As monkeypox cases continue to climb across the United States, many clinicians now need to counsel their patients on how to protect against the virus as well as provide treatment. Medscape Medical News spoke with John T. Brooks, MD, a medical epidemiologist with the Centers for Disease Control and Prevention (CDC) Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, to answer questions on how to talk about monkeypox with patients and other clinical issues related to the emerging infectious disease.
What populations or communities does the CDC consider most "at risk" for monkeypox?
This is remarkable insofar as monkeypox is a disease that has very disproportionately affected gay, bisexual, and other men who have sex with men (MSM). Over 95% of cases worldwide are occurring in persons who report male-to-male sexual contact, and their median age is right around the mid-30s. Not surprisingly — but sometimes surprising to people who aren't aware of sexually transmitted diseases (STDs) — about 40% of patients with monkeypox are HIV positive. This does not reflect some biologic risk because of HIV infection, but rather, behavioral risk related to how people who have HIV acquired the infection. The incidence of certain STDs in this population is also around 40%.
We see that in a paper published by Thornhill and colleagues in The New England Journal of Medicine, a substantial fraction of MSM with monkeypox had more than five sexual partners in the last 3 months, and almost 30% were diagnosed with a sexually transmitted infection at the time they were diagnosed with monkeypox.
How should clinicians approach the conversation about exposure to monkeypox with their patients?
Unfortunately, gay sex continues to be highly stigmatized in our culture, and in many parts of the world where this disease is endemic, homosexuality is criminalized. So it's important that we speak to persons who we believe are at risk for monkeypox without stigma and without discrimination — that we speak to people clearly with the facts. We hear from the community that they want to know what they need to know to protect themselves, but they want to know it in a professional way. For them, it's important to have the information they need to make an informed choice, and that empowers them to make the best choices with regard to harm reduction practices. But we need to do that without shame, without judgment, and by recognizing their lived experience as valid.
Is there certain language you would advise clinicians to use vs language that might be considered stigmatizing?
I'd recommend using people-first language. That means putting the person at the center of the disease rather than the disease as equal to the person. Instead of saying, "This is an HIV infected man or an HIV infected woman," you would say, "This is a person with HIV." The person comes first, and the condition is part of their life vs the person being defined by the condition. It's a small change to make but it's remarkable how empowering it is, both as a provider and a patient in terms of engendering trust.
The second thing is to just be nonstigmatizing and straightforward, and that doesn't mean you have to be a cold clinician speaking like a computer. You need to be empathetic. Lastly, be forgiving of yourself and of them. If somebody reacts with anger, try to understand where that anger was coming from. You may have said something that triggered a bad reaction based on their lived experience you're not aware of. We're all going to make mistakes in how we talk to people. Apologize for making a mistake and say, "Let me restate that a different way. I want to make sure you don't misunderstand me and that you realize I'm here to help take care of you. We're on this journey together."
How should clinicians deal with language like "sexually transmitted" when discussing monkeypox?
Dr King Holmes at the University of Washington in Seattle, who wrote the textbook on STDs, defines a disease as sexually transmitted if it requires human sexual contact to be spread. Gonorrhea and classic syphilis are two good examples. But there are many, many diseases that are spread through sexual contact although they don't necessarily use that as their primary mode of transmission, like hepatitis C, Ebola, Zika, human papillomavirus, herpes...I could go on and on. We would call those diseases "sexually transmissible" to raise awareness around the fact that they can be transmitted through the intimate contact of sex, but that isn't necessarily their only mode of transmission.
There's often some confusion that for something to be sexually transmissible or transmitted, it must be found in sexual fluids: that it has to be in semen or vaginal fluids, but that isn't necessarily the case. You could have close physical contact during sex, and that would have been sufficient to transmit Ebola. The same is true with monkeypox. We don't know yet that monkeypox is transmitted in sexual fluids. Its genetic material has been detected in semen, but with all things sexual, figuring out exactly what happened is complex. We tend to do a lot of things at once during sex: We kiss, we touch, we hug, and it's hard to just to parse out what the specific contact was sometimes.
