At the Los Angeles LGBT Center’s sexual health clinic, patients are normally seen within 24 hours. Recently, amid the monkeypox outbreak, it’s been a five-day wait.
At Open Door Health, an LGBTQ+ community clinic in Providence, R.I., a standard test for a sexually transmitted infection might take 15 minutes. Testing for monkeypox — between authorizing the test and donning and doffing PPE — has dragged up to an hour. Insurance reimbursement doesn’t cover all that added time.
At the Detroit Public Health STD Clinic, staff are so tied up responding to the outbreak that they enlisted local medical students to schedule vaccine appointments.
The recent surge of monkeypox cases has largely been concentrated among men who have sex with men, with the virus spreading through sexual contact. In some cases, symptoms have included lesions on the penis or anus. Many people with monkeypox also have HIV or another recent STI.
That means a large brunt of the response has fallen to clinics and organizations that specialize in STI and HIV/AIDS care, a network that for years has complained about a lack of resources even as they faced spiking STI rates. Clinics have rallied for their patients, overcoming red tape and fanning out to bars, clubs, and Pride events to expand access to testing, treatment, and vaccines. But even as monkeypox has been declared a public health emergency both domestically and globally, they haven’t been allocated additional funding. Providers and administrators warn they’re being stretched thin, running at a pace they won’t be able to keep up.
“When you’re working on the ground and you’re seeing how this is actually affecting people’s lives, there is a big urgency,” said Shira Heisler, the clinical lead at the Detroit STD clinic, describing how people scream in pain when their anal lesions get swabbed or how the lesions can scar people’s faces. “Everyone’s doing overtime without getting paid for it, because no one else can do it.”
The limitations on resources have consequences. At times, it’s taken extra days to diagnose monkeypox, which means it’s taking longer to connect patients with treatment. It also means that normal care dedicated to STDs and HIV is being shoved aside to handle the emergency. Advocates say they see what’s happening as another manifestation of the country’s underinvestment in public health infrastructure, coming on top of the hit the field took during the Covid-19 pandemic.
“We ended up using the same staff that we use to provide primary care services for people living with HIV and AIDS,” said Tracy Jones, the executive director of the AIDS Taskforce of Greater Cleveland. “Quite frankly, we were prioritizing monkeypox because people were just showing up.”
In some ways, trends with the monkeypox outbreak are looking up. Transmission has slowed, with average daily cases falling from more than 400 throughout much of August to about 200 now. The thicket providers had to push through to get patients tested or on the antiviral being used to treat the infection has cleared somewhat. But the danger has not passed. It’s not known if monkeypox can be contained in this country. Even if it can, with the virus spreading in so many more countries, providers will have to continue to be on the lookout for reintroductions.
And in other ways, the campaign has grown more difficult. Those who were eager to get vaccinated have done so. Now, clinics have to do the harder job of reaching additional people to vaccinate, a particularly crucial endeavor to help correct the disparities that have emerged, with infections among Black and Hispanic men outpacing those among white men while vaccine coverage is higher among white people.
“It is critical that education, vaccinations, testing, and treatment are equally accessible to all populations, but especially those most affected by this outbreak,” Rochelle Walensky, the director of the Centers for Disease Control and Prevention, said at a briefing this month. She highlighted a program aimed at improving vaccine equity, with campaigns at events like Southern Decadence in New Orleans and Pride events in Oakland and Atlanta.
While the Biden administration has requested about $4 billion from Congress for the monkeypox response, as part of a broader budget request that also included a $22 billion ask for Covid resources, lawmakers haven’t moved to authorize the money.
Earlier this month, the CDC told groups that had received grants for STD and HIV/AIDS care that they could tap those resources for monkeypox responses.
“Our local jurisdictions have received no resources specific for monkeypox,” Walensky said. “So not only have we had to move some of those resources around, but they’ve been stretched pretty thin with regard to the resources that have been available to them to address this outbreak.”
STI and HIV clinics rely on a hodgepodge of funding sources for their budgets. Some are federally qualified health centers, some depend on grants, and some get money through federal programs like Ryan White. Billing insurers accounts for just a portion of their funding, providers said.
