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 Monkeypox Claims First US Victim: What You Need to Know

Experts say the virus is particularly dangerous for people with weakened immune systems.

The first death from monkeypox in the US has been confirmed in Los Angeles County, according to the US Centers for Disease Control and Prevention. The person, whose identity has not been released, was reportedly severely immunocompromised and had been hospitalised.

According to the LA Department of Public Health, the announcement underscores the heightened risk the virus poses to individuals with compromised immune systems, including those with HIV, and the importance of seeking medical care if infection is detected or suspected.

The Texas Department of State Health Services reported the death of a Houston resident with monkeypox last month, but the role of the virus in the death hasn't been confirmed.  

More than 22,630 cases of monkeypox have been reported in the US as of 13 September, according to the CDC. Although cases appear to be decreasing, "a downward trend can be the most dangerous time if it opens the door to complacency," World Health Organization Director-General Tedros Adhanom Ghebreyesus warned during a press briefing on 7 September.

The US declared monkeypox a federal public health emergency on 5 August, making funds and resources available to tackle the health crisis. 

The announcement followed similar emergency declarations by California, Illinois and New York. All three states are home to large gay communities, and so far men who have sex with men have been the largest population affected by the outbreak. Of the known cases of monkeypox in the US, about 98% are in gay/bisexual men. 

Monkeypox isn't limited to LGBTQ people: Most cases in Africa, where the disease is endemic, aren't among gay men, the WHO reports.

It can be spread by direct skin-to-skin contact with infected lesions, rashes, scabs or fluids. It can also be spread by touching surfaces, clothing or other objects used by someone with monkeypox, and through large respiratory droplets, such as from coughing or sneezing.

When WHO declared the disease a global health emergency on 23 July, Tedros stressed the importance of policies that protect the dignity and civil liberties of affected communities. 

He warned that "stigma and discrimination can be as dangerous as any virus".

Here's what you need to know about monkeypox, including whether it's a sexually transmitted infection, how it affects the gay community, and how the virus might interact with HIV.

For more information on monkeypox, visit the GMHC, Human Rights Coalition, WHO and CDC resource pages.

What is monkeypox?

Monkeypox is a virus in the same family as smallpox, although it is milder and rarely fatal. It was first documented in humans in 1970 and is endemic in parts of Central and West Africa, particularly the Democratic Republic of Congo.

The first reported cases of monkeypox in the USA were in 2003, all linked to infected prairie dogs kept as pets.

Monkeypox can appear as a rash or as individual sores that look like pimples or blisters. They can appear almost anywhere on the body, including the hands, face, chest, groin and inside the mouth or anus. 

Mortality rates are very low, between 1% and 10% depending on the strain, and deaths usually occur in young children and people with weakened immune systems.

As of 14 September, one confirmed death has been linked to monkeypox in the US, while another death has not yet been confirmed as being linked to the virus.

Is monkeypox a sexually transmitted disease?

When the outbreak was first reported, medical experts were careful not to classify monkeypox as a sexually transmitted infection. The concern was that labelling monkeypox as an STI - and perpetuating the idea that it's only a threat to gay/bi men - would lead to stigma.

"The monkeypox rumours are harmful because they isolate a particular group of people and seem to 'blame' them for spreading this infection," Dr Michelle Forcier, a physician with the LGBTQ-affirming wellness site FOLX Health, told CNET's sister site Healthline in July.

Forcier also said that "calling the monkeypox virus an STI and linking it to our culture's view of sex as scary or shameful may discourage people who are exposed or infected from seeking medical care.

It may also lead people to mistakenly believe that precautions used for STIs will stop monkeypox. Condoms can help prevent transmission, but according to the CDC, "condoms alone are probably not enough to prevent monkeypox".

According to the WHO, the virus can be spread by any close skin-to-skin contact. This includes oral or penetrative sex with someone who has symptoms, but also coughing, sneezing, hugging or using contaminated towels, clothing or bedding.

However, most cases have been linked to sexual activity. David Harvey, executive director of the National Coalition of STD Directors, told CNN that his office refers to monkeypox as a "sexually associated" infection.

"With the data that is available now, we know that the primary mode of transmission is sexually associated -- contact that is sexual in nature," Harvey said. "Technically, a sexually transmitted infection is defined as an exchange of genital fluids that carry a virus or bacteria associated with a sexually transmitted infection." 

He added that more research needs to be done on whether monkeypox can be transmitted through semen or genital fluids to definitively label monkeypox as an STI.

Journalist Stephen Thrasher, author of The Viral Underclass, which explores how inequality fuels epidemics, says tiptoeing around the term does more harm than good.

"Naming who is affected and how transmission occurs is not homophobic or racist," Thrasher wrote in Scientific American in August. "Rather, not naming, researching, preventing, and addressing how transmission happens keeps people from understanding how to prevent infection, allows for unnecessary worry, and exacerbates racist and homophobic social determinants of health."