It's important to recognize that monkeypox can be transmitted through the close intimate contact of sex. But I also caution that you shouldn't be blinded to the fact that it may be transmitted by other means, or that it is necessarily limited to networks of MSM.
How would you advise patients on safe sex where monkeypox is concerned?
We recommend a harm reduction approach. We talk about "safer sex," rather than "safe sex." What that means is making choices that are acceptable to you for the amount of risk that you're willing to take. The CDC has a useful website looking at safer sex, large gatherings, and monkeypox.
If you want to be at very low risk, then you may want to not touch the other person and stand apart and masturbate together or have sex over the Internet — some way where there's not physical contact. If you're willing to get closer to people, then you can cover parts of your body that you're worried about potentially getting exposed. That can be with regular clothes, or there are leather or latex fetish materials that people can experiment with.
I'm sometimes asked if there a role for condoms here, including both male and female condoms. I would say yes, and here's why. In the current outbreak of this disease, we're seeing a remarkable prevalence of anogenital and oral mucosal lesions. The skin lesions also tend to be very concentrated in the anogenital area. These are tender spots, and people who have these lesions in their mouth, throat, anus, foreskin, or urethra find it to be excruciatingly painful. It's not clear how the virus is getting to these mucosal surfaces, but I don't think it's unreasonable to hypothesize that there's some form of direct inoculation occurring. For example, a penis that has virus on it is inserted into the anus, or an anus with virus on it has a penis inserted into it. In that circumstance, condoms used consistently may reduce the likelihood that the surface of those mucosal tissues are exposed to virus. But that won't protect someone from virus that may be on a person's thigh, their belly, their buttocks, or on the perineum, necessarily.
What are the most surprising things you've learned from your research into how this is affecting LGBTQIA+ persons?
The most unusual thing is the pain associated with this disease. You look at these photographs of lesions or you see them in person, and if you've dealt with a lot of STDs, you get used to saying, "I'm looking at this lesion and this monkeypox lesion looks a lot like herpes or folliculitis." But the pain that people are describing is so much greater than what someone may experience with those other diseases. People have throat pain so severe that they can't swallow water or eat, and they require a nasal gastric tube. People have urinary pain so severe that they just spasm and they cannot urinate and require a urinary catheter. That's really exceptional in the world of sexually transmissible diseases.
Monkeypox can also be quite scarring. If you get lesions on your face, or on exposed areas of your arms or legs, or in your genitalia, these can be cosmetically very sensitive areas. People can have some pretty large lesions along their chin and nose. Particularly if you have deeply pigmented skin, this can also lead to issues with altered pigmentation that can be cosmetically difficult for some people. We don't see this with other pox viruses like molluscum contagiosum or chickenpox. On the male penis in an uncircumcised man, you can get strictures of the foreskin that may require circumcision. I'm aware that in at least one clinic in New York, the uroplastics service is being consulted more often than you'd like to deal with issues around urethral stricture.
How should clinicians approach monkeypox treatment?
We really encourage people to take the pain story seriously. One of the first things I've learned is you really need to meet people where they are. When they explain their pain, accept it, be their ally. They really need you to listen to them, and don't hesitate to treat. Stool softeners are a simple solution to make defecation less painful if you've got a sore bum, and especially if you're going to move into using opioids for pain management. A number of people with monkeypox may need opioids for a short period of time, and you want to absolutely make sure that you've got stool softeners on board because opioids can be constipating. Many of us are very sensitized around misuse of opioids and other addictive substances. I think this is a place though where you need to also respond to the voice of "I have a person for whom these [medications] are merited and needed."
Tecovirimat (TPOXX) is an important agent that we've made available through compassionate use using an expanded access, investigational-new-drug protocol. I just want to caution that we don't know that TPOXX works. Its efficacy has never been studied or established in human beings. It was approved for the treatment of smallpox in the context of animal studies. In one of those studies, they had to use monkeypox, and it proved beneficial to nonhuman primates.