Clinics have been scraping together their response, but should the outbreak drag on, they will need additional resources, providers said — whether from Congress or state governments, or higher payouts from insurers. California authorized $41 million to combat monkeypox, with nearly $16 million going to local public health departments and community groups, but that appears to be an exception.
“We can’t do it forever,” Phil Chan, the chief medical officer at Open Door Health, said about their monkeypox efforts. “We’re going to have to figure out some funding source eventually.”
Chan and other providers said that the amount they’re being reimbursed for organizing and running monkeypox vaccine clinics is also not covering the associated costs. Kaiyti Duffy, the chief medical officer at the Los Angeles LGBT Center, said the clinic received higher reimbursement rates for Covid-19 vaccinations.
“We’re going to do that because who else will, but it is sinking us even further,” Duffy said about the vaccine clinics, which the center has been devoting nursing staff to twice a week. “We’re showing up in a way that we’re proud of but we know is unsustainable.”
Accounting for inflation, CDC funding for STD prevention fell 40% from 2003 to 2019, according to the National Coalition of STD Directors, even as reported STI cases reached all-time highs in 2019 for the sixth year in a row. Federal money during the pandemic helped bolster local public health efforts, but at the same time, agencies’ work on STIs was in many cases paused as staff were diverted to Covid. All the while, cases of chlamydia, gonorrhea, syphilis, and congenital syphilis have continued to climb.
The NCSD has called for Congress to allot STI clinics $500 million.
“The STI field has been tapped specifically for community education, outbreak investigation, contact tracing, vaccine distribution, and clinical care” during the monkeypox outbreak, David Harvey, NCSD’s executive director, said at a briefing this month. “Yet, for the past three months, we have been on the frontlines pleading with officials for the support that our networks and systems need desperately.”
Since the start of the monkeypox outbreak, these organizations have been hubs of information and clinical care. They’ve handled a deluge of phone calls from worried patients. They’ve set up vaccine clinics, and demanded the shots be distributed more equitably. And they’ve encountered bureaucratic barriers as they tried to help their patients.
Early in the outbreak, clinics had to get approval from a public health laboratory before they could test patients, creating both a headache and disincentive. The antiviral treatment tecovirimat, or Tpoxx, is being used under a special program that required doctors to first complete a mountain of paperwork. After providers and patient advocates complained, both those processes have been streamlined.
The response has at times required a hands-on approach, and pulling in help wherever it could be found. And it’s not just about getting people testing or writing prescriptions. Duffy noted that Tpoxx has to be taken twice a day with a meal of at least 600 calories and 25 grams of fat. Some of the clinic’s patients don’t have reliable access to food, so providers are having to navigate those extra challenges.
In Detroit, Heisler almost had to go to a neighboring county to pick up a patient’s Tpoxx early in the outbreak because it wasn’t available locally yet and the patient didn’t have transportation. Someone from that county wound up delivering it.
And when the strategy for administering vaccines changed — going from a more standard subcutaneous shot to an intradermal shot — a tuberculosis clinic in the same complex provided the different needles until the STI clinic could buy its own, Heisler said. Delivering intradermal shots also requires special training, so a TB nurse supervised the monkeypox vaccine clinic as administrators adapted to the new method.
Nicole Roebuck, the executive director of AID Atlanta, said that what’s occurred with monkeypox echoes how the organizations have been leaned on in the past.
“HIV organizations tend to be very good at doing more with less, very masterful at doing more with less,” Roebuck said. “And I honestly sometimes feel that folks rely on that. You know, ‘Oh, they’re just going to push through, they’re just going to do what they need to do.’ Because that’s why we’re here, right? We care about the people on the ground, so we’re going to do whatever we need to do — backflips, stay longer, clean bathrooms — those are just the types of people we hire.”
Roebuck raised another point as well.
“I feel like sometimes we’re used to this, we’re used to like being an afterthought,” she said. “And I wonder how that makes our members feel, our clients feel, our patients feel.”
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