Lao-Tzu Allan-Blitz, a global health specialist at Brigham and Women's Hospital, told NBC News that given the medical evidence, "it looks very clear to us that this is an infection that is sexually transmitted in the vast majority of cases.

How can I protect myself from monkeypox?

Vaccination is the best protection against infection, although access to Jynneos, the two-dose Food and Drug Administration-approved vaccine, is still limited.

In addition, because the virus can be spread on surfaces, health officials recommend frequent cleaning of bedding, sex toys and fetish equipment.

On 27 July, the WHO recommended that gay and bisexual men limit their sexual partners during the outbreak, especially while the availability of the vaccine is still limited.

"For men who have sex with men, this includes reducing the number of sexual partners, reconsidering sex with new partners, and exchanging contact details with any new partners to enable follow-up if needed," Tedros told reporters.

Journalist Stephen Thrasher, author of The Viral Underclass, which explores how inequality fuels epidemics, says tiptoeing around the term does more harm than good.

"Naming who is affected and how transmission occurs is not homophobic or racist," Thrasher wrote in Scientific American in August. "Rather, not naming, researching, preventing, and addressing how transmission happens keeps people from understanding how to prevent infection, allows for unnecessary worry, and exacerbates racist and homophobic social determinants of health."

Lao-Tzu Allan-Blitz, a global health specialist at Brigham and Women's Hospital, told NBC News that given the medical evidence, "it looks very clear to us that this is an infection that is sexually transmitted in the vast majority of cases.

How can I protect myself from monkeypox?

Vaccination is the best protection against infection, although access to Jynneos, the two-dose Food and Drug Administration-approved vaccine, is still limited.

In addition, because the virus can be spread on surfaces, health officials recommend frequent cleaning of bedding, sex toys and fetish equipment.

On 27 July, the WHO recommended that gay and bisexual men limit their sexual partners during the outbreak, especially while the availability of the vaccine is still limited.

"For men who have sex with men, this includes reducing the number of sexual partners, reconsidering sex with new partners, and exchanging contact details with any new partners to enable follow-up if needed," Tedros told reporters.

This message has divided some in the community.  

"We know from 40 years of experience with the AIDS epidemic that information that makes people feel ashamed of their sexual behaviour doesn't lead to good public health outcomes," said Jason Cianciotto, vice president of policy and communications at GMHC, a leading LGBTQ health organisation in New York.

GMHC began in the early 1980s as a grassroots AIDS organisation founded by Larry Kramer and others who felt that government officials were failing to act quickly in the face of a virus targeting gay and bisexual men.

With monkeypox, Cianciotto told CNET, his organisation is urging people to take care of themselves and each other. 

"That means making smart choices, recognising someone who might have symptoms and having a conversation with a potential sexual partner," Cianciotto said.

At the same time, he added, because the vaccine is still so scarce, "people need to think about the choices they make".

The CDC website recommends avoiding intimate, skin-to-skin contact if you or the other person has an illness or rash - even if it's not confirmed to be monkeypox. The agency suggests virtual sex and masturbation at least six feet away as alternatives to personal intimate contact to prevent the spread of the virus.

How is the gay community responding to monkeypox?

Adam Baran hosts a monthly sex party in Brooklyn. In light of the spread of monkeypox, he cancelled July's event. 

"I'm hoping, cautiously, that we might be able to have a party in August," Baran said. "But I've definitely had to take a 'wait and see' approach."

It's difficult to know how many precautions to take, said veteran New York nightlife promoter Daniel Nardicio, especially after more than two years of COVID lockdowns and isolation.

Nardicio hasn't stopped his weekly underwear party on Fire Island, a popular gay beach resort about two hours outside Manhattan. But he has included information about monkeypox in social media posts and event emails.

"With COVID, we just stopped everything," says Nardicio. "With this, we're monitoring things closely. Beyond that, I don't think we're in a position yet where we have to stop events.

Nardicio doesn't mind the WHO's recommendations for men who have sex with men. "It's not slut-shaming to tell someone to limit their partners when there's an outbreak," he said. "This is a community that is used to jumping into action and taking health crises seriously." 

Baran, Nardicio and Cianciotto all say they've seen massive interest in getting vaccinated in the gay community, far outstripping the availability of Jynneos.

"The desperation for the vaccine and the failure of the government to provide it is a big topic of conversation," Baran said. "Almost everyone I know is desperate to get vaccinated. In fact, the only people I know who aren't rushing to get vaccinated are monogamous couples who feel like, 'We're not the highest risk group - we're not going to take someone else's place.

Over the summer, pop-up monkeypox vaccination sites were set up on Fire Island. Nardicio credited Eddie Fraser, vice president for corporate relations at Northwell Health and a Fire Island regular, with helping to make it happen. 