People have the right to have compassionate access to potentially helpful drugs. At the same time, the scientists and physicians are obligated to do no harm, and we therefore also must link compassionate access for a drug to studies examining if that drug really works as advertised and is also not causing harm to people. That's why there are now these randomized clinical trials being stood up in parallel very, very rapidly to examine if TPOXX works, and if it does, at what stage of illness is it most beneficial? The names of the studies are great. The one in the United States has the acronym STOMP. The other study is being run in the United Kingdom, called PLATINUM.
There have been parallels made between this monkeypox outbreak and HIV. What are you seeing as similarities and differences?
The first similarity is we're in this place where we have medications that are available and need to get them to people quickly and compassionately, while also ensuring that we understand how they work. I've just been really struck by the parallel of the early antiretrovirals — when they first came out in the mid to late 80s — and what we're seeing now with TPOXX. Second, we have this disease that's once again affecting a marginalized, highly stigmatized, sexual minority. What's different today is that we've had the privilege of 30 years of education to learn more about human sexuality and to understand the damage of stigma and institutionalized discrimination. We have an opportunity now to use that knowledge to move forward and do a better job this time around.
Last, as with HIV, don't take your eye off the bouncing ball. Let's pay attention to the population and networks that are currently being affected but be aware that it can affect other networks and groups. Be on the lookout for unexpected cases. Those would be infections that are occurring in children and in heterosexual women who don't have contact with somebody within a network of MSM or clusters of infection that aren't among MSM. We're vigilant in monitoring other places where close contact occurs, such as correctional facilities or homeless facilities.
How are the data on monkeypox demographics, hospitalizations, and clinical outcomes being used to inform the clinical and epidemiologic strategy?
We do receive a lot of data from states and we're watching international data very closely. We use it to understand where the disease is going, and where we need to begin directing our efforts. One of the ways we've used it, very practically, is helping to determine where to direct vaccine resources. Jynneos, a US Food and Drug Administration–approved vaccine to protect against monkeypox, is in limited supply. So how do we decide where it goes? We've used a combination of estimating how large the population at risk is for every state — the estimated number of persons eligible for HIV preexposure prophylaxis plus the estimated fraction of MSM living with HIV. Then, we apply to that a multiplier of the number of monkeypox cases being reported in the jurisdiction. We look at both the size of the underlying at-risk population and where monkeypox cases are occurring right now and distribute vaccines based on a formula that takes both set of factors into account.
How is the CDC working with other countries' health agencies to share and compile monkeypox data?
We all look at each other's data to see what's going on in other countries, looking for trends. The other thing that all of us do is we look at each other's reports. The United Kingdom, the European Union, Canada, and the United States regularly put out technical reports and summaries of what's going on, and those contain valuable information. This happened during COVID-19 as well, but sometimes, some countries are a little ahead of us in terms of cases. Right now, the United States represents about one third of total worldwide cases. But before that was the case, there was a larger burden of disease in the United Kingdom, Spain, and the European Union. They were able to do some early data calculations to confirm the incubation period and to get ahead of some of the critical epidemiologic data before we had sufficient cases in our country to do the same.
I just want to say how important it is to share information that way, because each country is going to be at a different place in an outbreak that's multinational like this. Anything we can learn that can help others, we want to share quickly with other countries, including endemic countries in West and Central Africa. What we learned about vaccination and treatment in this country absolutely needs to be turned into data that can be used by those countries for their own endemic purposes.
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COMMENTARY
Treating Monkeypox: Q&A with the CDC's John T. Brooks, MD
John T. Brooks, MD
DisclosuresAugust 22, 2022
Editorial Collaboration
Medscape &
As monkeypox cases continue to climb across the United States, many clinicians now need to counsel their patients on how to protect against the virus as well as provide treatment. Medscape Medical News spoke with John T. Brooks, MD, a medical epidemiologist with the Centers for Disease Control and Prevention (CDC) Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, to answer questions on how to talk about monkeypox with patients and other clinical issues related to the emerging infectious disease.
