tag:theconversation.com,2011:/global/topics/men-who-have-sex-with-men-22408/articlesMen who have sex with men – The Conversation2024-03-26T16:03:55Ztag:theconversation.com,2011:article/2245532024-03-26T16:03:55Z2024-03-26T16:03:55ZZulu culture and sexual orientation: South African study reveals the health costs of stigma<p>Same-sex relationships are legal in South Africa and <a href="https://www.concourt.org.za/index.php/gay-and-lesbian-rights">protected</a> by the constitution. Unfair discrimination on the basis of sexual orientation is against the law. </p>
<p>But in practice many cultures don’t necessarily see this as a right.</p>
<p>Traditional Zulu culture, for example, perceives same-sex relationships and sexual intercourse as taboo and <a href="https://njas.fi/njas/article/view/185">unAfrican</a>. Statements like <a href="https://journals.sagepub.com/doi/pdf/10.1177/0146167209338072?casa_token=3Nlm_dy4VSAAAAAA:tsFKGVDS7M-aA6S7bf0WSEMP79fpblscX-UsoJ6oXi_G-VBMMicAAQVwROuOrvzsMm4JYDfjNu0CLdQ">“real men are not gay”</a> indicate some people’s ideas about masculinity and sexuality. </p>
<p>These cultural norms have profoundly negative effects on Zulu men who have sex with men.</p>
<p>This abuse often triggers <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5843994/">depression, suicide and drug abuse</a>. </p>
<p>As a public health specialist with an interest in marginalised groups, I conducted <a href="https://journals.co.za/doi/full/10.31920/2634-3649/2023/v13n1a2">research</a> looking into the role Zulu culture plays in discouraging men who have sex with men from accessing healthcare. </p>
<p>Stigma rooted in cultural beliefs was rife and many of the men we interviewed were too afraid to go to a health clinic.</p>
<p>This research is a tool for policymakers to use to ensure better healthcare for marginalised communities.</p>
<h2>How we went about our study</h2>
<p>In South Africa, men who have sex with men are categorised as a <a href="https://southafrica.iom.int/sites/g/files/tmzbdl1136/files/documents/KeypopPolicybrief.pdf">key population</a>, a vulnerable group more likely to get sexually transmitted infections, due to their socio-economic isolation. </p>
<p>Our study participants were living in <a href="http://umlazi.co.za/what-is-the-population-of-umlazi/">Umlazi</a>, an urban area of least 400,000 inhabitants in the province of KwaZulu-Natal. The province is the home of the Zulu monarchy and the majority of Zulu people – the largest ethnic group in South Africa. More than <a href="https://www.worlddata.info/languages/zulu.php">13 million</a> people speak isiZulu as their first language. </p>
<p>Many Zulu people forced from “<a href="https://www.sahistory.org.za/place/umlazi">white” towns</a> during apartheid ended up in Umlazi. <a href="https://www.sciencedirect.com/science/article/pii/S2666154323000728#:%7E:text=The%20mushrooming%20of%20informal%20settlements,Isipingo%2C%20Amanzimtoti%2C%20and%20Jacobs.&text=Fig.,1.">Informal settlements</a> have also mushroomed around Umlazi as those desperate for work flock to urban areas in search of jobs. </p>
<p>In our study we interviewed 25 participants, men who have sex with men, between the ages of 21 and 55. They were representative of different areas of KwaZulu-Natal as they had roots in Ulundi, Nongoma, uPhongolo, eDumbe and Vryheid. </p>
<p>They shared their experiences in a very emotional way. They described how they were frequently forced to conceal their sexual orientation to avoid being rejected or discriminated against. Study participants were representative of different areas of KwaZulu-Natal as they had roots in Ulundi, Nongoma, uPhongolo, eDumbe and Vryheid. </p>
<blockquote>
<p>Culture is very stigmatising, discriminatory, and depriving. I grew up in a community where people see same-sex relationships as culturally taboo, so tell me, how would you come out in such a community? People create culture; instead of discriminating against same-sex relationships, these same people must accept and embrace them as cultural norms. (Funani) </p>
</blockquote>
<p>For some participants, the traditional rite of passage from boyhood to manhood at the age of 21 was a source of alienation and pain.</p>
<blockquote>
<p>At the age of 21 you are celebrated as a man in the Zulu culture … you are dressed like a Zulu warrior with skin, a spear, and a shield. I was deprived of this because they said I am not a man. … I became sick because of this and was admitted to the hospital for weeks. I almost lost my life because I was deprived of my rights. (Linda) </p>
</blockquote>
<p>Yet another participant spoke about his experiences of not being accepted:</p>
<blockquote>
<p>I don’t care about culture because the culture has let me down as a gay man. Culture does not respect me … I would have killed myself in the more conservative rural areas because the culture does not accept me. I have suffered so many mental health crises because of this. (Sanele) </p>
</blockquote>
<h2>‘I could hear them laughing’</h2>
<p>The men consistently cited fear of discrimination and a lack of understanding among healthcare providers as reasons they avoided health clinics. </p>
<blockquote>
<p>I went to my local clinic because I had a sexually transmitted infection and needed care. When being attended to by the nurse, I was asked some silly questions that did not feel like they were taking my medical history. Then I was reprimanded about my sexuality as being culturally wrong and needing to change, which made me decide never to use my local clinic again. (Lindani) </p>
</blockquote>
<p>Most of the participants related to these experiences.</p>
<blockquote>
<p>I had a sexually transmitted infection and went to my local clinic for medical care. Getting there, a nurse attended to me, and during the section, she walked away to a separate room, where she went to tell other nurses about me. I could hear them laughing. I took my bags and left the clinic and never went back. (Siyanda) </p>
</blockquote>
<p>The impact on the men’s health could be critical:</p>
<blockquote>
<p>I would rather die with my sickness than use such facilities. (Anele) </p>
</blockquote>
<p>Another said:</p>
<blockquote>
<p>Due to my outfit I was kept in the queue for a long time, and when I was finally attended to, the nurse asked me if I am male or female. I respectfully answered her, and she called her other colleagues to make fun of me. (Solomon)</p>
</blockquote>
<h2>Cultural sensitivity</h2>
<p>Collaboration with cultural influencers and community leaders is essential to protect the rights of men who have sex with men while honouring cultural values. </p>
<p>Such interventions should be culturally appropriate, holding in esteem and respecting the Zulu traditions and values, as well as embracing the full spectrum of health matters encountered by men who have sex with men. </p>
<p>Similarly, healthcare providers should receive training to support this community and establish discrimination-free healthcare environments. </p>
<p>Efforts such as these would promote inclusivity and healthcare access for all.</p><img src="https://counter.theconversation.com/content/224553/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ikekhwa Albert Ikhile does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Same-sex relationships in Zulu culture are perceived as taboo and unAfrican. Some men who have sex with men avoid seeking care at health clinics.Ikekhwa Albert Ikhile, Postdoctoral Fellow, University of South AfricaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2221682024-02-12T14:14:27Z2024-02-12T14:14:27ZKenya’s sex workers have solutions to their problems, but international NGOs aren’t hearing them<p>In Kenya, rights organisations run by sex workers have gone into numerous partnerships with international organisations over the past decade. In <a href="https://research.vu.nl/en/publications/making-noise-sex-worker-led-organising-and-knowledge-politics-in-">recent research</a>, I set out to understand whether these relationships worked in favour of the sex workers and their organisations. My research focused on an organisation in Kenya’s capital, Nairobi, that supports male sex workers. </p>
<p>Kenya’s laws punish activities related to <a href="https://www.ohchr.org/sites/default/files/Documents/Issues/Migration/CallEndingImmigrationDetentionChildren/CSOs/RefugeeConsortium_of_Kenya_Annex2.pdf#page=57">sex work</a> and <a href="https://www.ohchr.org/sites/default/files/Documents/Issues/Migration/CallEndingImmigrationDetentionChildren/CSOs/RefugeeConsortium_of_Kenya_Annex2.pdf#page=59">same-sex relationships</a>. These laws, along with societal prejudice, force the men in my study to <a href="https://www.northumbriajournals.co.uk/index.php/IJGSL/article/view/1264">operate in the shadows</a>. </p>
<p>This exposes them to various types of violence. In response to their everyday experiences, more than 70 Kenyan organisations led by sex workers are doing what they can to achieve social justice. </p>
<p>Following interviews and conversations with 99 sex workers between 2018 and 2022, I found that in most cases, sex workers’ knowledge – based on their daily experiences – was sidelined. Donor organisations, despite having good intentions, sometimes fell short of their objectives because they didn’t draw on the knowledge held by marginalised communities. </p>
<p>By ignoring sex workers’ knowledge, development partnerships keep power imbalances unchanged. This leaves many issues that sex workers face – including insecurity, poverty and mental health – unresolved.</p>
<p>My findings illustrate that policies, services and support should include sex workers’ experiential knowledge and needs. </p>
<h2>The research</h2>
<p>Between 2018 and 2022, I conducted a 10-month study as part of my PhD project. I investigated how international NGOs worked with a community-based organisation led by Kenyan sex workers. Their collaborations were aimed at improving health and human rights outcomes. </p>
<p>My focus was how more powerful organisations, such as international NGOs, include sex workers’ knowledge and expertise in these partnerships.</p>
<p>I identified two primary issues affecting the relationship. </p>
<p>Firstly, international development agencies prioritised their own expertise over that of the communities they set out to help. This was despite NGO employees believing they had taken the perspectives of sex workers into account. They didn’t realise they weren’t listening to what sex workers were telling them. </p>
<p>Secondly, because it relied on statistics and frameworks, the development aid system made it difficult to incorporate other kinds of knowledge into intervention programmes. </p>
<h2>The gaps</h2>
<p>Development partnerships tend to <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/dech.12758">sideline the perspectives of sex workers</a>. </p>
<p>For example, NGOs asked the sex workers in my study to provide input on outreach strategies for HIV prevention. But they had already decided what they thought would work best – peer educators and a drop-in centre.</p>
<p>As one respondent in my research put it:</p>
<blockquote>
<p>(We ask them), ‘How do you plan to do outreach work; how do you plan to make the DICE (drop-in centre) more attractive to peer educators?’. And then we work around that. So, they get the idea, and then we fine-tune it with the team.</p>
</blockquote>
<p>This approach limits sex workers to providing local contacts rather than shaping the agenda based on their priorities. </p>
<p>This tokenistic approach leaves sex workers frustrated. They recognise their crucial role in the success of programmes but <a href="https://www.tandfonline.com/doi/full/10.1080/13691058.2020.1842499?role=tab&tab=permissions&scroll=top">are excluded</a> from the decision-making. </p>
<p>This has led to a strong programmatic focus on sex workers’ sexual health and HIV. But they’d like to address other issues too, like insecurity and mental health. </p>
<blockquote>
<p>Can the community get more services on mental health … condoms and lubes we can buy; you have empowered us enough. Now get to know our story, our sad moments, the violence we have faced and how it has affected us. How trying to make a living, get a job, a house has been the struggle and how we cope. That’s what we need.</p>
</blockquote>
<p>The focus on scientific evidence, professional knowledge and statistical data makes it difficult to discover and share what sex workers know. This knowledge comes from the experience of what it means to do sex work and <a href="https://theconversation.com/queerphobia-in-kenya-a-supreme-court-ruling-on-gay-rights-triggers-a-new-wave-of-anger-against-the-lgbtiq-community-204575">live as queer in Kenya</a>. </p>
<p>One respondent said:</p>
<blockquote>
<p>Now, most (of what) they are doing is health services, but you see the sex worker has been beaten, has been raped, so still the HIV prevalence wouldn’t really go down … They are talking about how to reach targets but this sex worker is still being violated, still being raped, still being beaten.</p>
</blockquote>
<p>It’s difficult to integrate such perspectives into the evidence-based policies typical of the international development aid system. Interviews with NGO employees illustrate that requirements for accountability add to the challenge.</p>
<blockquote>
<p>They (headquarters) have set out goals and strategies towards epidemic control and everything we do is guided in that context. We work within the context … and then we try … to take into account the more structural issues.</p>
</blockquote>
<h2>What can be done</h2>
<p>The sex workers in my study wanted their knowledge to be included in development partnerships. They identified three things they’d want development organisations to consider.</p>
<ol>
<li><p>Take sex workers’ experiential knowledge more seriously. Acknowledge that their insights are as important as academic and professional knowledge. </p></li>
<li><p>Acknowledge the leadership, creativity and expertise of marginalised communities. Allow these groups to design programmes based on their unique desires and needs. <a href="https://library.oapen.org/bitstream/handle/20.500.12657/60520/9781000843309.pdf?sequence=1#page=58">Community-led research methods</a> can help make this a reality. Support communities to address what they – instead of others – consider important and liberating.</p></li>
<li><p>Recognise and disrupt the power dynamics in the international aid system. Dominant actors need to unlearn the power differences in their relationships with communities, which are often uncritically perceived as natural. Critically examine assumptions and practices. Question the legitimacy of the expertise of donors in community collaborations, and see whether there are gaps created by sidelining sex work-related knowledge.</p></li>
</ol><img src="https://counter.theconversation.com/content/222168/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lise Woensdregt does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Sex workers have a deep understanding of their needs but development partnerships tend to prioritise scientific knowledge.Lise Woensdregt, Assistant Professor in Sociology, Vrije Universiteit AmsterdamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2137262023-10-02T12:38:37Z2023-10-02T12:38:37ZHIV self-test kits are meant to empower those at risk − but they don’t necessarily lead to starting HIV treatment or prevention<figure><img src="https://images.theconversation.com/files/550089/original/file-20230925-29-kvx1ps.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3058%2C2000&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Regular testing for HIV protects you and those around you.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/focus-on-an-hiv-self-test-with-seronegative-result-royalty-free-image/930075664">pixinoo/iStock via Getty Images Plus</a></span></figcaption></figure><p>HIV self-test kits were developed to make it easier for people to access HIV testing. However, <a href="https://scholar.google.com/citations?user=7RB_bZUAAAAJ&hl=en">our</a> <a href="https://scholar.google.nl/citations?user=weevnFsAAAAJ&hl=en">research</a> <a href="https://www.researchgate.net/profile/Oluwaseun-Badru">team</a> has found that many people who use self-test kits <a href="https://doi.org/10.1007/s10461-023-04162-5">do not go on to receive needed HIV treatment</a> or start preexposure prophylaxis, or PrEP, to prevent future infection.</p>
<p>In 2016, the World Health Organization <a href="https://www.who.int/publications/i/item/WHO-CDS-HIV-19.36">recommended HIV self-test kits</a> as a way for people to confidentially test for HIV in their homes or other private places. Each kit contains detailed instructions on how to administer the test and read the results without the help of a clinician. However, the instructions advise confirming results in a health facility to improve access to care, especially for those with a positive reading.</p>
<p>Our team conducted a systematic review and meta-analysis of published research and data to understand how HIV self-testing influences access to HIV care and sexual behavior. Specifically, we looked at whether a positive test result led someone to seek care in a hospital or health facility to start treatment and whether a negative test result led someone at risk of contracting HIV to take preventive measures. We also looked at whether test results affected the number of sexual partners, engagement in anal sex without a condom and frequency of condom use.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/D_IHm3p8RW0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">HIV self-test kits provide quick results.</span></figcaption>
</figure>
<p>Based on the 15 studies that met our criteria, we found that while HIV self-testing increased a person’s chances of finding an HIV clinic or doctor by 8%, many people <a href="https://doi.org/10.1007/s10461-023-04162-5">did not initiate HIV treatment or PrEP</a> following self-testing.</p>
<p><a href="https://doi.org/10.1007/s10461-023-04162-5">Female sex workers</a> who used HIV self-test kits were 47% more likely to seek medical care, but this did not reduce the number of clients they saw per night.</p>
<p>For <a href="https://doi.org/10.1007/s10461-023-04162-5">men who have sex with men</a>, using HIV self-test kits may have increased the amount of condomless anal sex they have, according to <a href="https://doi.org/10.1097/QAI.0000000000001709">one U.S. study</a>. Those who use HIV self-test kits were more likely to have condomless anal sex with HIV-positive and HIV-negative partners, as reported by <a href="https://doi.org/10.1007/s10461-022-03804-4">one Chinese study</a>.</p>
<h2>Why it matters</h2>
<p>Many people are living with HIV and receiving treatment. However, some HIV-positive people are unaware of their HIV status and are at risk of infecting other people. Routinely checking your HIV status is important to prevent the spread of HIV.</p>
<p>Unfortunately, HIV testing is low in many regions of the world. Researchers from <a href="https://doi.org/10.4102/sajhivmed.v22i1.1273">South Africa</a>, the <a href="https://doi.org/10.1136/bmjopen-2015-009480">Netherlands</a> and the <a href="https://doi.org/10.1080/09540121.2020.1766663">United States</a> have reported a lack of HIV testing among different parts of the population, including <a href="https://theconversation.com/men-who-have-sex-with-men-originated-during-the-hiv-pandemic-to-focus-on-behavior-rather-than-identity-but-not-everyone-thinks-the-term-helps-189619">men who have sex with men</a>. There are many barriers to HIV testing, including <a href="https://doi.org/10.1186/s12905-021-01590-0">lack of knowledge about HIV</a> and <a href="https://doi.org/10.1080/09540121.2020.1742867">fear of</a> <a href="https://theconversation.com/people-living-with-hiv-face-harmful-stigma-daily-dababys-rant-was-just-more-public-than-most-165443">stigma and discrimination</a>. </p>
<p>Despite the availability of HIV test kits, many people at heightened risk have never been tested for HIV. As our research shows, some of those who test positive don’t receive treatment. Nor do all those who test negative but are at risk of infection receive preventive treatment or change their sexual behavior.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Clinician handing patient condoms" src="https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/550092/original/file-20230925-29-e1or2l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Public health officials recommend talking to a doctor about HIV self-test results.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/the-doctor-advised-the-young-man-to-prevent-royalty-free-image/1210961713">Wasan Tita/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<h2>What still isn’t known</h2>
<p>We found only one study that looked at how HIV self-testing influences PrEP use among men who have sex with men. </p>
<p>More research is needed to better understand the link between HIV self-testing and HIV prevention.</p>
<h2>What’s next</h2>
<p>Our next step is to understand why people did or did not receive care following HIV self-testing. We plan on interviewing HIV self-test kit users about their experience using the self-test and whether they went on to receive care.</p>
<p>We hope the results of this study will help us build an intervention to increase access to care following an HIV self-test. This will contribute toward the national plan to <a href="https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview/">end the HIV epidemic by 2030</a> in the U.S.</p>
<p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take on interesting academic work.</em></p><img src="https://counter.theconversation.com/content/213726/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adeagbo Oluwafemi Atanda receives funding from University of Iowa and National Institutes of Health. </span></em></p><p class="fine-print"><em><span>Engelbert Bain Luchuo and Oluwaseun Abdulganiyu Badru do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many people at heightened risk for HIV have never been tested. Those who have self-tested for HIV often don’t go on to receive care or change their sexual behavior.Oluwafemi Atanda Adeagbo, Assistant Professor of Public Health, University of IowaEngelbert Bain Luchuo, Senior Research Associate, University of JohannesburgOluwaseun Abdulganiyu Badru, Ph.D. Candidate in Community and Behavioral Health, University of IowaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2055442023-05-16T12:41:13Z2023-05-16T12:41:13ZGay men can now donate blood after FDA changes decades-old rule – a health policy researcher explains the benefits<figure><img src="https://images.theconversation.com/files/525731/original/file-20230511-941-a7vrz0.jpg?ixlib=rb-1.1.0&rect=0%2C20%2C6709%2C4446&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Allowing gay and bisexual men to donate blood would help alleviate chronic blood supply shortages in the U.S.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/donating-blood-royalty-free-image/1093904562?phrase=blood+donation&adppopup=true">Petri Oeschger/Moment via Getty Images</a></span></figcaption></figure><p><em>The U.S. Food and Drug Administration announced on May 11, 2023, that it has officially <a href="https://www.npr.org/2023/05/11/1175622785/fda-blood-donations-gay-bisexual-men">dropped restrictions that prohibit gay and bisexual men</a> from donating blood under many circumstances on May 11, 2023. The ban was <a href="https://doi.org/10.1111/1468-0009.12114">initially put in place</a> in the early days of the AIDS epidemic, but for years medical professionals and gay rights advocates have argued that the ban was no longer medically justifiable and that it unnecessarily discriminated against <a href="https://theconversation.com/men-who-have-sex-with-men-originated-during-the-hiv-pandemic-to-focus-on-behavior-rather-than-identity-but-not-everyone-thinks-the-term-helps-189619">men who have sex with men</a>.</em></p>
<p><em><a href="https://luskin.ucla.edu/person/ayako-miyashita-ochoa">Ayako Miyashita</a> is a health policy researcher at the University of California, Los Angeles, who studies HIV treatment and prevention. She explains the history of the ban and the reasoning behind its long-awaited reversal.</em></p>
<h2>1. When and why did the ban begin?</h2>
<p>When the FDA <a href="https://doi.org/10.1111/1468-0009.12114">first implemented the blood donation ban</a> in 1983 for men who have sex with men, there were good reasons for broad regulations to ensure the safety of the blood supply. At the start of the AIDS epidemic, public health officials were dealing with an unknown virus that was spread through unknown means. Researchers <a href="https://doi.org/10.1126/science.6200936">formally identified HIV as the cause of AIDS</a> a year later, in 1984, and it took another year to approve the first test to screen blood donations for HIV in 1985.</p>
