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Public health authorities are scrambling to raise awareness of the growing monkeypox outbreak in advance of this weekend’s start of Pride Month celebrations.

In doing so, they are trying to strike a delicate balance — getting out the message that monkeypox may currently be a risk to men who have sex with men, without stigmatizing the community by linking them to a scary-sounding virus that can infect anyone in certain circumstances.

“The message is similar for all communities, which is vigilance if you have a rash that is different or that could be … monkeypox,” Demetre Daskalakis, director of the division of HIV/AIDS prevention at the Centers of Disease Control and Prevention, told journalists Thursday. “If you come back from the event and have a rash, it’s important to get medical attention, and just be aware that this is potentially circulating in some communities.”

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More than 300 confirmed and suspected monkeypox cases have been detected in about 20 countries so far in this unprecedented outbreak, which first came to light in mid-May. Many of the cases have been diagnosed in men who have sex with men. Media reports have linked a number of the cases to two large raves earlier this month in Spain and Belgium, though the start of the outbreak preceded those events.

There is no good time for monkeypox, an animal virus, to be transmitting person to person. But for it to be doing so as the world enters the annual month-long celebration of gay pride is particularly concerning to some experts, given the potential for spread of the disease to further amplify. The disease may result in more serious illness in HIV-positive people as well as people who are immunocompromised.

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“That is really what many colleagues are worried about and I think it is a legitimate cause of concern,” said Chikwe Ihekweazu, former head of the Nigeria Centre for Disease Control. Nigeria is one of a dozen countries in West and Central Africa where the monkeypox virus is considered endemic.

“In and of itself, it would in general be a fairly self-limiting viral infection that causes very unappealing skin lesions. But most people recover. Now the impact of the combination of that with other viruses such as HIV and especially in people that are untreated…?” Ihekweazu didn’t finish the sentence.

Ihekweazu is the senior author on a 2020 paper that reported more severe disease in people with HIV who contracted monkeypox between 2017 and 2018 in Nigeria. So far in this outbreak similar reports have not yet been made public, although Spanish authorities have revealed that two of their earliest cases were in people who were living with HIV.

There are two clades of the monkeypox virus. The Congo Basin clade has a high case fatality rate, roughly 10%, in Africa. But the current outbreak involves the West African clade. It is believed to have a case fatality rate of under 1% and maybe lower. There have been no reports of deaths so far in the current outbreak.

Anne Rimoin, a professor of infectious diseases epidemiology at the University of California, Los Angeles, has been studying monkeypox for the past 20 years. Rimoin, who terms the outbreak “concerning” rather than “alarming,” said it remains to be seen how much serious disease the virus will trigger if it spreads among people who are HIV-positive. But she stressed the situation bears watching.

“We just want to be keeping an eye on that and understanding what serial chains of transmission might look like in these populations,” she cautioned.

Monkeypox is not considered a sexually transmitted disease in the way that HIV is; there’s no evidence to date that the virus is transmitted in semen or vaginal fluids, for instance.

Its main mode of transmission appears to be direct contact with the lesions that an infected person develops. In this outbreak, there are multiple reports of infected people having lesions in the genital region or on the penis. So the type of contact people experience during sex can lead to transmission, if one of the partners is infected.

“This virus transmits with close contact and sexual contact is just inherently close contact,” Rimoin said. “It doesn’t have anything to do with gender or orientation or anything. It can infect anybody that has this kind of contact.”

The investigations into this outbreak are still in the early days. It is not clear how long the virus has been spreading outside of the endemic African countries, how many people have been infected, or how far afield it has traveled.

But David Heymann, who chairs an expert committee that advises the World Health Organization’s Health Emergencies Program, told STAT that he believes at this point that the virus is well-established in some quarters.

“I think we have to accept that this disease is now pretty well-implanted in certain risk populations,” he said. “I think it’s pretty widespread.”

Asked if he thought it was now too established to be stopped, Heymann said: “I don’t know what will happen in the long term.”

A “massive” education campaign is needed to inform people of the fact that monkeypox is spreading, said Heymann, a professor at the London School of Hygiene and Tropical Medicine.

“I think that it’s not too late to get this message out. And I would hope that somebody does get that message out and it gets into the networks of people who are informing the Pride parades and others that this is something important for people to understand,” he said. “However, as we know, understanding when there’s a few beers disappears and risks are taken.”

The CDC’s Daskalakis said the agency is working on a variety of fronts to get out the word, including through social media, medical providers, and social networking apps.

“We’ve really taken a broad approach to making sure the message goes out, but also really capitalizing on trusted messengers and platforms that communities experiencing the current increase in monkeypox cases actually listen to and pursue,” he said.

Ihekweazu said finding cases may not be easy. In Nigeria, which has been detecting cases on a regular basis since the autumn of 2017, many cases were only discovered because of intensive contact tracing around detected cases.

“From the cases we managed in Nigeria, just learning from that, I would suspect a fair level of cases wouldn’t be detected unless people are looking. But right now, of course, people are looking. So that in itself will potentially lead to more people being identified,” said Ihekweazu, who now heads the WHO’s new Berlin-based hub for pandemic and epidemic intelligence. “How that will lead to a change in behavior, it’s hard to say.”

But that active case finding — and the breaking of chains of transmission — will be critical if the virus is to be prevented from establishing itself as a human pathogen, something both Heymann and Rimoin agreed is not out of the realm of the possible.

“Of course, there’s concern that the virus could adapt and become more fit in the human population,” said Rimoin.

“There was a very small chance that monkeypox was going to find its way into the perfect scenario for [spread outside of Africa] … And it did,” she said. “Every once in a while, a virus is going to hit the jackpot.”

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