Monkeypox is Sexually Transmitted Infection

When monkeypox emerged, cases in Europe were in men who have sex with men (MSM). When the disease arrived on our shores in May 2022 it soon became evident that the virus, which had mostly been limited to Africa, was behaving differently. Cases in the US were also exclusively in MSM and the locations of the characteristic rash were telling. The men who sought care had lesions (collective term to describe the different stages of monkeypox skin rash) on the penis, perianal region, rectum and mouth. The rectal lesions caused significant pain and often ulcerated. The images were disturbing but far worse where the agonizing cries from those affected. There is a growing body of evidence that monkeypox virus is in saliva and semen. And people without symptoms, or before they have symptoms, are likely able to transmit the disease. This fits with the epidemiology we are seeing. Whether monkeypox was being transmitted from skin to mucosal membrane or in semen is semantics, it is a sexually transmitted infection. 

Vaccine was in short supply. One drug was available, but prescribers had to agree to participate in a research protocol in oder to get their patients the drug. Most could not deal with the paperwork and other requirements. Gay men went from doctor to doctor seeking help and were often turned away.

The public messaging from the NYC Health Department and the Centers for Disease Control and Prevention focused on:

- Anyone can get monkeypox

- The route of transmission is skin to skin

- The disease is mainly (not only) in MSM

The department was not accurately communicating risk, instead were focused on avoiding stigmatization (see Sandman, We weren't giving people truthful information so they needed could make decisions to protect themselves. I spoke to my supervisors who informed leadership. I spoke to leadership at conference calls. I had the audacity to suggest that a temporary period of abstinence could interrupt transmission. I was told this hasn't worked and we are not going to make the mistakes of the past. But monkeypox had JUST entered the population, unlike syphilis, gonorrhea, and chlamydia. Unlike HIV, it likely doesn't persist for that long. A temporary moratorium might work and was worth a try. At least a discussion.

On Friday, July 15th, at few minutes after 4PM the health department released new guidance on monkeypox.  The relevant excerpt is below: 

In addition to vaccine, prevention measures offer protection. These include avoiding close physical contact if sick, especially if there is a new or unexpected rash or sore. For those who choose to have sex while sick, it is best to avoid kissing and other face-to-face contact. Also, sores should be covered with clothing or sealed bandages. This may help reduce - but not eliminate - the risk of transmission. Cleaning hands, sex toys, and bedding before and after sex or other intimate activities is advised. When making plans, New Yorkers should consider the level of risk. Having sex or other intimate contact with multiple or anonymous people (such as those met through social media, dating apps, or at parties) can increase risk of exposures.

To suggest that covering lesions and avoiding kissing would reduce monkeypox transmission is reckless and dangerous. I consulted several colleagues I respect and they were likewise outraged. 

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