until they are fully recovered and the rash heals completely. Those who think they might have been exposed are advised to self-monitor for symptoms, refrain from sex and avoid gatherings that involve close contact for three weeks. Although it is not known whether the virus is transmitted in genital secretions, UKHSA recommends that people with monkeypox use condoms for eight weeks after infection as a precaution.
In addition, it is important for people who test positive for monkeypox and those who think they might have been exposed to cooperate with contact tracing efforts. Fortunately, men who have sex with men and their providers have experience managing sexually transmitted disease outbreaks that can be applied to monkeypox containment.
“The gay and bisexual communities have high awareness and rapid health-seeking behaviour when it comes to their and their communities’ sexual health,” Dr Kluge said. “Indeed, we should applaud them for their early presentation to health care services.”