What populations or communities does the CDC consider most "at risk" for monkeypox?
This is remarkable insofar as monkeypox is a disease that has very disproportionately affected gay, bisexual, and other men who have sex with men (MSM). Over 95% of cases worldwide are occurring in persons who report male-to-male sexual contact, and their median age is right around the mid-30s. Not surprisingly — but sometimes surprising to people who aren't aware of sexually transmitted diseases (STDs) — about 40% of patients with monkeypox are HIV positive. This does not reflect some biologic risk because of HIV infection, but rather, behavioral risk related to how people who have HIV acquired the infection. The incidence of certain STDs in this population is also around 40%.
We see that in a paper published by Thornhill and colleagues in The New England Journal of Medicine, a substantial fraction of MSM with monkeypox had more than five sexual partners in the last 3 months, and almost 30% were diagnosed with a sexually transmitted infection at the time they were diagnosed with monkeypox.
How should clinicians approach the conversation about exposure to monkeypox with their patients?
Unfortunately, gay sex continues to be highly stigmatized in our culture, and in many parts of the world where this disease is endemic, homosexuality is criminalized. So it's important that we speak to persons who we believe are at risk for monkeypox without stigma and without discrimination — that we speak to people clearly with the facts. We hear from the community that they want to know what they need to know to protect themselves, but they want to know it in a professional way. For them, it's important to have the information they need to make an informed choice, and that empowers them to make the best choices with regard to harm reduction practices. But we need to do that without shame, without judgment, and by recognizing their lived experience as valid.
Is there certain language you would advise clinicians to use vs language that might be considered stigmatizing?
I'd recommend using people-first language. That means putting the person at the center of the disease rather than the disease as equal to the person. Instead of saying, "This is an HIV infected man or an HIV infected woman," you would say, "This is a person with HIV." The person comes first, and the condition is part of their life vs the person being defined by the condition. It's a small change to make but it's remarkable how empowering it is, both as a provider and a patient in terms of engendering trust.
The second thing is to just be nonstigmatizing and straightforward, and that doesn't mean you have to be a cold clinician speaking like a computer. You need to be empathetic. Lastly, be forgiving of yourself and of them. If somebody reacts with anger, try to understand where that anger was coming from. You may have said something that triggered a bad reaction based on their lived experience you're not aware of. We're all going to make mistakes in how we talk to people. Apologize for making a mistake and say, "Let me restate that a different way. I want to make sure you don't misunderstand me and that you realize I'm here to help take care of you. We're on this journey together."
How should clinicians deal with language like "sexually transmitted" when discussing monkeypox?
Dr King Holmes at the University of Washington in Seattle, who wrote the textbook on STDs, defines a disease as sexually transmitted if it requires human sexual contact to be spread. Gonorrhea and classic syphilis are two good examples. But there are many, many diseases that are spread through sexual contact although they don't necessarily use that as their primary mode of transmission, like hepatitis C, Ebola, Zika, human papillomavirus, herpes...I could go on and on. We would call those diseases "sexually transmissible" to raise awareness around the fact that they can be transmitted through the intimate contact of sex, but that isn't necessarily their only mode of transmission.
There's often some confusion that for something to be sexually transmissible or transmitted, it must be found in sexual fluids: that it has to be in semen or vaginal fluids, but that isn't necessarily the case. You could have close physical contact during sex, and that would have been sufficient to transmit Ebola. The same is true with monkeypox. We don't know yet that monkeypox is transmitted in sexual fluids. Its genetic material has been detected in semen, but with all things sexual, figuring out exactly what happened is complex. We tend to do a lot of things at once during sex: We kiss, we touch, we hug, and it's hard to just to parse out what the specific contact was sometimes.