<p>Despite the ban on blood donations from men who have sex with men, there was some small risk that failures in <a href="https://doi.org/10.1111/trf.14195">donor screening</a> and <a href="https://www.federalregister.gov/documents/2011/07/19/2011-18093/quarantine-release-errors-in-blood-establishments-public-workshop">blood screening protocols</a> could lead to transmission of HIV or other diseases from blood transfusion. But over the years, scientific advancements and strict protocols have helped to nearly <a href="https://doi.org/10.1111/trf.12423">eliminate HIV transmission</a> through blood. In fact, the last documented transmission of HIV through the a U.S. donor’s blood product <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5941a3.htm">occurred nearly 15 years ago</a>.</p>
<p>Starting in 2013, the U.S. government began implementing a nationwide <a href="https://doi.org/10.1111/trf.13632">system to monitor</a> the safety of the U.S. blood supply for a variety of different pathogens, including HIV. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/526324/original/file-20230515-31713-uevzio.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A bag of donated blood." src="https://images.theconversation.com/files/526324/original/file-20230515-31713-uevzio.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/526324/original/file-20230515-31713-uevzio.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/526324/original/file-20230515-31713-uevzio.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/526324/original/file-20230515-31713-uevzio.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/526324/original/file-20230515-31713-uevzio.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/526324/original/file-20230515-31713-uevzio.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/526324/original/file-20230515-31713-uevzio.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Modern tests and screening protocols prevent blood of people with HIV or other diseases from getting into the U.S. blood supply.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/phlebotomist-adel-velasco-prepares-a-blood-donation-at-a-news-photo/1308846819?adppopup=true">MediaNews Group/Los Angeles Daily News via Getty Images</a></span>
</figcaption>
</figure>
<h2>2. Why lift the ban now?</h2>
<p>While the blood donation ban – as well as many other <a href="https://www.cdc.gov/hiv/policies/law/states/exposure.html">laws passed in the 1980s regarding HIV exposure and spread</a> – were reasonable at the time, the science has changed. Researchers and public health officials have gained a better understanding of how HIV is transmitted and the risks associated with different activities. Given today’s knowledge, many <a href="https://www.ama-assn.org/about/leadership/fda-must-lift-its-discriminatory-blood-donor-policy">medical experts believe</a> that the benefits of the ban no longer outweigh the hit to the blood supply or the harm caused by what is a discriminatory rule. </p>
<p>The FDA has been slowly working toward this change. In December 2015, the organization took a big step by allowing men who have sex with men to donate blood if they hadn’t had <a href="https://www.federalregister.gov/documents/2020/06/17/2020-13051/revised-recommendations-for-reducing-the-risk-of-human-immunodeficiency-virus-transmission-by-blood">sexual contact in one year</a>. That period was <a href="https://www.govinfo.gov/content/pkg/FR-2020-06-17/pdf/2020-13051.pdf">further reduced to three months</a> in April 2020, during the height of the COVID-19 pandemic, to help fight a <a href="https://www.redcross.org/about-us/news-and-events/press-release/2020/american-red-cross-faces-severe-blood-shortage-as-coronavirus-outbreak-threatens-availability-of-nations-supply.html">critical blood shortage</a>. </p>
<p>While a step in the right direction, these updates didn’t change the blunt assessment by the FDA that men who have sex with men are performing high-risk sexual behaviors and are themselves high-risk donors. Researchers and gay rights advocates have long argued that <a href="https://doi.org/10.1056/NEJMp2112329">time-based deferrals lack nuance</a> and fail to realistically consider the differences in risk associated with the type of sex, type of relationship, number of partners and frequency of sexual encounters.</p>
<p>The FDA’s latest <a href="https://www.fda.gov/regulatory-information/search-fda-guidance-documents/recommendations-evaluating-donor-eligibility-using-individual-risk-based-questions-reduce-risk-human">draft recommendations</a> go a long way toward improving clarity about what makes a person a high-risk donor and removes the blanket categorization of prospective donors based on their gender and sexual orientation alone.</p>
<p>Under the new guidelines, there is a way to differentiate between individuals who are monogamous and those who are not, as well as between those who have not engaged in anal sex in the prior three months and those who have. The recommendation now suggests that blood donor history questionnaires be used to evaluate an individual’s risk rather than a reliance on broad categorizations. If the assessment finds an individual to be high-risk, then the guidelines recommend that person be prevented from donating blood for three months.</p>
<h2>3. What effect could this have on the blood supply?</h2>
<p>The FDA’s latest move represents a seismic shift for men who have sex with men as well as for the <a href="https://theconversation.com/heading-into-the-third-year-of-the-pandemic-the-us-blood-supply-is-at-a-10-year-low-175906">critically low U.S. blood supply</a>. </p>
<p>According to recent research, a conservative estimate suggests that the lifting of the ban will lead to a <a href="https://williamsinstitute.law.ucla.edu/publications/blood-donation-ban-msm/">2% to 4% increase in the blood supply</a>. With the ongoing blood shortage, that increase could help save more than a million lives. In addition, removing gender and sexual orientation from the risk assessment for blood donation will take the U.S. one step further in addressing stigma and discrimination against men who have sex with men.</p><img src="https://counter.theconversation.com/content/205544/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ayako Miyashita does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In 1983, during the early days of the AIDS epidemic, the US Food and Drug Administration made the decision to ban gay men from donating blood. Now, 40 years later, it is dropping that rule.Ayako Miyashita, Adjunct Professor of Public Policy and Social Welfare, University of California, Los AngelesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1896192022-09-22T12:40:05Z2022-09-22T12:40:05Z‘Men who have sex with men’ originated during the HIV pandemic to focus on behavior rather than identity – but not everyone thinks the term helps<figure><img src="https://images.theconversation.com/files/485710/original/file-20220920-14360-lngmmg.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2121%2C1412&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The monkeypox pandemic has seen an increase in the use of the term "men who have sex with men."</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/rear-view-of-gay-couple-on-lookout-above-the-city-royalty-free-image/1195433903">Westend61/Getty Images</a></span></figcaption></figure><p>Since the <a href="https://www.npr.org/2022/08/05/1116036167/talking-about-monkeypox-effectively-without-stigmatizing-men-who-have-sex-with-m">global monkeypox outbreak</a> started to spread this past spring, more people are seeing the term “men who have sex with men,” or MSM, in the news and public health messages. You may have also heard this term in places like HIV prevention campaigns or at the doctor’s office.</p>
<p>I am a <a href="https://cph.osu.edu/people/jricks">behavioral scientist</a> who focuses on reducing health disparities and improving health equity for sexual and gender minority populations at highest risk for poor outcomes. At the most basic level, <a href="https://doi.org/10.1080/00224499009551551">men who have sex with men</a> is a term that was originally intended to describe the risk of HIV transmission associated with sex between two men. But in reality, MSM describes a diverse group of behaviors and identities, bringing with it a complex web of social, political and cultural considerations about how it’s used.</p>
<h2>Why use MSM?</h2>
<p>HIV researchers have used the term “men who have sex with men” <a href="https://doi.org/10.1007/BF01326525">since at least 1988</a> as a way to describe a particular type of sexual behavior that may affect health.</p>
<p>The acronym MSM, however, was <a href="https://doi.org/10.1902/jop.1994.65.5.393">introduced in 1994 as a new concept</a> by some researchers and community advocates in response to public health research and prevention efforts early in the HIV/AIDS pandemic. These efforts almost exclusively targeted men based on their sexual identity as gay. Community advocates <a href="https://prideindex.com/in-touch-with-cleo-manago/">criticized this approach</a> for excluding Black and Latino men who have sex with men who were affected by the pandemic but did not identify as gay, homosexual or bisexual. MSM was considered to be a more inclusive, less stigmatizing term that could be used to reach a broader range of people.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/485707/original/file-20220920-11202-cf9dvv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Demonstrators holding signs protesting against AIDS discrimination" src="https://images.theconversation.com/files/485707/original/file-20220920-11202-cf9dvv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/485707/original/file-20220920-11202-cf9dvv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=839&fit=crop&dpr=1 600w, https://images.theconversation.com/files/485707/original/file-20220920-11202-cf9dvv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=839&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/485707/original/file-20220920-11202-cf9dvv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=839&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/485707/original/file-20220920-11202-cf9dvv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1055&fit=crop&dpr=1 754w, https://images.theconversation.com/files/485707/original/file-20220920-11202-cf9dvv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1055&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/485707/original/file-20220920-11202-cf9dvv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1055&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">During the AIDS epidemic, new terminology arose to focus research and public health interventions on behavior rather than identity.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/AIDSDiscriminationProtest/96ceaffa64224626b88eae3bd88e7503">AP Photo/Rick Maiman</a></span>
</figcaption>
</figure>
<p>From a scientific perspective, using an identity-free term like MSM allows medical providers and public health practitioners to bypass the complexities of the social, cultural and political context of sexual orientation. Instead, they can then focus on the behavior that might put someone at risk for an infection such as HIV or monkeypox. This approach is <a href="https://pubmed.ncbi.nlm.nih.gov/16080458/">intended to help</a> increase the likelihood of screening, diagnosing and treating those at the greatest risk.</p>
<p>Prevention strategies that target people based on “what you do” rather than “who you are” reach more people who may be affected by a public health concern, including heterosexual men who have sex with men, rather than limiting outreach just to those who identify as gay or bisexual. They offer a larger number of men the opportunity to understand their risk and take the steps necessary for protection or treatment. They also help <a href="https://doi.org/10.2105/AJPH.2004.046714">decrease stigma</a> for those who identify as gay or bisexual.</p>
<h2>Limitations of MSM</h2>
<p>Despite its usefulness in some contexts, the term MSM has been hotly debated by scholars and community advocates since it was coined. <a href="https://doi.org/10.2105/AJPH.2004.046714">Disagreement</a> <a href="https://doi.org/10.2105/AJPH.2020.305870">on its use</a> is usually grounded in three arguments.</p>
<p>The first is that the term is ambiguous. Some researchers argue that distilling MSM down to “sex between two men” is too simplistic. For one, there are a number of nuances and factors that <a href="https://www.cdc.gov/hiv/group/msm/msm-content/prevention-challenges.html">influence the amount of risk</a> associated with sex between two men, such as how sex is performed and who and how many partners are in their sexual network. There is also confusion about how frequently or recently someone must have sex in order to be considered MSM. And there is <a href="https://doi.org/10.7448/IAS.19.3.20779">no consensus</a> about whether transgender men who have sex with men should be considered MSM. </p>
<p>The second critique is that the term <a href="https://doi.org/10.2105/AJPH.2004.046714">undermines the identities</a> of sexual minority group members, particularly people of color. Many public health researchers use MSM as a neutral term to push back against the idea that there is only one legitimate gay identity. However, some have criticized the term for erasing other sexual identities such as queer, two-spirited and same-gender loving by being the default term used in research, despite participants describing themselves as otherwise.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/JOSN1bKG3zQ?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">While HIV cases are largely decreasing across the U.S., high infection rates remain in Southern states.</span></figcaption>
</figure>
<p>Finally, the third argument is that the term conceals the social, political and cultural dimensions of health important for public health research and intervention. One of the greatest advantages of MSM is that it is grounded in tangible behaviors that researchers can target for health promotion and prevention efforts. But sexual health is influenced by a constellation of factors, and focusing on behavior alone is often not enough to completely protect against illness. </p>
<p>Beyond sexual behavior, <a href="https://doi.org/10.17226/25877">discrimination and social marginalization</a> put sexual minorities at significant risk of poor health outcomes. These can take the form of structural factors, such as anti-gay legislation, and community factors, such as discrimination and stigma. Interpersonal factors like relationship abuse and individual factors like internalized stigma also play a role. These factors <a href="https://doi.org/10.1016/j.mhp.2016.10.002">increase the risk of mental illness</a>, such as depression and suicidal thoughts, as well as risky health behaviors, such as sex without a condom or while under the influence of drugs.</p>
<p>Almost 30 years since it was introduced, the term MSM is becoming increasingly ubiquitous in both medical and public health spaces. But it does have limitations. Considering the sociopolitical context of whether MSM should be used, rather than using it by default, can help support the self-determination of those who belong to historically marginalized communities.</p><img src="https://counter.theconversation.com/content/189619/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>JaNelle Ricks does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The term ‘MSM’ allows public health interventions to gloss over the social, political and cultural complexities of identity. But it’s not without its limitations.JaNelle Ricks, Assistant Professor of Health Behavior and Health Promotion, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1886282022-08-16T20:39:37Z2022-08-16T20:39:37ZTreating monkeypox like an STI may help control the outbreak, but stigma is a danger<figure><img src="https://images.theconversation.com/files/479474/original/file-20220816-9810-ms19br.jpg?ixlib=rb-1.1.0&rect=0%2C77%2C1789%2C1319&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Monkeypox is transmitted mainly through direct contact with skin lesions, but the current outbreak is following patterns similar to STIs.</span> <span class="attribution"><span class="source">(NIAID, cropped from original)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>The recent monkeypox global outbreak, now declared by the World Health Organization as a <a href="https://www.who.int/europe/news/item/23-07-2022-who-director-general-declares-the-ongoing-monkeypox-outbreak-a-public-health-event-of-international-concern">Public Health Emergency of International Concern</a> (PHEIC), is sadly yet another reason for society to stigmatize and discriminate against the LGTBQ2SA+ community. This is in part because it has been suggested that monkeypox is a sexually transmitted infection (STI).</p>
<p><a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">Monkeypox started as a zoonosis</a> (an infection transmitted by contact with animals). However, this close relative of the variola virus (which causes smallpox) can also be transmitted from human to human, mainly through direct contact with the skin lesions. </p>
<p>Although transmission through semen and vaginal secretions has yet to be proven, it can be transmitted during sexual intercourse because of the obvious close contact it entails. </p>
<p>Cases have been identified for decades mainly in West African countries, but it was only recently when cases appeared in Europe and America that it caught the international attention it deserved. Cases continue to rise in many countries, to the point of prompting the WHO to declare it a PHEIC. </p>
<p><a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2207323">One excellent study</a> put together a series of 500 patients distributed across 16 countries. The researchers analyzed patients’ demographics as well as their clinical characteristics. They found that 98 per cent of the cases were men who prefer to have sex with men (MSM). Of note, 41 per cent of the cases were people living with HIV (PLWH). </p>
<h2>Characteristics of lesions</h2>
<p>Another finding was the characteristics of the lesions. Monkeypox used to present with skin lesions mainly on the face, trunk, arms and legs, but most of the reported cases during this global outbreak have had a different presentation. Many cases have lesions in the perineal region (73 per cent) or genitals or even around the mouth. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man in a black T-shirt is pointing at a large screen showing a series of images of skin lesions." src="https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=337&fit=crop&dpr=1 600w, https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=337&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=337&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An epidemiologist conducts monkeypox disease training to health investigators at the Salt Lake County Health Department on July 29, 2022, in Salt Lake City.</span>
<span class="attribution"><span class="source">(AP Photo/Rick Bowmer)</span></span>
</figcaption>
</figure>
<p>This could be consistent with sexual transmission as the lesions are presenting at the site of infection, a clinical course also described in <a href="https://doi.org/10.1016/S0140-6736(22)01436-2">this paper from Spain</a>. Additionally, 30 per cent of the patients also have another more common STI such as gonorrhea or syphilis, a pattern frequently found in many STIs. Managing a patient with an STI always implies ruling out other STIs. </p>
<p>Grouping diseases by their mode of transmission is helpful for doctors because it allows us to make mental lists of probable causes when confronted with a case. We call this differential diagnosis. </p>
<p>When a patient presents with a genital lesion, a health-care provider will establish a list of possible diagnoses based on the characteristics of the lesion, the accompanying symptoms and the local epidemiology. This makes it possible to treat empirically (before we can confirm the diagnosis) for the most probable cause. </p>
<h2>What is an STI?</h2>
<p>Any disease passed from one person to another through bodily fluids during a sexual encounter is <a href="https://www.who.int/health-topics/sexually-transmitted-infections#tab=tab_1">considered an STI</a>. However there are diseases that occur more frequently than others and as such are grouped in this category, such as chlamydia and gonorrhea. </p>
<p>Other diseases may be transmitted through genital secretions but are not considered an STI by the medical community. For example, Ebola has been shown to be <a href="https://doi.org/10.1371/journal.pmed.1003273">transmitted through genital secretions</a>, however it is not considered within the group of the more frequent STIs because it is not its main mode of transmission. </p>
<figure class="align-center ">
<img alt="A man in a plaid shirt getting an injection from a woman in a blue dress and face mask, both sitting in folding chairs, seen from behind" src="https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=432&fit=crop&dpr=1 600w, https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=432&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=432&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=543&fit=crop&dpr=1 754w, https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=543&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=543&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A man receives a monkeypox vaccine at an outdoor walk-in clinic in Montréal in July 2022.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Graham Hughes</span></span>
</figcaption>
</figure>
<p>The mode of presentation of monkeypox during this global outbreak has <a href="https://doi.org/10.1016/S0140-6736(22)01497-0">prompted the medical community</a> to consider monkeypox diagnosis, along with other STIs, in any person who has had a recent unprotected sexual contact, and presents with a painful skin lesion in the genitals, perianal region or mouth.</p>
<p>Considering monkeypox as an STI seems logical in order to face the current outbreak, but the <a href="https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2018-44/issue-2-february-1-2018/article-5-stigma-sexually-transmitted-infections.html">stigma and discrimination</a> this could cause is a major problem. An infection acquired through sex is still something that causes guilt and fear of rejection by society. STIs are still viewed by many as a <a href="https://slate.com/technology/2019/12/genital-herpes-stigma-history-explained.html">punishment for certain behaviours</a>. </p>
<p>Additionally, classifying monkeypox as an STI may create a false sense of security for people who may think they’re not at risk. Both stigma and a low perception of risk can hinder efforts for early identification of cases, rapid isolation and limitation of the outbreak. Worst of all, stigma related to this outbreak would perpetuate harms to the LGTBQ2SA+ community.</p>
<p>Monkeypox is behaving like an STI during this global outbreak, so including this diagnosis as part of sexual health management may be beneficial to stop transmission. However, bigger efforts addressing stigma and discrimination are necessary.</p><img src="https://counter.theconversation.com/content/188628/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Santiago Perez Patrigeon does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Monkeypox is not considered an STI but is spreading among sexual partners. Adding sexual health strategies to the public health response is helpful, but there is a danger of stigmatizing MPXV.Santiago Perez Patrigeon, Assistant professor, Division of Infectious Diseases, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1861692022-08-14T13:14:54Z2022-08-14T13:14:54ZWhy it’s important to tell people that monkeypox is predominately affecting gay and bisexual men<figure><img src="https://images.theconversation.com/files/478989/original/file-20220812-2527-jwfwgd.JPG?ixlib=rb-1.1.0&rect=444%2C22%2C2550%2C2097&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People inquire about receiving a monkeypox vaccine at an outdoor walk-in clinic in Montréal on July 23, 2022. The World Health Organization has declared the virus a global health emergency.