How do I get the monkeypox vaccine?

Many gay men have been frustrated by the rollout of the monkeypox vaccine, which is the responsibility of the federal government, and the lack of access to testing.

It wasn't until almost two months after the first cases were reported in New York that 300,000 doses of a vaccine owned by the US were finally shipped from a warehouse in Denmark.

The White House has made more than 1.1 million doses available to states and cities, but officials told the New York Times that the Department of Health and Human Services waited too long to ask Bavarian Nordic, which makes Jynneos, to bottle and fill the vaccine orders already purchased. In a statement, the department told the Times that its "response has accelerated to meet the evolving needs on the ground, and it will continue to accelerate. 

In New York, the NYC Health portal offers appointments at vaccination sites across the city. Community-based organizations like GMHC that do direct LGBTQ health outreach, including the Callen-Lorde Community Health Center and Mount Sinai Hospital, are given a select number of appointment slots, usually prioritized for sex workers, queer people of color, and other individuals in the highest-risk categories.

San Francisco has a list of drop-in and appointment vaccination sites on the city government website. Illinois ranks third in the number of cases after New York and California, and most cases have been reported in Chicago. The Chicago Department of Public Health website has a list of vaccination sites and appointment details.

Cianciotto said it's helpful that so many gay men are already engaged in health care and know where and how to access information. But he said that's not necessarily the case for low-income communities of colour, immigrants, and trans and gender-nonconforming people. 

And he's worried that if monkeypox spreads to other parts of the US, the response could be even worse. 

"Will Republican governors even ask for the vaccine?" he said. "We're getting hit with another virus while my community is facing what I think is the most anti-LGBTQ era in US history. I'm concerned about how this issue will be used to further the political agendas of a minority of elected officials and theocrats who use fear and anxiety to win elections.

Can monkeypox be cured?

There's currently no cure or treatment specifically for monkeypox, but existing antiviral drugs, particularly tecovirimat (known commercially as TPOXX), have been used to treat some patients. But the availability of TPOXX is limited and providers don't always know about it.

Are people with HIV at greater risk of monkeypox?

People with HIV are considered a priority group for vaccination against monkeypox. In Europe, among people with monkeypox whose HIV status was known, 30-50% were HIV-positive.

It's not yet clear whether HIV affects the risk of becoming infected or developing monkeypox after exposure. However, according to the CDC, people with advanced or untreated HIV may be at higher risk of more severe or prolonged symptoms.

"The increasing HIV prevalence among persons with monkeypox over time suggests that monkeypox may be increasingly transmitted among networks of persons with HIV infection," the agency said. "This underscores the importance of using HIV and STI prevention systems for monkeypox vaccination and prevention efforts."

But Dr Ina Park, a community medicine specialist at the University of California, San Francisco, said the numbers may not really mean that HIV increases the risk of getting monkeypox.

People with HIV tend to be more engaged with the health care system, Park told Medscape Medical News.

"Persons with monkeypox signs and symptoms who have established relationships with HIV or sexual health providers may be more likely to seek care," the CDC said in its 9 September Morbidity and Mortality Weekly Report, "and these providers may be more likely to recognize and test for monkeypox virus."

As for the health risk to HIV-positive people, the CDC says there's no evidence of increased hospitalisation or death among people on effective antiretroviral drugs. And the Food and Drug Administration-approved Jynneos vaccine to prevent monkeypox has been shown to be safe and effective in people with HIV.

However, people with an inadequately treated viral load (that is, a T-cell count of less than 350) have shown higher rates of secondary bacterial infections, as well as a greater likelihood of prolonged infectiousness and a continuous rash rather than discrete lesions. 

In addition, the rash associated with monkeypox can sometimes lead clinicians to confuse it with shingles, thrush, scabies, herpes or other rashes seen in people with HIV.

How is the Biden administration responding to the monkeypox outbreak?

The White House declared the outbreak a federal public health emergency in early August. In addition to increased resources, that's expected to facilitate coordination among federal, state and local health officials. 

On 2 August, Robert Fenton, who helped lead the Federal Emergency Management Agency's COVID-19 vaccination campaign, was named White House coordinator for monkeypox response.

Dr Demetre Daskalakis, director of HIV/AIDS prevention at the CDC, was named deputy coordinator. 

Torrian Baskerville, director of HIV and health equity at the Human Rights Campaign, applauded President Joe Biden for tapping two public health officials with significant experience and expertise. 

"But the reality," Baskerville said in a statement, "is that we need much more from our government, and the window for immediate action is closing fast.

In conclusion' The information contained in this article is for educational and informational purposes only and is not intended as health or medical advice. Always consult a physician or other qualified health provider regarding any questions you may have about a medical condition or health objectives.