Monkeypox and the unlearned lessons of what happened to HIV

“We don’t learn. But in no case also.” This is how resoundingly Nahum Cabrera, HIV coordinator of FELGTBI+. The spokesperson for the State Federation of Lesbians, Gays, Transsexuals, Bisexuals, Intersex and Others regrets that once again, a disease stigmatizes the group. If in the 80s it happened with HIV, now you see you are tripping over the same stone with monkeypox.

This disease, also called monkey poxhas already claimed two lives in Spain – the country with the most cases in Europe and the second in the world, behind the United States – and infections are approaching 5,000, according to data from the Ministry of Health this Friday.

The vast majority of patients notified to the surveillance system in Spain are men (4,863 versus 79 women). As quoted by EFE, eight out of ten infected people are men who have sex with men and the most likely transmission mechanism, in 2,287 cases for which this information is available, was through close contact in the context of a sexual intercourse in 80.6% of the occasions (and in 9.1%, due to close non-sexual contact).

A similar profile was found in study carried out by the Spanish Group for Sexually Transmitted Diseases and AIDS of the Spanish Academy of Dermatology and Venereology (AEDV), published this week in British Journal of Dermatology.

“The vast majority of patients are men who have sex with men and many are HIV positive or taking HIV pre-exposure prophylaxis or engaging in risky behaviors such as chemsex, many sexual partners… At the beginning of the epidemic, we saw that. Over time, the profile opens up and you no longer see people who have so many sexual risks”, warns Alba Català, lead author of the study and dermatologist at the Hospital Clinic of Barcelona.

As Català reminds us, monkeypox is not a sexually transmitted disease, but rather a contact disease —obviously, yes, during sex there is intimate and prolonged contact—. The same underlines Cabrera, who specifies that monkeypox and HIV are “two totally different infections”, although there is a parallelism of stigmatization: “In the 80s, we spoke of a purely sexual infection and it was a societal problem. Monkeypox is a contact disease that can affect anyone. It also shows that for monkeypox there is no barrier element, such as a condom.

The most important finding of the AEDV study is that the clinical presentation of the patients “differs a little from what had been published previously in the African cases”. “Most of the cases in Africa were due to respiratory droplets or saliva and what we have seen in most cases – until today, as it may change over time – is that they occur through skin-to-skin contact during sexual intercourse. This means that the virus enters the body in a different way and the skin lesions are also different, ”explains Català.

Instead of patients having a fever and then a chickenpox-like rash, “which evolves from a macula, which is the spot, then the bump, which is the papule, then the vesicle, then the pustule, then the scab” , what they observe in the cases here is that “where the virus goes in there are little white bumps that look like pustules but when you try to drain it or scratch it no pus comes out because it ‘is hard”. “These lesions are very characteristic and hardly resemble anything of other diseases and, once we have seen several cases, it is easy to recognize them”, he underlines.

According to the expert, “it was purely by chance that the epidemic started among men who have sex with men, because the virus does not have a particular appetite for this group”.

Nahum Cabrera also warns of the same thing, which has already happened with HIV: “People tell you ‘it’s for gays’, ‘since I’m not gay it won’t affect me’, they literally say it like that”. “A false sense of security is created in the heterosexual group and viruses do not understand sexual orientations or identities,” he points out.

“What stigma does is blow up consciences, create hatred, fear and, above all, if someone catches monkeypox, it harms their psychological health”, sums up the FELGTBI+ HIV coordinator about the consequences of grouping on the target.

Apart from the undeniable health problem caused by the spread of this disease, experts are concerned about this stigma. Thus, the voice of Cabrera, which joins many others who ask not to focus on homosexuals and bisexuals. For instance, UNAIDS, the Joint United Nations Program on HIV/AIDS, expressed concern. In the words of its deputy director, Matthew Kavanagh, “stigma and guilt undermine trust and the ability to respond effectively during outbreaks like this.” According to this organization, “just as we learned with so much effort the response to the AIDS pandemicall effective public health actions must be guided by the principles of solidarity, equality, non-discrimination and inclusion”.

“Let’s stop stigmatizing and promote preventive discourse,” said epidemiologist and president of the Spanish Association of Vaccinology Amós García Rojas via his Twitter account. “It can affect all of us and not a specific group,” he recalled.

The Ministry of Health itself has warned that if transmission gets out of control, “there is a significant risk that it moves to other population groups by the same mechanism of transmission, being possible the affectation of other groups, and the appearance of serious cases in the vulnerable populations”.

The same has been pointed out by the United States Centers for Disease Control and Prevention, which has insisted that “anyone can get monkeypox” and that focusing on gay and bisexual men “can inadvertently stigmatize” and “create a false sense of security” among those who are not.

Dermatologist Català reflects on another subject: “Not all men who have sex with men are at risk, it is a group that has more risky sexual practices, a small proportion of the whole”. “So was the sin of not explaining enough to this group that was at risk of this happening. It’s a double-edged sword: you don’t stigmatize them but you can’t protect them either. If I do not explain to you that you have this possibility of contracting this disease because of your sexual activity, that it is personal and that everyone does what they want, the fact of not informing is a way of not facilitating the control of this disease,” he explains.

“It’s amazing” to Cabrera that the World Health Organization has recommended fewer sexual partners, which he says heightens stigma. “We are surprised that the WHO, which is the highest medical establishment in the world, directly points to the LGTBI community as a precursor to the spread of a virus. The statements are in the same line as those of 40 years ago because of HIV, when we were stigmatized as a pink virus for the LTGBI collective”, he defends himself.

“We see it totally wrong, we think the WHO should focus on purely medical issues, not social issues. And having more or less sexual partners is a completely social issue. It’s like they said not to approach, not to touch, not to feel… Having more or less sexual partners is a personal decision and they infringe on everyone’s privacy and freedom”, continues -he. .

For the FELGTBI+ spokesperson, these are “very harsh statements that carry enormous stigma”. “The same thing is repeated 40 years ago, when smallpox is still a contact disease and not sexual and the WHO recommends to reduce sexual partners. It’s an inconsistency,” he said.

“The highest levels are again saying this is a gay issue and two things are happening. Being a gay and bisexual thing, the state doesn’t care so much anymore, it’s like a gay thing. And, just like when HIV started, it wasn’t until a massive swath of the population started dying that they started taking real action,” says Cabrera.

To the Federation, they ask to focus on the most effective measure and not on the charges. “If we eradicated smallpox in the 1970s, we can do it again, vaccinate the population,” he recalls.

However, he considers the number of vaccines that Spain receives insufficient and describes it as “a drop of water in a desert to try to irrigate it”. “We have the technology, it’s a super simple vaccine, which has already been invented. We’re just asking “let’s get to work,” he urges.