</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Graham Hughes</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/why-it-s-important-to-tell-people-that-monkeypox-is-predominately-affecting-gay-and-bisexual-men" width="100%" height="400"></iframe>
<p>Monkeypox virus, or MPXV, is an <a href="https://doi.org/10.1371/journal.pntd.0010141">emerging threat</a> to public health. The World Health Organization recently declared the current outbreak a <a href="https://doi.org/10.1001/jama.2022.12513">global public health emergency</a>.</p>
<p>For decades, several African countries have experienced ongoing <a href="https://doi.org/10.1371/journal.pntd.0007791">outbreaks of MPXV</a>, driven primarily by contact with animals and transmission within households. However, before last year, most people in Europe and North America had never even heard of the disease. That was until the current outbreak among gay, bisexual and other men who have sex with men.</p>
<h2>Debates over the epidemiology of MPXV</h2>
<p>Over the past several months, <a href="https://www.cdc.gov/poxvirus/monkeypox/reducing-stigma.html">a controversy</a> has raged about whether it’s OK to say that the current MPXV outbreak is primarily affecting gay and bisexual men, and that it is primarily being spread through close personal contact, such as sex. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/metaphors-matter-why-changing-the-name-monkeypox-may-help-curb-the-discriminatory-language-used-to-discuss-it-185343">Metaphors matter: Why changing the name 'monkeypox' may help curb the discriminatory language used to discuss it</a>
</strong>
</em>
</p>
<hr>
<p>As a social and behavioural epidemiologist working with marginalized populations, including gay and bisexual men, I believe it’s important that people know that sexual and gender minority men are the primary victims of this MPXV outbreak. I believe this knowledge will help us end the outbreak before it bridges into other communities. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/478988/original/file-20220812-1300-s3i976.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Yellow ovals (monkeypox virus particles) spread over a blue cell background" src="https://images.theconversation.com/files/478988/original/file-20220812-1300-s3i976.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/478988/original/file-20220812-1300-s3i976.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=589&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478988/original/file-20220812-1300-s3i976.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=589&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478988/original/file-20220812-1300-s3i976.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=589&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478988/original/file-20220812-1300-s3i976.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=740&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478988/original/file-20220812-1300-s3i976.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=740&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478988/original/file-20220812-1300-s3i976.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=740&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Monkeypox particles in an infected cell.</span>
<span class="attribution"><span class="source">(NIAID)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>For reference, more than <a href="https://doi.org/10.1056/NEJMe2210673">90 per cent of cases in non-endemic countries</a> have been transmitted through intimate sexual contact, and the vast majority of cases are among gay men. Very few cases are linked to community transmission. </p>
<p>While these statistics are undisputed, some have feared that identifying sexual behaviour as the primary cause of current MPXV transmission <a href="https://www.usatoday.com/story/life/health-wellness/2022/08/04/monkeypox-cases-spread-sti-std-stigma/10172342002/">would dampen the public health response</a>. Others have warned that connecting MPXV to an already stigmatized community will <a href="https://www.npr.org/2022/07/26/1113713684/monkeypox-stigma-gay-community">worsen stigma towards gay sex</a>. </p>
<h2>Non-sexual transmission is possible, and a considerable threat</h2>
<p><a href="https://www.cdc.gov/poxvirus/monkeypox/transmission.html">It is true that MPXV can transmit through more</a> casual contact and through fomites (<a href="https://www.news-medical.net/health/What-are-Fomites.aspx">inanimate objects</a> on which some microbes can survive, such as bed linens, towels or tables). </p>
<p>However, months into the current outbreak, we have not seen these routes emerge as important pathways of transmission. This may be due to <a href="https://www.newsweek.com/monkeypox-transmission-has-changed-scientists-dont-know-why-airborne-1715276">changes in the fundamental transmission dynamic of MPXV</a> or due to enhanced cleaning procedures implemented in response to COVID-19 in places such as gyms and restrooms. </p>
<h2>Why it’s crucial to know MPXV affects gay and bisexual men</h2>
<p>Informing the public about MPXV is important because public opinion plays an important role in <a href="https://doi.org/10.1001/jama.2020.11623">shaping public health policies</a>, such as who gets access to vaccines and what interventions are used to stop disease transmission. </p>
<p>A <a href="https://doi.org/10.1186/s12889-022-13539-5">recent study</a> conducted by my team aimed to demonstrate the importance of public health education by asking Canadians to participate in a discrete choice experiment. </p>
<figure class="align-center ">
<img alt="An arm with a tattoo of a flower and leaves being injected with a syringe" src="https://images.theconversation.com/files/478993/original/file-20220812-3855-u3hkeu.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478993/original/file-20220812-3855-u3hkeu.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=429&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478993/original/file-20220812-3855-u3hkeu.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=429&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478993/original/file-20220812-3855-u3hkeu.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=429&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478993/original/file-20220812-3855-u3hkeu.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=539&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478993/original/file-20220812-3855-u3hkeu.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=539&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478993/original/file-20220812-3855-u3hkeu.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=539&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A man receives a monkeypox vaccine at an outdoor walk-in clinic in Montréal on July 23, 2022.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Graham Hughes</span></span>
</figcaption>
</figure>
<p>We asked participants to choose between two hypothetical public health programs across eight head-to-head comparisons. Descriptions for each hypothetical program identified the number of years of life gained by patients, the health condition it addressed and the population it was tailored for. </p>
<p>From our analyses of this data, we learned a lot about how the public wants public health dollars to be spent and how their knowledge and bias shapes these preferences. There were five major takeaways:</p>
<ol>
<li><p><a href="https://doi.org/10.1016/j.socscimed.2014.11.022">People preferred interventions that added more years to participants’ life expectancy</a>. In fact, for one year of marginal life gained, there was a 15 per cent increase in the odds that participants chose that program. </p></li>
<li><p>We found that people tended to favour interventions that focused on treatment rather than prevention. While this approach is emotionally intuitive, large bodies of evidence suggest that <a href="https://www.rwjf.org/en/library/research/2009/09/cost-savings-and-cost-effectiveness-of-clinical-preventive-care.html">it is more cost-effective to prevent disease than to treat it</a>. As the old saying goes: An ounce of prevention is worth a pound of cure. </p></li>
<li><p>People generally preferred interventions for common chronic diseases — such as heart disease, diabetes and cancer — and were <a href="http://dx.doi.org/10.1136/bmjopen-2019-029747">less likely to favour interventions for behaviour-related conditions</a>, such as sexually transmitted infections. </p></li>
<li><p>People generally preferred programs focused on the general population as opposed to those tailored for key <a href="https://doi.org/10.1016/j.vhri.2018.05.004">marginalized populations</a>. In fact, people were least likely to prefer interventions tailored for sexual and gender minorities. </p></li>
<li><p>The bias against behavioural interventions and those tailored for key populations was overcome when the programs addressed a health condition that was widely understood to be linked to the population the program was tailored to. For example, people were more likely to support interventions for sexually transmitted infections when these interventions were tailored for people engaged in sex work or for gay and bisexual men.</p></li>
</ol>
<p>This study highlights why it is important to educate the public about health inequities. People are smarter, more pragmatic, and more compassionate than we give them credit for. If we take the time to share evidence with them about the challenges that stigmatized communities face, they will be more willing to support policies and efforts to address these challenges. </p>
<p>Ending MPXV quickly is critical, especially since the virus <a href="https://doi.org/10.1038/s41591-022-01907-y">has the potential to evolve</a> in ways that could make the disease more infectious. <a href="https://doi.org/10.1186/s40249-022-01007-6">Protecting gay and bisexual men first, protects everyone</a>.</p>
<p>We should, of course, always be aware of the potential harms and the corrosive effects of stigma. However, in public health, honesty really is the best policy.</p><img src="https://counter.theconversation.com/content/186169/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kiffer George Card receives funding from the Canadian Institutes for Health Research, the Canadian Research Coordinating Committee, Michael Smith Health Research BC, and Social Sciences and Humanities Research Council. He is affiliated with Simon Fraser University's Faculty of Health Sciences, The Institute for Social Connection, The Community-based Research Centre, the GenWell Project, The Island Sexual Health Society, and the Mental Health and Climate Change Alliance.</span></em></p>Engaging in open and honest dialogue with the public to increase understanding of health inequities has never been more important.Kiffer George Card, Assistant Professor in Health Sciences, Simon Fraser UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1882802022-08-11T20:05:09Z2022-08-11T20:05:09ZWhy doesn’t monkeypox have a new name yet?<p>As monkeypox vaccination programs roll out and health authorities release information about how to reduce the spread of the virus, progress on another aspect of the outbreak is lagging: its name.</p>
<p>On June 14, the Director-General of the World Health Organization (WHO), Tedros Adhanom Ghebreyesus, <a href="https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-covid-19-media-briefing--14-june-2022">said</a> the agency was:</p>
<blockquote>
<p>working with partners and experts from around the world on changing the name of monkeypox virus, its clades and the disease it causes.</p>
</blockquote>
<p>This followed a <a href="https://virological.org/t/urgent-need-for-a-non-discriminatory-and-non-stigmatizing-nomenclature-for-monkeypox-virus/853">letter</a> signed by 29 scientists around the world calling for a non-discriminatory and non-stigmatising name for the virus.</p>
<p>More than eight weeks later, nothing has changed yet.</p>
<p>Since mid-May 2022, as of August 10, 31,425 cases of monkeypox have <a href="https://www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html">been reported</a> in 82 countries – including 66 in <a href="https://www.health.gov.au/health-alerts/monkeypox-mpx/about">Australia</a> – which historically haven’t reported cases of the virus. </p>
<p>During the same period, 375 cases have been reported in seven countries that have historically reported monkeypox. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/478629/original/file-20220811-4746-26kwy4.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/478629/original/file-20220811-4746-26kwy4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478629/original/file-20220811-4746-26kwy4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=322&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478629/original/file-20220811-4746-26kwy4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=322&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478629/original/file-20220811-4746-26kwy4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=322&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478629/original/file-20220811-4746-26kwy4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=404&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478629/original/file-20220811-4746-26kwy4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=404&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478629/original/file-20220811-4746-26kwy4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=404&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Confirmed monkeypox cases globally. Orange = has not historically reported monkeypox; blue = has historically reported monkeypox.</span>
<span class="attribution"><a class="source" href="https://www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html">CDC</a></span>
</figcaption>
</figure>
<p>While the focus has been on changing the name of monkeypox, it’s the names of the two main clades (organisms derived from a common ancestor) that are most geographically <a href="https://www.statnews.com/2022/06/11/monkeypox-virus-name-stigma/#:%7E:text=In%20a%20position%20paper%20published,the%20current%20names%20are%20discriminatory">discriminatory</a>. They are currently named the Congo Basin (or Central Africa) clade and the West Africa clade.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/monkeypox-in-australia-should-you-be-worried-and-who-can-get-the-vaccine-187917">Monkeypox in Australia: should you be worried? And who can get the vaccine?</a>
</strong>
</em>
</p>
<hr>
<h2>How is the name of a disease created?</h2>
<p>In 2015, the WHO, in consultation and collaboration with the World Organization for Animal Health and the Food and Agriculture Organization of the United Nations, <a href="https://www.who.int/publications/i/item/WHO-HSE-FOS-15.1">identified</a> best practices for the naming of new human diseases. These conclude:</p>
<ul>
<li><p>if the causative pathogen is known, it should be used as part of the disease name with additional descriptors; for example, <em>novel</em> coronavirus respiratory syndrome</p></li>
<li><p>names should be short (minimum number of characters) and easy to pronounce; for example, H7N9 </p></li>
<li><p>potential acronyms should be evaluated to ensure they also comply with these best practices </p></li>
<li><p>geographic locations, such as cities, countries, regions, and continents should be avoided; poor earlier examples include Murray Valley encephalitis and Spanish flu </p></li>
<li><p>people’s names (such as <a href="https://www.cdc.gov/parasites/chagas/gen_info/detailed.html#:%7E:text=Chagas%20disease%20is%20caused%20by,referred%20to%20as%20American%20trypanosomiasis.">Chagas disease</a>) and the names of species (such as swine flu and bird flu) should be avoided.</p></li>
</ul>
<p>Naming of the disease caused by SARS-CoV-2, COVID-19, did not include the name of the pathogen. But it did comply with the other criteria and, fortunately, was not called Wuhan disease or China virus.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/todays-disease-names-are-less-catchy-but-also-less-likely-to-cause-stigma-131465">Today's disease names are less catchy, but also less likely to cause stigma</a>
</strong>
</em>
</p>
<hr>
<h2>How is the name of a virus created?</h2>
<p>The WHO is not directly responsible for naming or renaming viruses, clades of viruses and the diseases those viruses cause. Naming virus species is the responsibility of the <a href="https://ictv.global/">International Committee on Taxonomy of Viruses</a>.</p>
<p>Monkeypox is a member of the <a href="https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/smallpox-and-other-orthopoxvirus-associated-infections">orthopoxvirus family</a> and related to smallpox, which was eradicated in 1979. Unlike other bugs, such as parasites like malaria (<em>Plasmodium falciparum</em>) and bacteria like “golden staph” (<em>Staphylococcus aureus)</em>, there is still <a href="https://link.springer.com/article/10.1007/s00705-019-04477-6">not a consistent system</a> of assigning binomial (two words) Latinised names to viruses. </p>
<p>A subcommittee of the International Committee on Taxonomy of Viruses is in the process of finalising a proposal for new binomial names for all the poxviruses, including monkeypox.</p>
<figure class="align-center ">
<img alt="3D visualisation of a monkeypox cell" src="https://images.theconversation.com/files/478657/original/file-20220811-26-wdm2i8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478657/original/file-20220811-26-wdm2i8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=311&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478657/original/file-20220811-26-wdm2i8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=311&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478657/original/file-20220811-26-wdm2i8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=311&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478657/original/file-20220811-26-wdm2i8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=391&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478657/original/file-20220811-26-wdm2i8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=391&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478657/original/file-20220811-26-wdm2i8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=391&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">We’re still waiting for the new binomial name for monkeypox.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/monkeypox-cell-infectious-disease-molecules-blood-2160385559">Shutterstock</a></span>
</figcaption>
</figure>
<p>Most viral conditions have <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it">different names</a> for the disease it causes and the virus itself. </p>
<p>In the case of the novel coronavirus causing the current pandemic, the short name of the disease is COVID-19, while the virus is named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). </p>
<h2>Why is it so hard to change the name of monkeypox virus?</h2>
<p>Monkeypox is not a <a href="https://www.smh.com.au/national/should-we-be-worried-about-the-spread-of-monkeypox-20220729-p5b5lu.html">new</a> virus; it was discovered in 1958. </p>
<p>While on the face of it, the name monkeypox does not seem stigmatising (other than to monkeys) some have <a href="https://theconversation.com/whats-in-a-name-why-giving-monkeypox-a-new-one-is-a-good-idea-185307">pointed out</a> that monkeys are rarely associated with the Western world, and this association with the global South could be seen as problematic. The word monkey has also been employed in racist slurs against people of colour.</p>
<p>Monkeypox is also a misnomer because monkeys <a href="https://theconversation.com/australia-secures-450-000-new-monkeypox-vaccines-what-are-they-and-who-can-have-them-187691">are not</a> its natural host, which is probably in rodents. The name of the virus was given because it was first identified in laboratory monkeys in Copenhagen.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australia-secures-450-000-new-monkeypox-vaccines-what-are-they-and-who-can-have-them-187691">Australia secures 450,000 new monkeypox vaccines. What are they and who can have them?</a>
</strong>
</em>
</p>
<hr>
<p>However, there is a problem with the names of the virus’s clades. The two main clades are named after West Africa and the Congo Basin, the latter causing <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">more severe illness</a>. This contravenes the WHO’s efforts to avoid naming viral diseases after countries or continents. </p>
