Monkeypox and HIV are strange bedfellows with a common thread — stigma — and what has quickly become an all too familiar target — men who have sex with men (MSM).
In light of the rapidly evolving monkeypox outbreak, Medscape Medical News sat down with Paul Volberding, MD, professor emeritus at the University of California, San Francisco and one of veterans of the early days of the HIV/AIDS epidemic, to discuss how the missteps of the past can mitigate present challenges.
Medscape: Reports on the monkeypox outbreak started trickling out last week, with numerous organizations — the World Health Organization (WHO), European Centre for Disease Control and Prevention (ECDC), and others — providing situational and case analyses that appeared to focus on MSM gatherings as initial transmission points. Do you see any similarities between how these reports are playing out compared with the early days of HIV/AIDS?
Paul Volberding, MD: It’s been amazing. You know the early reports, there’s an animal issue, something that sounds like smallpox and then it turns out that some of the early cases are occurring in gay men. In the early days of the AIDS epidemic, there were issues around sexual practices and voyeuristic commentary on what happens in gay sex. I’m totally reminded of the reaction when HIV cases were diagnosed in Haitians and then Haitians were added to the list of early groups that were thought to be culpable for the AIDS epidemic.
Just today, I’ve seen news reports from Africans saying that you’re targeting us in the same way. It shows our reflexes of blaming and targeting and stigmatizing continue. There’s a tendency for many groups in our country and globally to start pointing fingers, and in this case pointing fingers at the gay community again. I think that there’s a horrible possibility that it will continue; it’s raising all of the same issues.
Medscape: Using the HIV/AIDS epidemic as a framework, would you say that stigma — both initially and throughout the decades — is significantly intertwined with outcomes?
Volberding: There are so many ways in which stigma affects how the public perceives transmissible diseases like HIV, and also how people themselves facing the infections experience these kinds of epidemics. In the situation of gay men with HIV — especially in the early days — many were quite closeted; families were unware, people were engaging in often anonymous sexual activities. That did help increase transmission in the numbers of people affected early on. And as treatment and testing became available, this stigma resulted in many not being tested, not doing what they could have been doing in terms of prevention, which furthered transmission.
To this day, in this country and definitely globally, the fact that many — either with HIV infection or at risk for it — haven’t been tested or even if they have, haven’t looked for treatment, all of this is the result of stigma. I think in contrast to all the progress that we’ve made in terms of developing treatments for HIV, we still haven’t made much of an impact on the stigma.
Medscape: One of the things that the ECDC monkeypox surveillance report highlights is that we’re moving into the summer months, a time for increasing numbers of social and mass gatherings. It’s ironic that this is playing out just as folks are starting to let down their guards over COVID, almost like a perfect storm of events. And at the same time, the new CDC HIV Surveillance Report details a 17% decline in new HIV diagnoses. Do you have any thoughts about the confluence of these factors and possible clinical ramifications?
Volberding: It depends on how real this outbreak proves to be; if the numbers remain very small as they are in this country, I would hope that monkeypox will go away pretty quickly. But the more cases that we hear about, the more attention will be drawn to this, and the gay community is going to be smack in the middle of it. With the COVID pandemic, there was a lot of concern at first that people who are HIV infected would be at incredible risk and that’s proved not to be the case. But as a result of COVID, people stopped going to regular healthcare [appointments], prescriptions for preexposure prophylaxis [PrEP] dropped off, HIV testing decreased — the things that are so much part of the prevention strategy for the HIV epidemic. So, the reaction to one epidemic clearly affects another one and I think that the same risk is there within monkeypox.
Medscape: What are some of the key learnings from HIV that might be useful to primary care clinicians who are going to be on the front lines as monkeypox unfolds?
Volberding: It’s been interesting to see some of the infectious disease people who’ve become front and center with the COVID pandemic being turned to now to comment on monkeypox and that is a good thing; they’re very good communicators (and educators) about infectious diseases. You know, I think that the risk that rumors will start is high in this situation and rumors and false information are connected to stigma. One [thing] that will be most useful is for us to be generating and sharing factual information as quickly as possible.
What we’ve learned so far is that monkeypox is a kind of virus that is easily spread by direct, in a sense, person-to-person, skin-to-skin contact. But before we kind of latch on to that, we should take a step back and make sure that we know what we are talking about. You know, gay men are not the only people in the world who are going to be assembling in big numbers this summer; Memorial Day weekend is a great time for picnics and parties and everything else, swimming pools, etc. So, before we go crazy, we need to really focus on the facts.
Medscape: We live in a 24-hour news cycle, and social media is often a hotbed of misinformation spread deliberately by bad actors. What are the steps that MSM and transgender women can take to shield themselves before the rumor mill gains full steam?
Volberding: I think of this situation…a new scary virus so [a] ‘let’s blame Africa’ kind of connection. Gay men might be involved; ‘let’s blame gay men.’ The risk of this becoming a large problem is real. So you need to turn to good information, to sources that have proven now with the COVID pandemic to be reliable, people like Ashish Jha, Peter Hotez, Carlos del Rio. They’re people who are very knowledgeable about infectious diseases, very aware of the HIV epidemic, and also careful thinkers. I think that the gay community should be encouraged to turn to those people before being drawn to the scary stuff that we are going to be hearing about in social media.
Medscape: In the 1980s, politics started to play a huge role in how AIDS was perceived. Today, we are living in an environment that is, likewise, supercharged in ways that might translate into further stigmatizing the gay and transgender communities and possibly, forcing them back into the closet. What types of parallels can be drawn to make sure that that doesn’t happen?
Volberding: It’s so much more political now than it was in the early HIV epidemic; there are so many ways in which information is available everywhere in real time. The best outcome would be that this outbreak is small and self-contained and goes away. But if it continues to be in the news, it’s going to generate the reaction that you are talking about; I don’t think that there is any question about it.
Volberding reports no relevant financial relationships.
Liz Scherer is an independent journalist specializing in infectious and emerging diseases, cannabinoid therapeutics, neurology, oncology, and women’s health.