It's important to recognize that monkeypox can be transmitted through the close intimate contact of sex. But I also caution that you shouldn't be blinded to the fact that it may be transmitted by other means, or that it is necessarily limited to networks of MSM.
How would you advise patients on safe sex where monkeypox is concerned?
We recommend a harm reduction approach. We talk about "safer sex," rather than "safe sex." What that means is making choices that are acceptable to you for the amount of risk that you're willing to take. The CDC has a useful website looking at safer sex, large gatherings, and monkeypox.
If you want to be at very low risk, then you may want to not touch the other person and stand apart and masturbate together or have sex over the Internet — some way where there's not physical contact. If you're willing to get closer to people, then you can cover parts of your body that you're worried about potentially getting exposed. That can be with regular clothes, or there are leather or latex fetish materials that people can experiment with.
I'm sometimes asked if there a role for condoms here, including both male and female condoms. I would say yes, and here's why. In the current outbreak of this disease, we're seeing a remarkable prevalence of anogenital and oral mucosal lesions. The skin lesions also tend to be very concentrated in the anogenital area. These are tender spots, and people who have these lesions in their mouth, throat, anus, foreskin, or urethra find it to be excruciatingly painful. It's not clear how the virus is getting to these mucosal surfaces, but I don't think it's unreasonable to hypothesize that there's some form of direct inoculation occurring. For example, a penis that has virus on it is inserted into the anus, or an anus with virus on it has a penis inserted into it. In that circumstance, condoms used consistently may reduce the likelihood that the surface of those mucosal tissues are exposed to virus. But that won't protect someone from virus that may be on a person's thigh, their belly, their buttocks, or on the perineum, necessarily.
What are the most surprising things you've learned from your research into how this is affecting LGBTQIA+ persons?
The most unusual thing is the pain associated with this disease. You look at these photographs of lesions or you see them in person, and if you've dealt with a lot of STDs, you get used to saying, "I'm looking at this lesion and this monkeypox lesion looks a lot like herpes or folliculitis." But the pain that people are describing is so much greater than what someone may experience with those other diseases. People have throat pain so severe that they can't swallow water or eat, and they require a nasal gastric tube. People have urinary pain so severe that they just spasm and they cannot urinate and require a urinary catheter. That's really exceptional in the world of sexually transmissible diseases.
Monkeypox can also be quite scarring. If you get lesions on your face, or on exposed areas of your arms or legs, or in your genitalia, these can be cosmetically very sensitive areas. People can have some pretty large lesions along their chin and nose. Particularly if you have deeply pigmented skin, this can also lead to issues with altered pigmentation that can be cosmetically difficult for some people. We don't see this with other pox viruses like molluscum contagiosum or chickenpox. On the male penis in an uncircumcised man, you can get strictures of the foreskin that may require circumcision. I'm aware that in at least one clinic in New York, the uroplastics service is being consulted more often than you'd like to deal with issues around urethral stricture.
How should clinicians approach monkeypox treatment?
We really encourage people to take the pain story seriously. One of the first things I've learned is you really need to meet people where they are. When they explain their pain, accept it, be their ally. They really need you to listen to them, and don't hesitate to treat. Stool softeners are a simple solution to make defecation less painful if you've got a sore bum, and especially if you're going to move into using opioids for pain management. A number of people with monkeypox may need opioids for a short period of time, and you want to absolutely make sure that you've got stool softeners on board because opioids can be constipating. Many of us are very sensitized around misuse of opioids and other addictive substances. I think this is a place though where you need to also respond to the voice of "I have a person for whom these [medications] are merited and needed."
Tecovirimat (TPOXX) is an important agent that we've made available through compassionate use using an expanded access, investigational-new-drug protocol. I just want to caution that we don't know that TPOXX works. Its efficacy has never been studied or established in human beings. It was approved for the treatment of smallpox in the context of animal studies. In one of those studies, they had to use monkeypox, and it proved beneficial to nonhuman primates.