<p>Unfortunately, many media outlets use photos of Africans, often children, with the tell-tale rash. This heightens perceptions that this is an “African disease” that has escaped to the Western world.</p>
<p>Despite the WHO naming criteria announced in 2015, the agency has been unable to change the name of the Middle East Respiratory Syndrome (MERS), caused by a camel coronavirus. In fact, one of the largest outbreaks of MERS was in <a href="https://www.who.int/westernpacific/emergencies/2015-mers-outbreak">South Korea</a>.</p>
<p>One of the main reasons given for not changing the name is that it could disconnect future researchers from research papers written over more than five decades. This seems a weak argument because it’s almost certain that future researchers will be aware of the original name.</p>
<p>Another challenge is that the name would need to be changed in the International Classification of Diseases (ICD) which is used around the world for medical billing and clinical epidemiology studies. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1557481401947127810"}"></div></p>
<p>There is an apparent consensus among virologists that the new name will be something like Orthopoxvirus monkeypox. “That’s certainly the majority proposal at this stage,” according to the chair of the poxvirus <a href="https://www.statnews.com/2022/08/01/the-campaign-to-rename-monkeypox-gets-complicated/">subcommittee</a> of the International Committee on Taxonomy of Viruses. </p>
<p>This is not much of a change and is inconsistent with WHO’s naming criteria. </p>
<p>There is, however, <a href="https://www.science.org/content/article/rename-monkeypox-remove-geographic-stigma-researchers-say">more optimism</a> the two clades could shed their geographic names to something like clades 1 and 2.</p>
<h2>Focus on prevention and control</h2>
<p>During the long process of changing its name, the prevention and control of monkeypox <a href="https://theconversation.com/monkeypox-in-australia-should-you-be-worried-and-who-can-get-the-vaccine-187917">remain the same</a>:</p>
<ul>
<li>surveillance</li>
<li>finding cases, isolation and contact tracing</li>
<li>behaviour change communication to reduce the number of sexual partners</li>
<li>vaccination of close contacts and treatment of severe illness with antiviral drugs.</li>
</ul>
<p>This needs close engagement with communities most affected by the virus – men who have sex with men. It’s crucial to <a href="https://theconversation.com/monkeypox-isnt-like-hiv-but-gay-and-bisexual-men-are-at-risk-of-unfair-stigma-183571">prevent stigma</a> and discrimination, not because of the name of the virus itself but those who are most vulnerable to infection.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/monkeypox-isnt-like-hiv-but-gay-and-bisexual-men-are-at-risk-of-unfair-stigma-183571">Monkeypox isn’t like HIV, but gay and bisexual men are at risk of unfair stigma</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/188280/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Toole receives funding from the National Health and Medical Research Council.</span></em></p>As monkeypox vaccination programs roll out and health authorities work to reduce the spread of the virus, progress is lagging on renaming it.Michael Toole, Associate Principal Research Fellow, Burnet InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1882952022-08-10T20:13:25Z2022-08-10T20:13:25ZWe need to talk about monkeypox without shame and blame<p>The recent global outbreak of <a href="https://www.health.gov.au/diseases/monkeypox-mpx">monkeypox</a> largely among <a href="https://www.npr.org/2022/07/26/1113713684/monkeypox-stigma-gay-community">men who have sex with men</a> has raised concerns homophobia will undermine effective prevention efforts. There are also fears the disease will fuel homophobic stigma and discrimination.</p>
<p>Even the name monkeypox <a href="https://theconversation.com/whats-in-a-name-why-giving-monkeypox-a-new-one-is-a-good-idea-185307">is stigmatising</a> due to long-held <a href="https://www.npr.org/sections/goatsandsoda/2022/08/01/1113908154/critics-say-monkeypox-is-a-racist-name-but-its-not-going-away-anytime-soon">racist appropriation of the term monkey</a> and the false implication the virus is transmitted by monkeys. </p>
<p>The <a href="https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-covid-19-media-briefing--14-june-2022">World Health Organization</a> has said the name needs to change, but has not agreed on or announced a new one. Currently, <a href="https://www.aconhealth.org.au/monkeypox">advocates for the LGBTQA+ community</a> are using the term MPX, the term I will use here. </p>
<p>MPX is, of course, not the first infectious disease to affect men who have sex with men. So there are things we must learn and things we must not repeat from the public health response to HIV. </p>
<h2>Lessons from HIV</h2>
<p>When HIV emerged among communities of gay and bisexual men in the 1980s, fear and uncertainty about the cause and nature of the virus led to <a href="https://theconversation.com/lessons-from-the-history-of-hiv-aids-in-australia-how-activism-changed-the-image-of-an-illness-4052">vilification of gay and bisexual men</a>. </p>
<p>HIV was initially named “<a href="https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2021.306348">gay-related immune deficiency</a>” or GRID and there was speculation it was caused by men’s excessive sex or drug use (specifically use of <a href="https://theconversation.com/weekly-dose-amyl-started-as-a-poison-antidote-now-a-common-party-drug-64610">amyl nitrate</a>). </p>
<p>As well as sparking calls for a crackdown on the rights and freedoms of LGBTQA+ communities, the view gay and bisexual men were to blame for HIV obstructed effective public health responses. </p>
<p>Famously, in the United States, then President Ronald Reagan <a href="https://www.nbcnews.com/feature/nbc-out/lgbtq-history-month-early-days-america-s-aids-crisis-n919701">made no public mention of HIV or AIDS</a> until more than 12,000 American citizens had died, and HIV had spread widely into many communities.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1555388887098220544"}"></div></p>
<p>Although today, globally, <a href="https://www.unaids.org/en/resources/fact-sheet">HIV affects more women</a> than men, it is still difficult to disentangle <a href="https://www.unaids.org/en/resources/presscentre/featurestories/2012/august/20120828punitivelaws">HIV-related stigma from homophobia</a> or stigma against other affected populations, including injecting drug users or sex workers. </p>
<p><a href="https://theconversation.com/charlie-sheen-and-ten-million-dollars-worth-of-hiv-stigma-50909">Stigma creates barriers</a> to HIV prevention as people are reluctant to talk about HIV or <a href="https://doi.org/10.1186/s12889-018-6156-4">seek testing</a> for fear of being associated with stigmatised groups. It also perpetuates a fundamental lack of empathy for people living with HIV.</p>
<p>For these reasons, it’s important we don’t approach MPX in these terms. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/whats-in-a-name-why-giving-monkeypox-a-new-one-is-a-good-idea-185307">What's in a name? Why giving monkeypox a new one is a good idea</a>
</strong>
</em>
</p>
<hr>
<h2>A new approach?</h2>
<p>There are <a href="https://www.latimes.com/california/story/2022-07-21/monkeypox-government-response-we-can-do-better">some reports</a> of MPX being used to justify homophobic sentiment or actions. However, a crucial difference between this disease and HIV is <a href="https://www.scientificamerican.com/article/blaming-gay-men-for-monkeypox-will-harm-everyone/">the world has learned</a> from HIV. </p>
<p>There is now better understanding of the insidious ways <a href="https://www.thelancet.com/journals/landia/article/PIIS2213-8587(20)30127-3/fulltext">stigma and discrimination undermine public health</a>. HIV also taught us to be cautious about the potential for public health messaging to contribute to stigma, especially when an illness is associated with <a href="https://www.nihr.ac.uk/blog/the-perfect-storm-how-covid-19-public-health-messages-may-not-serve-ethnic-minority-communities/30257">marginalised cultural or racial groups</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1556700872834514945"}"></div></p>
<p>Health policy makers have been <a href="https://www.theguardian.com/world/2022/may/23/un-denounces-homophobic-and-racist-reporting-on-monkeypox-spread">fast to condemn</a> stigmatising media reporting of MPX. Meanwhile the community-based HIV sector has mobilised existing infrastructure and experience to support <a href="https://www.acon.org.au/">advocacy and MPX education</a> for men who have sex with men. </p>
<p>Importantly, we now have better knowledge about the effectiveness of <a href="https://pubmed.ncbi.nlm.nih.gov/31210141/">sex-positive approaches</a> to preventing HIV and other sexually transmissible infections (STIs). <a href="https://doi.org/10.1080/26410397.2019.1593787">Such approaches</a> affirm the pleasures and benefits of sex, aim to build open dialogue about safe sex and ensure people can seek testing without fear of judgement or backlash.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/lessons-from-the-history-of-hiv-aids-in-australia-how-activism-changed-the-image-of-an-illness-4052">Lessons from the history of HIV/AIDS in Australia – how activism changed the image of an illness</a>
</strong>
</em>
</p>
<hr>
<h2>The impact of sexual moralising</h2>
<p>We have learned lessons from HIV. However, MPX has exposed the ways sexual moralising is ever-present in public health, undermining sex-positive health promotion. </p>
<p>Observers of early media responses to MPX note efforts to avoid stigmatising gay and bisexual men have <a href="https://www.theguardian.com/commentisfree/2022/jun/23/monkeypox-outbreak-public-information-virus-homophobia">led to obtuse and confusing reporting</a> about the ways in which the disease, <a href="https://theconversation.com/how-does-monkeypox-spread-an-epidemiologist-explains-why-it-isnt-an-sti-and-what-counts-as-close-contact-188130">although not classified as an STI</a>, can be spread through close physical contact and why gay and bisexual men may be at risk of exposure.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1556259227836055552"}"></div></p>
<p>Reporting has been deliberately vague because there is very limited cultural space for speaking about group sex, casual sex or sex with multiple partners without these practices, and people involved, <a href="https://www.nytimes.com/2022/08/04/opinion/monkeypox-communication.html">being shamed</a>. </p>
<p>Despite increasing acceptance of sexual diversity, people’s <a href="https://www.ippf.org/sites/default/files/2016-10/Putting%20Sexuality%20back%20into%20Comprehensive%20Sexuality%20Education_0.pdf">right to engage in pleasurable sex</a> outside a married, monogamous relationship is rarely affirmed. Young women, for example, are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8296320/">shamed</a> for having “too many” sexual partners, while calls for comprehensive, <a href="https://theconversation.com/sex-ed-needs-to-talk-about-pleasure-and-fun-safe-sex-depends-on-it-and-condom-use-rises-176572">pleasure-based sex education</a> are controversial. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/sex-ed-needs-to-talk-about-pleasure-and-fun-safe-sex-depends-on-it-and-condom-use-rises-176572">Sex ed needs to talk about pleasure and fun. Safe sex depends on it and condom use rises</a>
</strong>
</em>
</p>
<hr>
<p>While the world has come a long way toward acceptance of same-sex marriage, homophobia often drives condemnation of gay and bisexual men’s sexual cultures. </p>
<p>This is most visible in relation to public health. For example, when pre-exposure prophylaxis (PrEP) first became available to prevent HIV, public funding for it <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4566537">was critiqued</a> by some on the grounds this amounted to subsidising gay and bisexual men’s <a href="https://blogs.bmj.com/medical-ethics/2016/10/08/sex-and-other-sins-public-morality-public-health-and-funding-prep/">promiscuity</a>.</p>
<p>When considered through the lens of public health, casual sex is <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1467-9566.2012.01475.x">often equated with irresponsibility</a>. People’s right to seek sex and intimacy can also be devalued or <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6951379/">seen as irrelevant</a>. </p>
<p>We know, however, <a href="https://www.who.int/news/item/11-02-2022-redefining-sexual-health-for-benefits-throughout-life">acknowledging the significance</a> of sexual identities and sexual connection in people’s lives is the best way to engage communities in sexual health promotion.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/monkeypox-isnt-like-hiv-but-gay-and-bisexual-men-are-at-risk-of-unfair-stigma-183571">Monkeypox isn’t like HIV, but gay and bisexual men are at risk of unfair stigma</a>
</strong>
</em>
</p>
<hr>
<h2>A sex-positive approach</h2>
<p>As current vaccine supplies for MPX are limited in many jurisdictions, including Australia, <a href="https://theconversation.com/australia-secures-450-000-new-monkeypox-vaccines-what-are-they-and-who-can-have-them-187691">priority access is being given</a> to high-risk groups, including men who have sex with men who have multiple sexual partners. </p>
<p>Given men are being asked to disclose their sexual practices to obtain a vaccine, assurance of non-stigmatising health care will be essential for this program to be successful. </p>
<p>A sex-positive approach to MPX prevention will also support more open conversations so people can gain a better handle on risk and prevention, no matter who they are.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australia-secures-450-000-new-monkeypox-vaccines-what-are-they-and-who-can-have-them-187691">Australia secures 450,000 new monkeypox vaccines. What are they and who can have them?</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/188295/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer Power receives research funding from the Australian Research Council and the Australian Department of Health. </span></em></p>Some of the sexual moralising we saw with HIV is still with us. That makes it harder for men who have sex with men to come forward for vaccines and testing.Jennifer Power, Associate Professor and Principal Research Fellow at the Australian Research Centre in Sex, Health and Society, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1881302022-08-08T12:21:17Z2022-08-08T12:21:17ZHow does monkeypox spread? An epidemiologist explains why it isn’t an STI and what counts as close contact<figure><img src="https://images.theconversation.com/files/477915/original/file-20220805-32086-ju4jk8.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1024%2C654&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Vaccination can help reduce the risk of monkeypox infection.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/people-wait-in-line-to-recieve-the-monkeypox-vaccine-before-news-photo/1241959588">Kena Betancur/AFP via Getty Images</a></span></figcaption></figure><p>Monkeypox is caused by a virus that, despite periodic outbreaks, is <a href="https://doi.org/10.1080%2F14787210.2019.1567330">not thought to spread easily from person to person</a> and historically <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">has not spurred long chains of transmission within communities</a>. Now, many researchers are left scratching their heads as to why monkeypox seems to be propagating so readily and unconventionally in the current global outbreak.</p>
<p>The monkeypox virus typically spreads through <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON381">direct contact with respiratory secretions, such as mucus or saliva</a>, or <a href="https://news.un.org/en/story/2022/07/1123212">skin lesions</a>. Skin lesions traditionally appear soon after infection as a rash – small pimples or round papules on the face, hands or genitalia. These lesions may also appear inside the mouth, eyes and other parts of the body that produce mucus. They can last for several weeks and be a source of virus before they are fully healed. <a href="https://www.who.int/news-room/questions-and-answers/item/monkeypox">Other symptoms</a> usually include fever, swollen lymph nodes, fatigue and headache.</p>
<p>I am an <a href="https://public-health.tamu.edu/directory/fischer.html">epidemiologist</a> who studies emerging infectious diseases that cause <a href="https://theconversation.com/whats-the-difference-between-pandemic-epidemic-and-outbreak-133048">outbreaks, epidemics and pandemics</a>. Understanding what’s currently known about how monkeypox is transmitted and ways to protect yourself and others from infection can help reduce the spread of the virus.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/v2J7rXuOiuw?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The U.S. declared monkeypox a public health emergency on Aug. 4, 2022.</span></figcaption>
</figure>
<h2>How is this outbreak different from prior ones?</h2>
<p>The current monkeypox epidemic is a bit unusual in a few ways. </p>
<p>First, the sheer scope of the current epidemic, with <a href="https://worldhealthorg.shinyapps.io/mpx_global/">over 25,000 cases worldwide as of early August</a> and in countries where the virus has never appeared, sets it apart from previous outbreaks. Monkeypox is <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON390">endemic to specific areas in central and western Africa</a>, where cases occur sporadically and outbreaks are usually contained and quickly burn out. In the current outbreak, global spread has been rapid. Young men, mostly ages 18 to 44, account for the majority of cases, and over 97% identify as men who have sex with men (MSM). <a href="https://doi.org/10.2807/1560-7917.ES.2022.27.22.2200422">Some superspreading events</a> associated with air travel, international gatherings and multiple-partner sexual encounters contributed to early transmission of the virus.</p>
<p>Second, <a href="https://worldhealthorg.shinyapps.io/mpx_global/">the way symptoms are appearing</a> may facilitate spread among people who don’t yet know they are infected. <a href="https://doi.org/10.1111/bjd.21790">Most</a> <a href="https://doi.org/10.1136/bmj-2022-072410">patients</a> reported mild symptoms without fever or swollen lymph nodes, symptoms that typically appear before a skin rash is visible. While most people do develop skin lesions, many reported having only a single papule that was often obscured inside a mucosal area, such as inside the mouth, throat or rectum, making it easier to miss.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/Y9bjHNpqOro?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Monkeypox is not a new disease.</span></figcaption>
</figure>
<p>A number of people reported no symptoms at all. Asymptomatic infections are more likely to go undiagnosed and unreported than those with symptoms. But it is not yet known how asymptomatic individuals may be contributing to spread or how many asymptomatic cases may be undetected so far.</p>
<h2>Who is at risk of getting monkeypox?</h2>
<p>For <a href="https://www.nytimes.com/2022/08/03/well/live/monkeypox-risk.html">most people</a>, the risk of getting monkeypox is currently low. Anyone who has prolonged, close contact with an infected person is at risk, including partners, parents, children or siblings, among others. The most common settings for transmission are <a href="https://worldhealthorg.shinyapps.io/mpx_global/">within households or health care settings</a>.</p>
<p>Because of sustained transmission within the community of men who have sex with men, they are considered an <a href="https://www.washingtonpost.com/health/2022/07/27/monkeypox-gay-men-vaccine-treatment/">at-risk group</a>, and targeted recommendations can help allocate resources and limit transmission. While monkeypox is <a href="https://www.washingtonpost.com/health/2022/07/28/who-monkeypox-advice-men-sex/">spreading primarily among MSM</a>, this does not mean that the virus will remain confined to this group or that it won’t jump to other social networks. The virus itself has no regard for age, gender, ethnicity or sexual orientation. </p>
<p><a href="https://www.who.int/publications/m/item/monkeypox-public-health-advice-for-men-who-have-sex-with-men">Anyone</a> who comes into direct contact with the monkeypox virus is at risk of being infected. <a href="https://worldhealthorg.shinyapps.io/mpx_global/">New cases</a> are recorded daily, with additional countries and regions reporting their first cases and already affected countries observing a continued rise in infections. </p>
<p>As with most infections, <a href="https://www.nytimes.com/2022/08/03/well/live/monkeypox-risk.html">other factors</a>, such as the amount of viral exposure, type of contact and individual immune response, play a role in whether an infection takes hold.</p>
<h2>Is monkeypox an STI?</h2>
<p>While sexual encounters are currently the predominant mode of transmission among reported cases, monkeypox is <a href="https://www.healthline.com/health-news/monkeypox-is-not-a-sexually-transmitted-infection-what-experts-want-you-to-know">not a sexually transmitted infection</a>. STIs are spread primarily through sexual contact, while monkeypox can spread through any form of prolonged, close contact.</p>
<p>Close contact that transmits the monkeypox virus involves encounters that are typically more intimate or involved than having a casual conversation or standing next to someone in an elevator. Transmission requires exchange of mucosal fluids or direct contact with the virus in sufficient quantity to seed an infection. This could occur through physical contact during kissing or cuddling.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/477920/original/file-20220805-32086-wtyh4h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Electron microscope image of monkeypox particles" src="https://images.theconversation.com/files/477920/original/file-20220805-32086-wtyh4h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/477920/original/file-20220805-32086-wtyh4h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=515&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477920/original/file-20220805-32086-wtyh4h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=515&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477920/original/file-20220805-32086-wtyh4h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=515&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477920/original/file-20220805-32086-wtyh4h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=648&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477920/original/file-20220805-32086-wtyh4h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=648&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477920/original/file-20220805-32086-wtyh4h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=648&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This microscopy image shows monkeypox particles, colored red, within an infected cell, colored blue.</span>
<span class="attribution"><a class="source" href="https://flic.kr/p/2noh3om">NIAID/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Because sexual encounters involve direct skin-to-skin physical contact where bodily fluids may be exchanged, these close encounters can transmit viruses more easily. Recently, monkeypox DNA has been detected in feces and <a href="https://doi.org/10.1016/S1473-3099(22)00513-8">various body fluids</a>, including saliva, blood, semen and urine. But the presence of viral DNA does not necessarily mean that the virus can infect someone else. Transmission from these sources is still under investigation.</p>
<p>As the virus moves through populations, <a href="https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-covid-19-media-briefing--27-july-2022">public health officials</a> focus on getting the message out to the most at-risk and hardest hit communities about how to stay safe. Currently, breaking the transmission chain among sexual contacts is a priority, including but not limited to <a href="https://www.who.int/publications/m/item/monkeypox-public-health-advice-for-men-who-have-sex-with-men">MSM communities</a>. Targeted messaging is meant to protect the health of a specific group, <a href="https://www.npr.org/2022/07/26/1113713684/monkeypox-stigma-gay-community">not to stigmatize</a> the intended audience. </p>
<p>Other modes of transmission may play a greater role outside the MSM community. <a href="https://worldhealthorg.shinyapps.io/mpx_global/">Household transmission</a>, where individuals may come into close contact with infected people or contaminated items, is one of the most common types of exposure. Research is ongoing into the potential <a href="https://doi.org/10.1101/2022.07.21.22277864">airborne and respiratory droplet</a> spread of monkeypox in the current situation. </p>
<p>Outbreaks are <a href="https://doi.org/10.1016/S2589-7500(20)30268-5">dynamic situations that evolve over time</a>, which is why public health messages may change as the epidemic progresses. Not every outbreak looks or behaves the same way – even pathogens seen in previous outbreaks can be different the next time around. As researchers learn more about how the disease is transmitted and identify changes in patterns of spread, public health officials will provide updates about specific forms of contact, behaviors or other factors that could increase infection risk. While changing guidelines can be frustrating or confusing, keeping up to date with the latest recommendations can help you protect yourself and stay safe. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/477913/original/file-20220805-35557-qales6.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1024%2C683&q=45&auto=format&w=1000&fit=clip"><img alt="People lining up to get monkeypox vaccine" src="https://images.theconversation.com/files/477913/original/file-20220805-35557-qales6.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1024%2C683&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/477913/original/file-20220805-35557-qales6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477913/original/file-20220805-35557-qales6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477913/original/file-20220805-35557-qales6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477913/original/file-20220805-35557-qales6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477913/original/file-20220805-35557-qales6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477913/original/file-20220805-35557-qales6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Prioritizing at-risk groups to get vaccinated can help control the spread of the virus.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/healthcare-workers-with-new-york-city-department-of-health-news-photo/1411672704">Spencer Platt/Getty Images News via Getty Images</a></span>
</figcaption>
</figure>
<h2>What do I do if I’ve been exposed to monkeypox?</h2>
<p>Anyone who has been infected can help contain spread by isolating from others, including pets. Covering skin lesions, wearing a mask in shared spaces and decontaminating shared surfaces or items, such as bed linens, dishes, clothes or towels, can also reduce spread. </p>
<p>You can also help interrupt the transmission chain by participating in <a href="https://www.who.int/publications/i/item/WHO-MPX-Surveillance-2022.2">contact tracing</a>, notifying public health officials of others who may have been exposed through you, which is a basic tenet and common practice of disease control.</p>
<p>The Centers for Disease Control and Prevention has further guidance on how to control monkeypox spread in both <a href="https://www.cdc.gov/poxvirus/monkeypox/clinicians/infection-control-home.html">household settings</a> and <a href="https://www.cdc.gov/poxvirus/monkeypox/specific-settings/congregate.html">shared living facilities</a>.</p>
<p>Lastly, <a href="https://www.cdc.gov/poxvirus/monkeypox/considerations-for-monkeypox-vaccination.html">getting vaccinated</a> as soon as possible can still protect you from severe illness even if you’ve already been infected.</p><img src="https://counter.theconversation.com/content/188130/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rebecca S.B. Fischer receives funding from Fogarty International Center at the National Institutes of Health (K01TW010863)</span></em></p>While the majority of monkeypox cases thus far have been recorded among men who have sex with men, everyone is still at risk of contracting the disease.Rebecca S.B. Fischer, Assistant Professor of Epidemiology, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1878822022-08-02T16:23:22Z2022-08-02T16:23:22ZMonkeypox: an expert explains what gay and bisexual men need to know<figure><img src="https://images.theconversation.com/files/477132/original/file-20220802-25-xbeprm.jpg?ixlib=rb-1.1.0&rect=70%2C0%2C7800%2C5184&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Monkeypox is from the same virus family as smallpox.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/monkeypox-virus-3d-illustration-zoonotic-poxviridae-2164832913">Kateryna Kon/ Shutterstock</a></span></figcaption></figure><p>Since early May, more than <a href="https://www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html">23,000 cases of monkeypox</a> have been reported worldwide. This is the <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2207323">largest ever global outbreak</a> of the disease.</p>
<p>Cases have now been reported in 78 countries including the UK, Spain, Germany, France, the US and Brazil. Given the scale of the outbreak, the World Health Organization (WHO) has now declared the <a href="https://theconversation.com/monkeypox-world-health-organization-declares-it-a-global-health-emergency-heres-what-that-means-186518">current monkeypox epidemic</a> a global health emergency. </p>
<p>While anyone can get monkeypox, the current outbreak is overwhelmingly affecting sexually active gay, bisexual and other men who have sex with men. In fact, our recent study which looked at 528 monkeypox infections since the start of the outbreak found that <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2207323">98% of these infections</a> had occurred in this group. Here’s what these men need to know.</p>
<h2>How it spreads</h2>
<p>Monkeypox is a disease caused by infection with the human monkeypox virus, which comes from the same virus family as smallpox. In fact, symptoms are quite similar to smallpox and include fever, headache, muscle aches, chills, cold symptoms (such as a cough or sore throat). </p>
<p>Symptoms are also accompanied by a rash that appears in blisters on the face, genitals, the chest and back, and on the hands and feet. Some people also experience very painful sores in the mouth or inside the bottom. For most people, the disease usually resolves within two to three weeks. </p>
<p>Monkeypox spreads through close physical contact with an infected person. Typically this means skin-to-skin contact, especially contact with the rashes and skin lesions caused by the disease. But it can also be spread through large respiratory droplets (such as coughing and sneezing). </p>
<p>It can also spread through contact with bed sheets, towels or other fabrics that have come in contact with the infected person’s sores. We know that the virus can persist on surfaces for a long time – sometimes <a href="https://www.cdc.gov/poxvirus/monkeypox/specific-settings/home-disinfection.html">up to several weeks</a>.</p>
<p>According to our study, 95% of monkeypox infections so far were spread as a result of sexual contact. Around 95% of the people in our study had a rash, mostly occurring on the genitals. Approximately 41% had sores inside the body (including in the anus or mouth). </p>
<p>Our research also revealed that the monkeypox virus was found in more than 90% of the semen samples we tested. However, we don’t yet know whether the virus is infectious in semen.</p>
<p>All this may explain why the virus is primarily spreading through networks of men who have sex with men. </p>
<figure class="align-center ">
<img alt="A young man receives a vaccine from a healthcare worker. The worker is wearing white surgical gloves to administer the needle." src="https://images.theconversation.com/files/477133/original/file-20220802-4813-vg681r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/477133/original/file-20220802-4813-vg681r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477133/original/file-20220802-4813-vg681r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477133/original/file-20220802-4813-vg681r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477133/original/file-20220802-4813-vg681r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477133/original/file-20220802-4813-vg681r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477133/original/file-20220802-4813-vg681r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Many countries are now offering this at-risk groups vaccines to protect them.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-man-receiving-injection-medical-assistant-650761495">Africa Studio/ Shutterstock</a></span>
</figcaption>
</figure>
<p>It’s worth stressing the virus can spread through any contact with lesions or large respiratory droplets from an infected person. This means that it can spread in households through any close personal contact with an infected person – not just as a result of sexual intimacy. However, during the current outbreak, our study suggests that this kind of non-sexual transmission has so far occurred very rarely, in less than 1% of cases.</p>
<h2>Providing protection</h2>
<p>Many countries are offering vaccinations to sexually active gay and bisexual men who are at greatest risk of contracting the disease. Used prior to exposure, research suggests the vaccine can provide around <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1083791/Recommendations-for-pre-and-post-exposure-vaccination-during-a-monkeypox-incident-17-june-2022.pdf">85% protection from infection</a>. If given between four and 14 days after exposure to monkeypox, the vaccine may potentially <a href="https://www.cdc.gov/poxvirus/monkeypox/considerations-for-monkeypox-vaccination.html">reduce symptoms of the disease</a>.</p>
<p>The WHO has also recommended that at-risk groups limit <a href="https://www.theguardian.com/world/2022/jul/27/monkeypox-who-chief-advises-at-risk-men-reduce-number-sexual-partners">how many sexual partners they have</a> and take steps to protect themselves from contact. However, recommending abstinence really doesn’t go far enough, especially given we already have a vaccine which can prevent monkeypox. This is why getting vaccinated (and making sure that everyone has equal access to these vaccines) is of such great importance. </p>
<p>Given that the epidemic at this time is affecting almost exclusively men who have sex with men, directing accurate and relevant public health messages and working together with the community to develop acceptable interventions is what’s needed to help prevent harm and further spread.</p>
<p>One of the difficulties is that gay and bisexual men represent a marginalised community that has already faced stigmatisation and discrimination, particularly during the HIV/Aids pandemic. Nobody wants to repeat that.</p>
<p>But public health messages are most effective when targeted at people who are most at risk of a <a href="https://www.who.int/news-room/questions-and-answers/item/monkeypox?gclid=Cj0KCQjw852XBhC6ARIsAJsFPN0mI30C8Zwoh6y9tnQuRusGAHI9ZCsiEZ1HhJTBOVDn79Y3t5DTiXoaAniQEALw_wcB">particular condition</a>. Some even argue that messaging <a href="https://www.nbcnews.com/nbc-out/out-health-and-wellness/lesions-headaches-debilitating-pain-gay-men-monkeypox-share-stories-rcna36789">hasn’t been targeted enough</a> during this outbreak.</p>
<p>Although public health agencies such as the WHO, CDC, ECDC and <a href="https://ukhsa.blog.gov.uk/2022/05/24/information-on-monkeypox-and-our-investigation-into-recent-cases/">UKHSA</a> have already done a lot to provide clear, non-stigmatising guidance to at-risk groups, it may be important ensure this information is now disseminated in places where they will have the greatest impact – such as on dating apps, for example.</p>
<p>There’s a small window to contain the spread of monkeypox – and it may have already closed. There are already reports of infections in both <a href="https://www.gov.uk/government/publications/monkeypox-outbreak-epidemiological-overview/monkeypox-outbreak-epidemiological-overview-29-july-2022">women</a> and <a href="https://www.bloomberg.com/news/articles/2022-07-29/as-monkeypox-spreads-kids-can-get-monkeypox-too">children</a>. But the fact that the disease still seems to primarily be occurring in one group means that, with the right interventions, the course of the outbreak could still be changed and that group protected. </p>
<p>The most important thing now is ensuring all countries have equal access to vaccines and treatment to protect against the further spread of infections. The declaration of a worldwide pandemic by the WHO will hopefully serve to co-ordinate the global response and open up the possibility of mass production of several vaccines with access for all. The question is whether it will be fast enough.</p><img src="https://counter.theconversation.com/content/187882/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chloe Orkin receives funding from Gilead Sciences, Viiv Healthcare, Astra Zeneca, Merck Sharpe and Dohme and Janssen for advisory boards, lectureships, travel scholarships and I have also received research grants from the same companies to my institution. </span></em></p>How it spreads and how to protect yourself.Chloe Orkin, Chair Professor of HIV Medicine, Queen Mary University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1879172022-08-02T03:00:00Z2022-08-02T03:00:00ZMonkeypox in Australia: should you be worried? And who can get the vaccine?<p>On July 23, World Health Organisation Director-General Tedros Adhanom Ghebreyesus took the unprecedented step and <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01419-2/fulltext">declared</a> the monkeypox outbreak a “public health emergency of international concern” – the highest global alert level for a disease outbreak. </p>
<p>Following this and with <a href="https://www.health.gov.au/health-alerts/monkeypox-mpx/about#current-status">45 cases in Australia</a>, Chief Medical Officer Paul Kelly <a href="https://www1.racgp.org.au/newsgp/clinical/monkeypox-now-a-disease-of-national-significance?feed=RACGPnewsGPArticles">declared</a> last week that monkeypox is now a “communicable disease incident of national significance”.</p>
<p>So what is monkeypox? And who’s eligible for a vaccine?</p>
<p>Most cases in the current global outbreak are occurring among men who have sex with men. How can this group and others who are at risk protect themselves?</p>
<h2>What is monkeypox?</h2>
<p>Monkeypox <a href="https://news.un.org/en/story/2022/07/1123212">is not a new disease</a>, it was found in the late 1950s in lab primates in Denmark, and was first diagnosed in humans in an infant in the 1970s in the Democratic Republic of Congo.</p>
<p>In the past, monkeypox has mainly been <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">transmitted</a> from infected animals to humans (it is a zoonotic disease), and has been endemic to West and Central Africa. Transmission can occur through contact with infected animals including rodents, mice, rats, squirrels, monkeys and other primates.</p>
<p>But in this outbreak we’re seeing human-to-human transmission.</p>
<p>There are two distinct <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">strains</a> of monkeypox. These are the Central African and the West African types, the latter of which is believed to be one linked to the current global outbreak.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1527568824752828416"}"></div></p>
<p>According to US Centers for Disease Control and Prevention (CDC) data, 23,620 cases have been <a href="https://www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html">reported</a> since May in 80 countries, with 73 countries that had no previous reported monkeypox cases. </p>
<p>There have been at least <a href="https://www.smh.com.au/world/south-america/first-monkeypox-deaths-recorded-outside-africa-in-brazil-and-spain-20220730-p5b5vf.html">seven deaths</a>. </p>
<p>Most of the cases in Australia have been in New South Wales and Victoria, among returned travellers and men who have sex with men, and in the age group 21-40 years.</p>