People have the right to have compassionate access to potentially helpful drugs. At the same time, the scientists and physicians are obligated to do no harm, and we therefore also must link compassionate access for a drug to studies examining if that drug really works as advertised and is also not causing harm to people. That's why there are now these randomized clinical trials being stood up in parallel very, very rapidly to examine if TPOXX works, and if it does, at what stage of illness is it most beneficial? The names of the studies are great. The one in the United States has the acronym STOMP. The other study is being run in the United Kingdom, called PLATINUM.
There have been parallels made between this monkeypox outbreak and HIV. What are you seeing as similarities and differences?
The first similarity is we're in this place where we have medications that are available and need to get them to people quickly and compassionately, while also ensuring that we understand how they work. I've just been really struck by the parallel of the early antiretrovirals — when they first came out in the mid to late 80s — and what we're seeing now with TPOXX. Second, we have this disease that's once again affecting a marginalized, highly stigmatized, sexual minority. What's different today is that we've had the privilege of 30 years of education to learn more about human sexuality and to understand the damage of stigma and institutionalized discrimination. We have an opportunity now to use that knowledge to move forward and do a better job this time around.
Last, as with HIV, don't take your eye off the bouncing ball. Let's pay attention to the population and networks that are currently being affected but be aware that it can affect other networks and groups. Be on the lookout for unexpected cases. Those would be infections that are occurring in children and in heterosexual women who don't have contact with somebody within a network of MSM or clusters of infection that aren't among MSM. We're vigilant in monitoring other places where close contact occurs, such as correctional facilities or homeless facilities.
How are the data on monkeypox demographics, hospitalizations, and clinical outcomes being used to inform the clinical and epidemiologic strategy?
We do receive a lot of data from states and we're watching international data very closely. We use it to understand where the disease is going, and where we need to begin directing our efforts. One of the ways we've used it, very practically, is helping to determine where to direct vaccine resources. Jynneos, a US Food and Drug Administration–approved vaccine to protect against monkeypox, is in limited supply. So how do we decide where it goes? We've used a combination of estimating how large the population at risk is for every state — the estimated number of persons eligible for HIV preexposure prophylaxis plus the estimated fraction of MSM living with HIV. Then, we apply to that a multiplier of the number of monkeypox cases being reported in the jurisdiction. We look at both the size of the underlying at-risk population and where monkeypox cases are occurring right now and distribute vaccines based on a formula that takes both set of factors into account.
How is the CDC working with other countries' health agencies to share and compile monkeypox data?
We all look at each other's data to see what's going on in other countries, looking for trends. The other thing that all of us do is we look at each other's reports. The United Kingdom, the European Union, Canada, and the United States regularly put out technical reports and summaries of what's going on, and those contain valuable information. This happened during COVID-19 as well, but sometimes, some countries are a little ahead of us in terms of cases. Right now, the United States represents about one third of total worldwide cases. But before that was the case, there was a larger burden of disease in the United Kingdom, Spain, and the European Union. They were able to do some early data calculations to confirm the incubation period and to get ahead of some of the critical epidemiologic data before we had sufficient cases in our country to do the same.
I just want to say how important it is to share information that way, because each country is going to be at a different place in an outbreak that's multinational like this. Anything we can learn that can help others, we want to share quickly with other countries, including endemic countries in West and Central Africa. What we learned about vaccination and treatment in this country absolutely needs to be turned into data that can be used by those countries for their own endemic purposes.
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Cite this: Treating Monkeypox: Q&A with the CDC's John T. Brooks, MD - Medscape - Aug 22, 2022.
Tables
Authors and Disclosures
Authors and Disclosures
Author
John T. Brooks, MD
Chief Medical Officer, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention; Chief Medical Officer, Multinational Monkeypox Outbreak Response, Centers for Disease Control and Prevention
Disclosure: John T. Brooks, MD, has disclosed no relevant financial relationships.