<p>The <a href="https://www.abc.net.au/news/2022-07-28/monkey-pox-declared-a-disease-of-significance-australia/101277158">declaration</a> that monkeypox is now a disease of national significance means the outbreak requires national policies, interventions and public health messaging, with the deployment of more <a href="https://www.health.gov.au/news/chief-medical-officers-statement-declaring-monkeypox-a-communicable-disease-incident-of-national-significance">resources</a> to assist affected areas and groups most at risk.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1551165925319114753"}"></div></p>
<h2>Symptoms and transmission</h2>
<p>The incubation period – the time taken to develop the disease after exposure to the virus – is usually around <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">6-13 days</a>.</p>
<p>Transmission generally requires <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">close contact</a> with an infected person. It can be transmitted via respiratory droplets.</p>
<p>It can also be transmitted through direct contact with body fluids or the rash (“lesions”), often through skin-on-skin contact, or indirect contact such as through contaminated clothing or bedding.</p>
<p>Transmission <a href="https://www.bmj.com/content/bmj/378/bmj-2022-072410.full.pdf">may occur</a> from people without symptoms, or with barely-detectable symptoms.</p>
<p><a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">Symptoms</a> are similar to smallpox, though less severe. They can include:</p>
<ul>
<li>fever</li>
<li>headache</li>
<li>aches</li>
<li>fatigue</li>
<li>sweats and chills</li>
<li>cough and sore throat</li>
<li>a rash that can look like blisters or pimples, which can be painful. These “lesions” typically go through several stages before eventually falling off.</li>
</ul>
<p>The CDC <a href="https://www.cdc.gov/poxvirus/monkeypox/symptoms.html">says</a> most people who get the virus will develop the rash.</p>
<p>A <a href="https://www.bmj.com/content/378/bmj-2022-072410">study</a> in the British Medical Journal published last week also found 88% of 197 people with monkeypox in London had lesions on their genitals or anus. </p>
<p>Symptoms generally last between two and four weeks, and the disease usually resolves on its own. Most adults with a healthy immune system <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">won’t have severe illness</a> and won’t experience long-term harmful effects.</p>
<p>There’s no specific treatment for monkeypox yet. People with the infection should be given supportive treatment and light dressings on the rash, depending on the symptoms. Antivirals such as “tecovirimat” have been made available to patients in some countries who have or are at high risk of severe disease, such as being <a href="https://www.cdc.gov/poxvirus/monkeypox/treatment.html">immunocompromised</a>.</p>
<p>People with the infection should <a href="https://www.cdc.gov/poxvirus/monkeypox/clinicians/isolation-procedures.html">isolate</a> immediately for the duration of the illness – usually two to four weeks, until the lesions heal. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1548083891419746305"}"></div></p>
<h2>Higher risk groups</h2>
<p>Monkeypox can affect anyone. But men who have sex with men are at higher risk at the moment. WHO Director-General Tedros Adhanom Ghebreyesus <a href="https://twitter.com/DrTedros/status/1552382934300200960">said</a> 98% of cases so far are among men who have sex with men. </p>
<p>It’s important we provide as much information about the virus as possible, and it’s absolutely crucial we do this in a way that is not stigmatising.</p>
<p>This outbreak is seeing cases spread via close prolonged contact from sexual activity in the LGBTIQ+ group. Many from this group want to take proactive actions to help their community.</p>
<p>Specific actions governments can take <a href="https://cdc.gov/poxvirus/monkeypox/sexualhealth/index.html">include</a>: </p>
<ul>
<li>prioritising vaccines as a matter of urgency for those most at risk</li>
<li>targeting public health messaging so the LGBTIQ+ community can make informed decisions.</li>
</ul>
<p>Actions individuals can take include:</p>
<ul>
<li>maintaining contact details of sexual partners in case of need to follow up </li>
<li>avoiding sex if you have a rash until you get tested </li>
<li>considering avoiding skin to skin contact during large gatherings</li>
<li>if diagnosed with monkeypox, <a href="https://www.cdc.giov/ngpoxvirus/monkeypox/clinicians/isolation-procedures.html">avoiding</a> close physical contact, including sexual contact, with other people for the duration of the illness.</li>
</ul>
<p>The CDC says condoms <a href="https://www.cdc.gov/poxvirus/monkeypox/sexualhealth/index.html">may help</a> lower the risk of spread if the lesions are confined to the genital and/or anal region, but they’re likely not enough to prevent transmission on their own.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/monkeypox-this-is-an-entirely-new-spread-of-the-disease-184085">Monkeypox: ‘This is an entirely new spread of the disease’</a>
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</em>
</p>
<hr>
<h2>Who should have the vaccine?</h2>
<p>Australia has secured small supplies of two smallpox vaccines, which provide protection against monkeypox.</p>
<p>The vaccine advisory body, the Australian Technical Advisory Group on Immunisation (ATAGI), has recommended key risk groups be administered the vaccines. They <a href="https://www1.racgp.org.au/newsgp/clinical/monkeypox-now-a-disease-of-national-significance">include</a>: </p>
<ul>
<li>those identified as a high risk monkeypox contact in the past 14 days</li>
<li>men who have sex with men who are at high risk of exposure. This includes those living with HIV, or with a recent history of a high number of sexual partners or group sex</li>
<li>sex workers, with clients in high-risk categories</li>
<li>and anyone in the risk categories planning travel to a country experiencing a significant outbreak, with vaccination recommended four to six weeks prior to leaving.</li>
</ul>
<p>ATAGI has <a href="https://www.health.gov.au/sites/default/files/documents/2022/08/atagi-clinical-guidance-on-vaccination-against-monkeypox-atagi-clinical-guidance-on-vaccination-against-monkeypox_0.pdf">stated</a> that vaccination within four days of exposure to someone who’s infectious with monkeypox will provide the highest chance of preventing disease.</p>
<p>Avoiding close contact with people who have the infection can help prevent transmission. Monkeypox doesn’t spread as easily as the coronavirus and can be kept under control if we are cautious.</p>
<h2>The need for vaccine equity and global health leadership</h2>
<p>We can’t repeat the “vaccine nationalism” we’ve seen during COVID with rich countries hoarding vaccine doses, as this will unjustly prolong the outbreak.</p>
<p>Currently, <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01419-2/fulltext">according</a> to The Lancet medical journal, a smallpox vaccine sold as “Jynneos” in the US costs around US$100 a dose. The WHO has <a href="https://www.who.int/news/item/23-07-2022-second-meeting-of-the-international-health-regulations-(2005)-(ihr)-emergency-committee-regarding-the-multi-country-outbreak-of-monkeypox">called on</a> countries and manufacturers to ensure the vaccines, as well as diagnostics and therapeutics, are made available “at reasonable cost” where most needed.</p>
<p>Thus we have major political and policy challenges ahead and will need strong global health leadership going forward.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-vaccine-nationalism-could-doom-plan-for-global-access-to-a-covid-19-vaccine-145056">Why 'vaccine nationalism' could doom plan for global access to a COVID-19 vaccine</a>
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</em>
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<img src="https://counter.theconversation.com/content/187917/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jaya Dantas is Professor of International Health in the Curtin School of Population Health where she teaches a core unit in the Masters in Public Health and Master of Sexology course and leads a program of research in refugee and migrant health. She is currently lead CI on grants funded by Healthway and CI on a DISER grant. Jaya is the International Health SIG Convenor of the Public Health Association of Australia, has been appointed to the Global Gender Equality in Health Leadership Committee of Women in Global Health, Australia and is on the Editorial Advisory Group of the Medical Journal of Australia. She has lived experience of infectious diseases in India and Africa.</span></em></p>Most cases in the current global outbreak are occurring among men who have sex with men. So how can this group and others who are at risk protect themselves?Jaya Dantas, Deputy Chair, Academic Board; Dean International, Faculty of Health Sciences and Professor of International Health, Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1707942021-12-02T13:43:56Z2021-12-02T13:43:56ZUse of HIV prevention treatments is very low among Southern Black gay men<figure><img src="https://images.theconversation.com/files/431188/original/file-20211109-21-cgzyrl.jpg?ixlib=rb-1.1.0&rect=18%2C18%2C5988%2C3989&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Black men who have sex with men in Southern states have a low rate of using HIV prevention treatments.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/selective-focus-of-medicine-being-in-hands-of-a-royalty-free-image/698025480?adppopup=true"> yacobchuk/iStock/Getty Images Plus via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p>
<h2>The big idea</h2>
<p>Use of antiretroviral treatments to prevent HIV infection – called pre-exposure prophylaxis or PrEP – is very low among high-risk populations with poor access to HIV care, especially Black men in the South who have sex with men. That’s the main finding of <a href="https://doi.org/10.3390/ijerph18189715">our new study</a>, which suggests public health officials will need to do more outreach to this population if they hope to end the HIV pandemic by 2030. </p>
<p>The U.S. Food and Drug Administration has approved the use of two oral medications for PrEP, <a href="https://www.cdc.gov/hiv/pdf/prep_gl_patient_factsheet_truvada_english.pdf">Truvada</a> and <a href="https://www.cdc.gov/hiv/clinicians/prevention/prep.html">Descovy</a>, to prevent HIV in high-risk populations – for example, people whose sexual partner is HIV-positive. Both medications are clinically indicated for use among gay men. </p>
<p>The widespread adoption of these treatments is a crucial component of the United States strategy <a href="https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview">for ending the domestic HIV epidemic by 2030</a>. Multiple clinical trials have proved that these treatments are safe and highly effective at protecting people from becoming HIV-positive if used appropriately. </p>
<p>According to the U.S. Centers for Disease Control and Prevention, PrEP lowers the risk of contracting HIV from sex <a href="https://www.cdc.gov/hiv/risk/prep/index.html">by around 99%</a>. </p>
<p><a href="https://doi.org/10.3390/ijerph18189715">Our study</a> found several barriers to PrEP use among Southern Black gay men. They include stigma, homophobia, poverty, access and transportation issues, distrust of the medical system, negative attitudes from health care providers and misinformation about PrEP. </p>
<p>Our review and findings were based on assessment of existing research and data on this population. This includes epidemiological data from organizations such as the CDC.</p>
<p>We concluded that programs need to be structured in ways that effectively address the varied concerns and different barriers to care that these men experience, as well as encouraging more PrEP use among these men. </p>
<h2>Why it matters</h2>
<p>The <a href="https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview">national plan for ending the HIV epidemic by 2030</a> prioritizes widening PrEP use. Six of the seven states identified as key to the plan’s success are in the South. </p>
<p>According to the recent <a href="https://www.cdc.gov/hiv/statistics/overview/ataglance.html">CDC HIV Surveillance Report</a>, the South accounts for more than half of all new HIV diagnoses in the U.S. Men who had sex with men comprised 69% of the new national HIV diagnoses, with the rate higher among Black gay men. </p>
<p><a href="https://doi.org/10.1016/j.annepidem.2017.02.003">Another CDC study</a> shows that half of Black gay men in the U.S will be diagnosed with HIV in their lifetime. </p>
<p>Almost all insurers <a href="https://theconversation.com/hiv-prevention-pill-prep-is-now-free-under-most-insurance-plans-but-the-latest-challenge-to-the-affordable-care-act-puts-this-benefit-at-risk-171086">must cover 100%</a> of PrEP treatment, which is designated a required preventive treatment under the Affordable Care Act. Nonetheless, the nationwide HIV infection rate among Black and Latino gay and bisexual men <a href="https://www.statnews.com/2021/11/30/despite-interventions-black-and-hispanic-men-are-contracting-hiv-at-the-same-rates-as-10-years-ago/?utm_source=STAT+Newsletters&utm_campaign=82c89e62ff-MR_COPY_01&utm_medium=email&utm_term=0_8cab1d7961-82c89e62ff-153726530">has remained the same for the past 10 years</a>, according to the CDC.</p>
<p>These facts point to the need for rigorous research and PrEP promotion and awareness among these Black men and other underserved populations.</p>
<h2>What still isn’t known</h2>
<p>CDC <a href="https://doi.org/10.1016/j.annepidem.2018.05.003">surveillance data from 2015</a> reveals that of an estimated 1.1 million adults who would benefit from PrEP use, 71% were gay men. However, there are no publicly available or coordinated statewide or regional data measuring PrEP uptake among eligible adults. </p>
<p>This is particularly true in the Southern states that are <a href="https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-supplemental-report-vol-25-1.pdf">disproportionately affected</a> by the HIV epidemic. </p>
<p><a href="https://doi.org/10.3390/ijerph18189715">In our review</a>, we also observed a lack of interdisciplinary scientific research exploring the complex interactions between the many barriers to sexual health care by <a href="https://www.statnews.com/2021/11/30/despite-interventions-black-and-hispanic-men-are-contracting-hiv-at-the-same-rates-as-10-years-ago/?utm_source=STAT+Newsletters&utm_campaign=82c89e62ff-MR_COPY_01&utm_medium=email&utm_term=0_8cab1d7961-82c89e62ff-153726530">Southern Black gay men</a>. </p>
<h2>What’s next</h2>
<p>To dig deeper into issues identified in our review, we hope to gather data on PrEP use among Black gay men in South Carolina, where we are based, and other Southern states. </p>
<p>Our long-term goal is to collaborate with these men to develop, implement and evaluate culturally acceptable HIV prevention interventions to reduce HIV incidence in the community.</p>
<p>[<em>Too busy to read another daily email?</em> <a href="https://memberservices.theconversation.com/newsletters/?source=inline-toobusy">Get one of The Conversation’s curated weekly newsletters</a>.]</p><img src="https://counter.theconversation.com/content/170794/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Oluwafemi Atanda Adeagbo receives funding from the University of South Carolina Advanced Support Program
for Innovative Research Excellence-I (ASPIRE–Grant no: 115400-21-56809).</span></em></p><p class="fine-print"><em><span>Xiaoming Li receives funding from National Institutes of Health</span></em></p>This finding suggests public health efforts will have to address the treatment barriers these men face – like poverty or homophobia – to meet the nation’s goal of ending the HIV epidemic by 2030.Oluwafemi Atanda Adeagbo, Research fellow, University of South CarolinaXiaoming Li, Professor of Health Promotion, Education and Behavior, University of South CarolinaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1725152021-11-28T09:08:44Z2021-11-28T09:08:44ZThe people most at risk of HIV in Kenya aren’t using preventive drugs: we asked why<figure><img src="https://images.theconversation.com/files/433692/original/file-20211124-19-1tp8spg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">GettyImages</span> <span class="attribution"><span class="source"> Brent Stirton/Getty Images for the GBC</span></span></figcaption></figure><p>There has been a <a href="https://phia.icap.columbia.edu/wp-content/uploads/2020/04/KENPHIA-2018_Preliminary-Report_final-web.pdf">gradual decline</a> of new HIV cases overall in Kenya – from a high of <a href="https://aidsinfo.unaids.org/">230,000</a> new infections in 1992 to 33,000 in 2020. But there are particular population groups that are at higher risk of contracting HIV than the general population. In these groups, new HIV cases remain unacceptably high. </p>
<p>This is especially true among gender and sexual orientation minorities, including men who have sex with men and transgender women. Transgender women – individuals assigned male gender at birth, but who currently identify as female – have been documented to have the <a href="https://pubmed.ncbi.nlm.nih.gov/23260128/">highest risk</a> for HIV infection globally.</p>
<p>Data from sub-Saharan Africa on transgender women remain limited. But recent findings from <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6563853/">Kenya</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527771/">Nigeria</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/33000918/">South Africa</a> provide corroborating evidence of increased risk of HIV infection in transgender women.</p>
<p>The increased risk for HIV infection in transgender women is <a href="https://pubmed.ncbi.nlm.nih.gov/24322537/">driven</a> by a combination of factors. The mismatch between their current identity and government issued documents makes transgender women more likely to be unemployed, engage in sex work, and face violence from clients or even law enforcement. </p>
<p>Additionally, receptive anal sex has previously been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3929859/">shown</a> to be an independent predictor of HIV acquisition. Stigma and criminalisation of same-sex relationships makes it difficult for either transgender women or men who have sex with men to seek preventive services in public healthcare facilities. This further <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3929859/">compounds</a> their risk for <a href="https://pubmed.ncbi.nlm.nih.gov/23260128/">infection with HIV</a>.</p>
<p>Since 2017, the Health ministry in Kenya has been promoting use of pre-exposure prophylaxis (<a href="https://www.cdc.gov/hiv/basics/prep/about-prep.html">PrEP</a>) as part of HIV prevention efforts. These preventive medicines are recommended for use in both the general populations and those at increased <a href="https://www.who.int/news-room/fact-sheets/detail/hiv-aids">risk</a> for HIV acquisition. Transgender women and men who have sex with men would be ideal candidates for PrEP use.</p>
<p>However, <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0244226">recent data</a> from Kenya demonstrated subdued uptake and adherence to PrEP in men who have sex with men. Additionally, <a href="https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30285-6/fulltext">retention in PrEP</a> care for those who take it up is reduced with high rates of loss to follow-up.</p>
<p>In our <a href="https://pubmed.ncbi.nlm.nih.gov/33465090/">recent study</a>, my colleagues and I set out to explore the opinions of healthcare providers, leadership of community-based organisations and current PrEP users. We wanted to find out what they thought about Kenya’s PrEP programme. We sought to understand the perceived or experienced barriers to joining and staying on PrEP programmes. We were also interested in their views on how to improve PrEP provision.</p>
<h2>What we did</h2>
<p>Data were collected between February 2018 and April 2019 in coastal Kenya. Healthcare providers working in an HIV clinic at a public hospital were invited to participate in two focus group discussions, at the start of PrEP rollout at the facility and again a year later. The leaders of community-based organisations that have programmes for either men who have sex with men or transgender women were invited to separate focus group discussions. Finally, we invited transgender women and men who have sex with men to in-depth interviews. They were either currently on PrEP or had defaulted. </p>
<p>The discussions and interviews explored for PrEP knowledge, perceived or actual challenges to PrEP uptake and retention in care, and how to improve PrEP programming. Data from all three sources were used to paint a complete picture of the PrEP provision landscape in Kenya.</p>
<h2>What we found</h2>
<p>Four major themes emerged out of the analysis. </p>
<p>First, healthcare providers admitted to feeling ill-prepared for the massive PrEP roll-out in Kenya. They felt bombarded with targets without enough training or consideration of the increased workload. A year later they seemed less combative, but more passive about PrEP programming. Rather than proactively driving demand, they preferred that potential users present themselves to the facility and ask for PrEP. One said,</p>
<blockquote>
<p>While the research may have been done and it showed that PrEP works, we are lacking follow-up systems … I feel like we were not ready for the implementation.</p>
</blockquote>
<p>Second, we found differences in motivation for PrEP uptake between men who have sex with men and transgender women. Transgender women seemed to be strongly motivated by recognition of their increased risk for HIV infection and desire to remain HIV negative. A transgender woman said,</p>
<blockquote>
<p>I wish to remain HIV negative. I know that being a trans is putting me at risk for HIV. So, when I heard that PrEP was available here (hospital), I was among the first to ask for it.</p>
</blockquote>
<p>For men who have sex with men, the motivation to use PrEP was to facilitate condomless sex. One of the men remarked:</p>
<blockquote>
<p>… before I knew about PrEP, I had two partners. When I started using PrEP, I added two more (partners), as I felt protected (by PrEP). Now I have four partners. </p>
</blockquote>
<p>Third, healthcare providers did not consider transgender women to be at any increased risk for HIV infection. And they did not understand a need to give transgender women additional attention. This was reflected in the view of one healthcare provide:</p>
<blockquote>
<p>… they (transgender women) are just at the same level as anybody else exposed to HIV … They are not at a very high risk of acquiring HIV. </p>
</blockquote>
<p>Fourth, all respondents seemed to agree that the public hospital was not an ideal venue for PrEP provision. A leader of one community-based organisation felt PrEP uptake and retention would be better if there were additional incentives.</p>
<blockquote>
<p>There are some specific needs like those hormones, therapy, legal, because it is very expensive … that can be a plus for us.</p>
</blockquote>
<h2>Recommendations</h2>
<p>PrEP is available. But access continues to be limited. The limited access is due to a combination of healthcare provider attitudes and the sentiment among men who have sex with men and transgender women who feel unwelcome in public health facilities. There is an urgent need for alternative PrEP dispensing environments. These must be spaces where men who have sex with men and transgender women can feel free to access comprehensive HIV prevention services. </p>
<p>Healthcare providers need to be trained to accommodate the needs of these populations. Programming guidelines must recognise transgender women as an at-risk population.</p>
<p>Working with community-based organisations may help create tailor-made solutions that are available to the populations that most need them.</p><img src="https://counter.theconversation.com/content/172515/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Makobu Kimani is a SANTHE (Sub-Saharan African Network for TB/HIV Research Excellence) Fellow.</span></em></p>Stigma and criminalisation of same-sex relationships makes it difficult for transgender women and men who have sex with men to seek preventive services. This compounds their risk for HIV infection.Makobu Kimani, Post-doctoral researcher, KEMRI-Wellcome Trust Research Program, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1003742018-07-23T14:29:08Z2018-07-23T14:29:08ZThe HIV pandemic: time to recalibrate and target the weak spots<figure><img src="https://images.theconversation.com/files/228830/original/file-20180723-189310-pb058s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">More than 15 000 researchers, activists and policymakers descend on Amsterdam this week for the 22nd International Aids Conference.</span> <span class="attribution"><span class="source">Marcus Rose/IAS</span></span></figcaption></figure><p><em>HIV remains a global challenge. Between 36.7 million and 38.8 million people live with the disease worldwide. And more than 35 million have died of AIDS related causes since the start of the epidemic in the mid-1980s. Two years ago the International Aids Society and The Lancet put together a commission made up of a panel of experts to <a href="https://www.thelancet.com/commissions/global-health-HIV">take stock</a> and identify what the future response to HIV should be. The report is being released to coincide with the <a href="http://www.aids2018.org/About">22nd International Aids Conference</a> in Amsterdam. The Conversation Africa’s Health and Medicine Editor Candice Bailey spoke to Head of the International AIDS Society Professor Linda-Gail Bekker, who also led the commission, about its report.</em> </p>
<p><strong>What have we learnt about the global HIV response in the last 30 years?</strong> </p>
<p>The world had an emergency on its hands 30 years ago with the arrival of HIV. A huge amount of effort was put into trying to find solutions. And there were some incredible breakthroughs. First was the miracle of lifesaving antiretroviral treatment, the biggest game changer over the last three decades. Great strides have been made in rolling out the treatment. UNAIDS tells us that <a href="http://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf">22 million people</a> are currently on treatment. That’s truly remarkable.</p>
<p>But we’ve also learnt that relying on the current pace is insufficient. That’s clear from the figures. In some countries the incidence is rising, and in many parts of the world the incidence rate has stalled or plateaued. We are not seeing the downturn that we need to be able to reach the global goal of <a href="http://www.unaids.org/en/resources/campaigns/World-AIDS-Day-Report-2014">ending the HIV pandemic by 2030</a>. </p>
<p>The biggest lesson we’ve learnt is that we need to reinvigorate the prevention message especially since we have new tools to combat HIV transmission in many different settings. This includes <a href="https://theconversation.com/one-year-in-lessons-on-rolling-out-an-hiv-prevention-pill-in-south-africa-88255">Pre-exposure prophylaxis</a> (PrEP) – a daily antiretroviral that’s given to people who have a high risk of contracting HIV to lower their chances of getting infected – as well as treatment as prevention, which involves giving people living with HIV antiretrovirals to suppress their viral loads. </p>
<p>For a sustainable response and looking forward to the next era, it will be important to position our responses to HIV within the broader health agenda. Patients don’t only have HIV, they have other issues. There are mental health needs and there are sexual and reproductive health needs, so HIV treatment and care must fit into that broader agenda. This will enable a more sustainable response.</p>
<p>This is a challenge in many parts of the world where HIV is in a siloed response and people are only treated by HIV specific services. There needs to be a service delivery model that considers the broader health agenda. This goes beyond integration. We need to think about where can we take the lessons from HIV into other diseases. In the case of HIV, person centred and community-based care has become critical to ensure people get access to treatment. </p>
<p>The message is simple: the epidemic is far from over and it’s not time to disengage. We’re here for the long haul. To ensure we have a sustainable approach we need to recalibrate.</p>
<p>The commission is calling for a new way of doing business that will seek common cause with other global health issues. We understand that the HIV response will need resources. This will be a great way to get a double bang for the buck.</p>
<p><strong>What’s still going wrong?</strong></p>
<p>In many regions we have left whole sectors of the population behind. These include men who have sex with men, women who trade sex and people who inject drugs. They aren’t getting proper services because of policy, prejudice and stigma.</p>
<p>And different regional pockets need particular attention. One is in Eastern Europe and Central Asia where there has been a 30% increase in new infections since 2010. This is particularly concerning. Its clear that whole regions are being left behind because of politics, denial and stigma.</p>
<p>Here the administrations are not doing the evidence based thing – they are failing their people and the response. </p>
<p>Another pocket is West and Central Africa. These are countries that are not reducing rates of infection as quickly as we had hoped, often due to limited resources. Nigeria, for example, needs help with the reduction of mother to child transmission.</p>
<p>These are areas that are going to need attention, help and encouragement. </p>
<p>But we don’t want to put out the notion that we are in trouble across the world.</p>
<p>In East and South Africa, for example, we have made significant gains. There is still a lot to be done but the trends are going in the right direction. In many ways South Africa really is a good news story because its administration and politics favour an enthusiastic response to do the right thing. Domestic funding around HIV has increased. South Africa still has the biggest number of people in the world living with HIV – 7.9 million according to the <a href="http://www.hsrc.ac.za/uploads/pageContent/9234/SABSSMV_Impact_Assessment_Summary_ZA_ADS_cleared_PDFA4.pdf">latest HSRC report</a>. But the country is beginning to turn the ship around. That’s something we can be incredibly proud of.</p>
<p>There are, nevertheless, still pockets that need attention. For example, adolescent girls and young women under the age of 25 in KwaZulu-Natal are roughly three times more likely than men younger than 25 to be living with HIV. We have had them in our sights but we now need a concentrated effort to tackle HIV in this cohort otherwise we will miss the target.</p>
<p>We need to look at the evidence and where can we make an impact with integrated care. This would be through HIV programmes that are part of sexual and reproductive health along with economic empowerment initiatives such as getting girls to stay in school and making sure they have opportunities to make autonomous decisions about sexual and reproductive health. </p>
<p>Doing everything for everyone is a waste of money and time. We need to sharpen the tip of our response. We must put our responses where we get the biggest bang for buck and call on those resources that offer prevention and treatment. </p>
<p><strong>What are the biggest challenges between now and 2030?</strong></p>
<p>Resources are the constant challenge globally. We live in a world where politics is unpredictable. We need to constantly advocate for funding while diversifying funding opportunities.</p>
<p>The second challenge is stigma and discrimination. Policy and ideology that is counter productive also feeds into stigma and discrimination. We need to do to something about laws that criminalise behaviour, like sex work, and stigmas towards intravenous drug users, gay people and men who have sex with men. Decriminalising sex work in South Africa, for example, would go a long way to reduce stigma, enable services and help the public health approach. </p>
<p>Continuing to understand how to reach young women and girls and protect them socially and medically; those are also big challenges. </p>
<p>Finally, in South Africa there is a challenge to find men who are not in the health services and get them into care and onto treatment. We know that a suppressed viral load means no HIV transmission and so this should be on its agenda.</p><img src="https://counter.theconversation.com/content/100374/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Linda-Gail Bekker receives funding from various research funding agencies on a competitive funding basis.</span></em></p>The HIV epidemic is far from over and it’s not time to disengage, says International Aids Society President Linda-Gail Bekker.Linda-Gail Bekker, Professor of medicine and deputy director of the Desmond Tutu HIV Centre at the Institute of Infectious Disease and Molecular Medicine, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/951632018-05-15T13:23:35Z2018-05-15T13:23:35ZProviding healthcare to men who have sex with men is complex but possible<figure><img src="https://images.theconversation.com/files/218244/original/file-20180509-34009-14z8zzy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There needs to be a wide range of sexual health services for men who have sex with men.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Research has shown that addressing HIV in certain <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4228373">key populations</a> is a priority in order to end the epidemic in the general population.</p>
<p>Key populations are groups identified by the World Health Organisation that warrant specific attention in health programmes because they face a particularly high risk of getting HIV and other sexually transmitted infections. They are also marginalised and do not have good access to health services. </p>
<p>One of these groups is men who have sex with men (MSM). It is critical to ensure that they are able to get access to HIV prevention and treatment services. </p>
<p>But in many parts of sub-Saharan Africa, including South Africa, men who have sex with men <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780345/">encounter stigma and prejudice</a> when they use health services. This often limits their access to healthcare. </p>
<p><a href="http://journals.lww.com/stdjournal/Abstract/publishahead/Utilization_of_Sexually_Transmitted_Infection.98418.aspx">Our research</a> shows that it’s possible to provide good quality care in the public sector to men who have sex with men.</p>
<p>We looked at health services specifically designed and provided at a set of South African government clinics. We found that men who accessed these services did well on antiretroviral regimens. </p>
<h2>South Africa’s reality</h2>
<p>An estimated <a href="http://www.unaids.org/en/regionscountries/countries/southafrica">7.1 million people in South Africa are living with HIV</a>. That’s about 12.6% of the general population. </p>
<p>Among men who have sex with men, this figure <a href="https://www.cambridge.org/core/journals/epidemiology-and-infection/article/age-bias-in-survey-sampling-and-implications-for-estimating-hiv-prevalence-in-men-who-have-sex-with-men-insights-from-mathematical-modelling/A301257CE75A110D4BD61594764A8E98">may be as high as 34.6%</a>. </p>
<p>Providing health services to this group is challenging partly because of its diversity. Many men who have sex with men do not see themselves as gay. They may identify as bisexual or straight, or not label themselves in this way at all. This makes it difficult to find ways to reach out to them. </p>
<p>Their sexual practices also vary which can increase their risk of contracting HIV. For example, some men have anal sex without a condom, which is risky. But not all men who have sex with men have anal sex. </p>
<p>So sexual health services for men who have sex with men need to understand and meet the needs of a wide range of men. The challenge is that they usually have to access regular health services where they feel they are not understood and experience discrimination. They often feel unable to explain their sexual history to health workers. </p>
<p>Our study looked at how a health service targeted at men who have sex with men, <a href="http://www.health4men.co.za/sexual-health-services/">Health4Men clinics</a>, provided by an NGO in government run, primary care health facilities could help to solve these problems. </p>
<p>There are three Health4Men clinics in Johannesburg and one in Cape Town. They provide comprehensive sexual health services, including preventing and treating HIV and other sexually transmitted infections. </p>
<h2>Filling the gaps</h2>
<p>Of the gay and bisexual men who were tested for HIV at the clinics close to 40% were HIV positive. The figure was 14% for straight men. </p>
<p>We found that the clinics were very successful in helping men remain on antiretroviral treatment. More than 80% of the men who started antiretroviral treatment at the clinics were still taking their medication two years later. There was no difference in the retention patterns between gay and straight men. </p>
<p>People on antiretroviral therapy must take treatment for the rest of their lives. But keeping people on treatment is a challenge.</p>
<p>In addition, men who have sex with men are often unaware of their sexually transmitted infections because there often aren’t visible symptoms. This often means that they don’t seek treatment. Finding and treating these infections is important because untreated sexually transmitted infections increase the risk of contracting HIV. </p>
<p>Part of the reason that Health4Men services have been successful is the presence of male health care workers. They are specially trained to be sensitive to diversity in gender and sexuality, and to understand the specific needs and health problems affecting men who have sex with men. Their presence seems to make many men feel more comfortable discussing sexual matters. </p>
<p>And based on our research, the clinics attracted men who identified as gay, bisexual and straight, showing that they were considered safe spaces. </p>
<h2>Meeting the needs</h2>
<p>To stop the spread of HIV, South Africa needs to expand access to specialised health services for men who have sex with men. Services should also be provided in community spaces linked to health facilities. </p>
<p>Implementing these specialised services in rural areas is a bit more challenging due to limited resources. But in these areas health workers should be trained to understand diversity in gender and sexuality. Training health workers about diversity has been shown to reduce prejudicial <a href="https://www.ncbi.nlm.nih.gov/pubmed/27835058">attitudes toward men who have sex with men</a>.</p>
<p>In the end, what is important is that HIV prevention services – including regular testing, access to condoms and lubricant, treatment of sexually transmitted infections and PrEP (a pill taken daily to prevent HIV infection) – reach HIV-negative men who have sex with men. It’s also crucial for those who are already HIV-positive to have access to antiretroviral therapy to decrease the spread of HIV.</p><img src="https://counter.theconversation.com/content/95163/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kate Rees works for Anova Health Institute. </span></em></p><p class="fine-print"><em><span>Remco Peters works for the Anova Health Institute</span></em></p>In many parts of sub-Saharan Africa men who have sex with men encounter stigma and prejudice when accessing health services.Kate Rees, Honorary Research Associate, Public Health Medicine, University of Cape TownRemco Peters, Extraordinary Professor in the Department of Medical Microbiology, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/882552017-12-01T12:33:07Z2017-12-01T12:33:07ZOne year in: lessons on rolling out an HIV prevention pill in South Africa<figure><img src="https://images.theconversation.com/files/197282/original/file-20171201-10147-184x2y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">NIAID</span></span></figcaption></figure><p>Last year South Africa became the first country on the continent to register the use of a drug that could be used as an oral pre-exposure prophylaxis for HIV prevention. Pre-exposure prophylaxis, referred to as PrEP, is the use of anti-retroviral drugs by people who do not have HIV to prevent them from becoming infected. </p>
<p>The idea behind PrEP has been to target high risk populations where new infections remain consistently high. This includes sex workers, men who have sex with men, injection drug users and young women.</p>
<p>Following a <a href="http://apps.who.int/iris/bitstream/10665/197906/1/WHO_HIV_2015.48_eng.pdf">recommendation</a> by the World Health Organisation to use the drug as an additional HIV prevention choice South Africa registered <a href="http://www.mccza.com/documents/2e4b3a5310.11_Media_release_ARV_FDC_PrEP_Nov15_v1.pdf">Tenofovir/Emtricitabine</a> last year.</p>
<p>By June this year South Africa’s PrEP programme was being implemented at 17 sites that were serving sex workers and men who have sex with men. The programme had also been expanded to provide the drug at nine clinics at seven tertiary institutions which serve more than 120,000 young people. </p>
<p>The PrEP rollout data shows that there is a relatively slow, but increasing, uptake of PrEP. There are concerns. One year after the licence was procured there are fears that the rollout isn’t sufficiently targeting one of the country’s most high risk populations: young women.</p>
<p>This is a critical cohort of people in the fight against new HIV infections. Studies show that young women in South Africa, aged between 15 and 24 years have the <a href="http://www.unaids.org/en/resources/campaigns/2014/2014gapreport/gapreport">highest HIV incidence</a>. About 1,745 new HIV infections occur among these young women every week. </p>
<p>An additional factor that makes the group so important in bringing down infections is that they represent a <a href="http://www.indexmundi.com/south_africa/demographics_profile.html">substantial section</a> – about 10% – of the population. </p>
<p>Unless this problem is solved the rates of new infections in South Africa are unlikely to be reduced. </p>
<h2>Great idea, challenging to deliver</h2>
<p>After South Africa procured the licence for the HIV prevention tablet, the National Department of Health launched a national policy and set of guidelines to rollout PrEP and provide test and treat services. Test and treat allows people to access antiretrovirals as soon as they test positive.</p>
<p>The government’s cost-effectiveness analyses suggested that the greatest impact of PrEP would be in populations that have a substantial risk for HIV infection. As a result the policy focused initially on providing PrEP at a limited number of sex worker sites. This would help them learn more about real world delivery prior to scale up. </p>
<p>But here lies the issue. There is a high level of political will and desire in the government to rollout PrEP to young women who are at risk, but the health system requirements are complex. Cost is also a consideration. There is a need to establish how best to identify young women at highest risk and how best to offer and retain young women on PrEP. </p>
<h2>Next steps</h2>
<p>PrEP is new technology that has the potential to alter the HIV epidemic particularly among women. But a narrow focus on a single technology alone is unlikely to solve health and social challenges associated with HIV. </p>
<p>South Africa needs to pay careful attention to access and service delivery issues and constraints, and to engage communities as PrEP is scaled up so that its potential is fully realised.</p>
<p>There are a number of small scale research projects mainly in and around Johannesburg and Cape Town that could help inform how best to deliver PrEP to young women. More than 500 adolescent girls and young women between the ages of 16-24 years are being enrolled in the projects. The aim is to to learn more about scalable models of PrEP delivery for adolescents in countries like South Africa which has limited resources. </p>
<p>Without an understanding of best practices and most cost effective scalable delivery models for young women, it will be challenging for South Africa to maximise the impact of core HIV prevention, treatment, and care interventions. </p>
<p>Another critical step to filling the gaps would be to generate greater community awareness about PrEP. Many people don’t know that there is an antiretroviral pill that, if taken every day, can reduce a person’s risk of being infected with HIV. Getting the message across is difficult because the legacy of concerns about antiretrovirals and their side effects persist in many communities. </p>
<p>This is not just about awareness but about the need for a broader conversation about how we address the underlying issues that continue to shape HIV risks in young women. Stigma, violence against women, judgemental attitudes about young people having sex all make it more difficult for people to accept PrEP and to use it effectively. </p>
<p>A broader conversation is needed to increase knowledge and awareness of PrEP, its potential to change the course of the epidemic, and where it fits in to a broader programme of HIV prevention.</p><img src="https://counter.theconversation.com/content/88255/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sinead Delany-Moretlwe has received a drug donation from Gilead Sciences for a demonstration project.</span></em></p><p class="fine-print"><em><span>Saiqa Mullick does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>South Africa’s data rollout of its pre-exposure prophylaxis shows that there is a relatively slow, but increasing, uptake. However, more needs to be done to target young women.Sinead Delany-Moretlwe, Associate Professor and Director: Research at the Wits Reproductive Health and HIV Institute I, University of the WitwatersrandSaiqa Mullick, Director of Implementation Science, Wits Reproductive Health & HIV Institute, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/691922016-11-27T10:13:13Z2016-11-27T10:13:13ZRings and things … other ways to prevent HIV are on the cards<figure><img src="https://images.theconversation.com/files/147636/original/image-20161126-32008-25tr76.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pre-exposure prophylaxis is providing an exciting new innovation to tackle HIV prevention. </span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p>The rate of HIV infection remains greater than the number of people initiating treatment. This imbalance will stop the eradication of HIV/AIDS. It begs for increased investment into primary prevention.</p>
<p>Primary prevention caters to people who are HIV negative. It aims to reduce their chance of becoming infected. There are certain populations, now referred to as <a href="http://apps.who.int/iris/bitstream/10665/197906/1/WHO_HIV_2015.48_eng.pdf">key populations</a>, in whom the burden of infection is disproportionately high. These include men who have sex with men, sex workers, people who inject drugs, transgender people, and, in sub-Saharan Africa, adolescent girls and young women. Primary prevention should be tailored, and scaled up, for these groups.</p>
<p>Primary prevention can be provided in a number of ways. But the most exciting new innovation is pre-exposure prophylaxis (PrEP). PrEP is the use of anti-retrovirals by HIV-uninfected people to prevent HIV transmission. It is commonly given as a daily pill (sold as <a href="https://theconversation.com/how-a-drug-can-help-prevent-5000-girls-being-infected-with-hiv-every-week-52539">Truvada</a>) to be taken orally in the same way that contraceptives are used to prevent pregnancy or antimalarial pills are taken before travelling to a high malaria risk area.</p>
<p>Numerous <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1011205">clinical trials</a> and demonstration projects in diverse settings and populations have been conducted with PrEP all showing that it works. PrEP is easy to take. It is also largely side effect free and safe. There is one hitch: it has to be taken consistently at the time of HIV exposure. Adherence has been oral PrEP’s biggest stumbling block. </p>
<p>That’s why a huge effort is being made to find alternative ways to take PrEP. New formulations in the pipeline include long-acting injections, monthly vaginal rings, implants and topical gels, films and dissolving topical pills. The hope is that new formulations will make PrEP more accessible and convenient, particularly for adolescents and young people who may find a daily intervention cumbersome.</p>
<h2>Adherence is PrEP’s Achilles’ heel</h2>
<p>Adherence is key. To block HIV transmission PrEP must be “in the system” at the time of HIV exposure. Its effectiveness decreases rapidly when this “effective coverage” is inconsistent. Good adherence gives almost 100% HIV transmission prevention. Poor adherence results in little to no protection. </p>
<p>This is why, where possible, a daily dose during times of risk is recommended. But this may be difficult to achieve for some.</p>
<p>In PrEP trials the following reasons were given for poor adherence:</p>
<ul>
<li><p>fear/experience of side effects, </p></li>
<li><p>fear of interactions with alcohol and other drugs, </p></li>
<li><p>forgetfulness, </p></li>
<li><p>dislike of pill-taking, and </p></li>
<li><p>fear of the discrimination associated with taking an anti-HIV pill. </p></li>
</ul>
<p>Alternative dosing strategies using longer acting formulations and PrEP delivery methods may well be another way to increase PrEP effectiveness.</p>
<h2>New PrEP frontiers</h2>
<p>Topical gels, which can be applied pre and post sex to rectal and vaginal tissue, were the first alternative formulations to be tested. But the results in women have been inconsistent. This formulation still holds promise in men who have sex with men although efficacy trials haven’t yet been conducted.</p>
<p>An alternative strategy is a monthly vaginal ring, which in its current form contains slow-release dapivirine (another antiretroviral). <a href="https://theconversation.com/why-a-new-vaginal-ring-could-be-a-game-changer-in-hiv-prevention-55367">Two large phase III clinical trials</a> have demonstrated that the ring is effective and can reduce the chance of HIV infection by 27%-31%. In a sub analysis of different ages, older women once again fared better than young women. </p>
<p>The benefit of the vaginal ring is that there are less side effects because the drug is released locally and only a small amount enters the blood stream. The other huge plus is that women are encouraged to insert and forget, only changing the ring on a monthly basis. The obvious catch is that this is only suitable for women and vaginal intercourse. </p>
<p>The vaginal ring is undergoing further investigation.</p>
<p>Another tool that is being investigated and could overcome the need for a daily pill is a long-acting monthly injection. An injection of the antiretroviral cabotegravir (cabotegravir LA) has been shown to be very effective at lowering viral loads in people being treated for HIV when administered every two months. </p>
<p>Also being investigated are dissolving vaginal films – a bit like the breath fresheners that can be bought over the counter – as well as quick dissolving pills. </p>
<p>Perhaps most exciting of all is the prospect of an implant, a small rod which can be surgically placed just under the skin and will be able to slowly release antiviral protection over months. </p>
<p>Finally, new formulations are currently being investigated that will combine treatment for both contraception and preventing sexually transmitted infections. It is hoped that these multifunctional preventions may further encourage people to consistently use these products.</p>
<p>A new challenge to the field is how these new clinical trials can be efficiently designed. To qualify for first-line use of PrEP, new pills and products will need to have improved or equivalent efficacy compared to the current oral PrEP. And they would need to have reduced or equivalent side effects. All these formulations and delivery methods are still in the early stages of testing, but look to be out on the market within the next two to five years depending on their success.</p>
<h2>PrEP for Africa</h2>
<p>In sub-Saharan Africa, teenage girls and young women are <a href="http://www.unaids.org/en/resources/documents/2014/Adolescentgirlsandyoungwomen">most at risk of HIV</a> infection. There are 2000 new infections in this group every week. These women are vulnerable because of the high prevalence of both gender-based violence and the commonality of age-disparate relationships and transactional sex. These conditions can make it difficult for women to negotiate safer sex practices. PrEP would enable these women to protect themselves in advance, without their partner’s knowledge or consent.</p>
<p>Kenya and <a href="http://www.mccza.com/documents/2e4b3a5310.11_Media_release_ARV_FDC_PrEP_Nov15_v1.pdf">South Africa</a> are the only two African countries that have granted regulatory approval for PrEP. Neither have started to roll it out. </p>
<p>New interventions can only be useful if deployed and scaled up to the populations most in need. This raises questions of cost versus impact. It is hoped that new formulations and delivery systems will enhance choice, encourage use, and provide a platform from which PrEP roll out can be advocated.</p><img src="https://counter.theconversation.com/content/69192/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Linda-Gail Bekker receives funding from a variety of research funding agencies. She is affiliated with The Desmond Tutu HIV Centre at University of Cape Town. She is conducting an adolescent PrEP demonstration study in which Gilead has donated oral Truvada. </span></em></p>Trials have shown that rates of HIV infection are reduced if people not infected with HIV take anti-retrovirals - known as pre-exposure prophylaxis (PrEP). But adherence to a daily dose is a problem.Linda-Gail Bekker, Professor of medicine and deputy director of the Desmond Tutu HIV Centre at the Institute of Infectious Disease and Molecular Medicine, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/499852015-11-09T03:56:04Z2015-11-09T03:56:04ZWhy men who have sex with men have problems with health care in Africa<figure><img src="https://images.theconversation.com/files/101052/original/image-20151106-16242-bwvlk2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In Malawi men who have sex with men can access healthcare services but they do not always get adequate treatment, care and support.</span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p>Providing prisoners, sex workers, adolescents and men who have sex with men with sexual and reproductive health services has been advocated by the <a href="http://www.who.int/hiv/pub/guidelines/briefs__sw_2014.pdf">World Health Organisation</a> and the <a href="http://www.unaids.org/en/resources/presscentre/featurestories/2014/07/20140711who">United Nations</a> and several other international bodies. As a result, most national governments have heeded this advice and cater for these groups, known as <a href="http://www.amfar.org/uploadedFiles/_amfarorg/Articles/On_The_Hill/2013/Key%20Populations%20Issue%20Brief%20-%20Final%20(2).pdf">key populations</a>. </p>
<p>One critical part of accessing quality and effective sexual and reproductive health services is to strengthen HIV prevention and to provide everyone with access to HIV treatment, care and support. </p>
<p>But, in many African countries, knowledge to guide HIV programming for men who have sex with men is only just developing. And when there are guidelines, the services are not always available. This means that many people in these key populations do not get the services they need. </p>
<h2>Mixed messages</h2>
<p>The Malawian National HIV Prevention Strategy specifically acknowledges that these populations must be targeted in its HIV programming. But homosexuality is still a <a href="http://www.pinknews.co.uk/2015/03/10/malawi-health-minister-no-plans-to-drop-anti-gay-laws/">crime</a> in the country. And even though there is a <a href="https://www.hrw.org/news/2012/11/06/malawi-courageous-move-suspend-anti-gay-laws">moratorium</a> on criminalising male-male sexual relationships, men who have sex with men have difficulty getting access to health services.</p>
<p>Tanzania also criminalises homosexuality. It has nevertheless started to implement different harm-reduction HIV interventions for key populations, including <a href="http://nacopha.or.tz/nacopha-news/up-coming-events/60-recognition-and-profiling-of-most-at-risk-populations-with-hiv-and-aids-in-tanzania-meeting-.html">men who have sex with men</a>. An estimated <a href="http://www.jiasociety.org/index.php/jias/article/view/18742">15%</a> of men who have sex with men are HIV positive in the country. The figure is double in the country’s capital <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4156794/">Dar es Salaam</a>. </p>
<p>The figures are similar in Malawi, where the crude HIV prevalence is 15.4%. Just over 90% of the HIV infections were reported as previously <a href="http://www.ncbi.nlm.nih.gov/pubmed/24321110">undiagnosed</a>.</p>
<h2>Inconsistent services</h2>
<p>Several studies on men who have sex with men have been done in Malawi and Tanzania. </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2080530/">One</a> in Malawi reflects the negative general public attitudes towards these men. Many of the <a href="http://link.springer.com/article/10.1007%2Fs10461-010-9861-2">studies</a> also show that stigma and discrimination are common. </p>
<p>The <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4049421/">research</a> shows that there is still a low uptake of HIV prevention and health services among these men. They fear seeking health services and disclosing their sexual orientation because of discrimination. Another <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657212/">study</a>, which corroborates this, shows that only 9% of men who have sex with men in Malawi disclosed their sexual practices to a health care provider. </p>
<p>Our <a href="http://www.ncbi.nlm.nih.gov/pubmed/19024336">study</a> shows that only 18% of the men who have sex with men that were interviewed said they were exposed to HIV prevention messages that were relevant to them. </p>
<p>While some men are aware of the HIV risks, they believed that within their wider community there is a general lack of HIV information for men who have sex with men, low awareness of the appropriate prevention and low perception of risks related to HIV infection.</p>
<p>Although health workers said they provided services to everyone without regard of sexual orientation, the men interviewed in our study said they experienced constrained access to services. </p>
<p>Health care providers themselves face a number of challenges. One is their concern about adverse <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4049421/">repercussions</a> if they provide services to men in same sex sexual relationships.</p>
<p>Another is that they lack awareness. We asked health workers how capable they were at establishing the sexual history of their patients. This would include asking questions about a person’s sexual orientation and sexual practices so that they could better understand the individual’s risk and what clinical care was needed. This was clearly an area of great difficulty.</p>
<p>Our experience as a medical school testifies that our graduates may not be ready to take down the <a href="http://www.cdc.gov/std/treatment/sexualhistory.pdf">sexual history</a> of their patients in a nonjudgmental way. This clearly will have an impact on their ability to provide sexual reproductive and health services. </p>
<p>This observation is anecdotal and more work is required to quantify the extent to which this a major limitation in clinical management. We will be doing more <a href="http://www.ehpsa.org/resources/evidence/5-msm-malawi/file">research</a> into:</p>
<ul>
<li><p>What affects these men from accessing the health system?</p></li>
<li><p>How can the systems and access be improved?</p></li>
<li><p>What interventions exist and how can they be used in the two countries?</p></li>
<li><p>What is the best way to communicate with these men?</p></li>
</ul>
<p>Conducting a similar study in Malawi and Tanzania will allow the researchers to cross-fertilise their expertise and share the lessons learnt, which would strengthen the findings.</p><img src="https://counter.theconversation.com/content/49985/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adamson S. Muula receives funding from the Evidence for HIV Prevention in Southern Africa (EHPSA) which is managed by Mott MacDonald. The EHPSA Program is funded by the DfID and other funders.</span></em></p>Malawi and Tanzania have created programs to provide sexual and reproductive health services and HIV interventions. But men who have sex with men say it’s still difficult to access care.Adamson S. Muula, Professor of Epidemiology and Public Health, University of MalawiLicensed as Creative Commons – attribution, no derivatives.