Monkeypox crisis in the UK needs urgent funding: sex, vaccines and Pride
NOTE: for updated information on expected vaccine efficacy after one compared to two doses and the possible impact of HIV please see: How good is the monkeypox vaccine?
Simon Collins, HIV i-Base
Since 16 May when seven cases of monkeypox (MPX) had been reported, numbers in the UK have approximately doubled every week and by 1 July more than 1075 people had been diagnosed. 
MPX is no longer a novel concern that can be absorbed into the work of sexual health clinics and handled by contact tracing.
MPX quickly developed into a health crisis in the UK, that mainly affects networks of gay and bisexual men. Although most cases were initially in London, MPX has now been reported across the UK.
Healthcare responses: the need for rapid emergency funding
The rapid escalation in cases calls for emergency funding to enable services to respond adequately. Emergency funding needs to support diagnosis, treatment, management, prevention and information.
Health policies underestimated the spread of MPX and are now following the crisis rather than leading an adequate response.
- Sexual health clinics, already overstretched, are underfunded to cope with this new outbreak, both for testing and care.
- There is lack of laboratory support to include MPX swabs and samples as part of routine sexual health screening. This could detect asymptomatic infections and current levels of immune responses to plan a vaccine programme.
- Vaccine supplies are so low that the initiative to offer vaccines to people at highest risk is based on single doses rather than the recommended two dose schedule. No further details have been announced. See detailed report later in this issue of HTB. 
- Single vaccine shots will significantly reduce expected efficacy compared to two doses. Plans for vaccine roll-out for gay men in New York and Montreal use the two-vaccine schedule. 
- Less than 1 in 20 people (5%) are being offered tecovirimat, the likely best treatment. This is being restricted to severe infection, defined as requiring hospitalisation and/or having more than 100 ulcers or blisters. So with only 95 ulcers, advice is to stay home for three weeks and to isolate. Wider access should be offered open-label in addition to any plans for a randomised clinical study. 
- The early reliance on contact tracing might help individual cases and is still important. But it is now unable to reduce infections on a population level.
- Unlike COVID-19, so far at least, no support has been announced to help people who are being asked to isolate.
MPX is highly infectious in close contact. It is very easily transmitted during close physical contact, whether or not this is sexual.
Saliva is a more likely route than sexual fluids making kissing and oral sex possible risks.
So even though MPX is not primarily sexually transmitted, nearly all cases are in men who are gay, bisexual or who otherwise sleep with men. Unfortunately, our communities were unlucky in having some of the early cases.
It is important that many community organisations have been included in shaping the response to MPX and this has helped to limit stigma that might otherwise have been linked to the outbreak. Community projects are using their networks to provide information about risk.
But as the UK enters Pride week, the rapid expansion in MPX cases means that communities need direct information about risk. This should be more than advising people to watch out for spots and to wash their hands frequently, as this will have little impact on stopping the current outbreak.
Instead, the clearest and most direct advice for an individual to avoid MPX during Pride week is to not have sex in high-risk settings. And to not have sex with anyone who has had higher-risk sex.
Recent cases reported from Portugal included two important observations. Firstly, that some MPX spots can be difficult to differentiate from an insect bite. Secondly, that one case included a single internal ulcer in the rectum (that was only identified by proctoscopy due to local pain). This case should inform the discussion about the potential for MPX as an STI. 
And this strategy will probably work on a population level too. This information is provided knowing that any message to reduce sex will have limited acceptability. It is also possible that the suggestion will produce some less than supportive community responses. This is also an important part of the community response.
This is a short term suggestion – maybe for four weeks. This covers roughly once cycle (allowing one week from infection to symptoms and three weeks for recovery. Four weeks is long enough to limit the current spread and limit further overloading sexual health services. It is short enough to be socially acceptable as an emergency response.
This strategy includes not having sex in settings where connecting with multiple partners is easy, whether at private parties, saunas, darkrooms or cruising grounds. These settings generally have low light and limited other contact. Plus MPX can remain infectious on hard surfaces for weeks, and on soft materials, likely longer. 
Even with careful cleaning, sex-on-premises venues are likely to only be able to reduce risk. In situations where higher risk sex occurs, swapping contact details in case one of you later tests positive for MPX, might be an appreciative acknowledgment of respect.
An otherwise excellent webinar organised by the WHO last week on the implications of MPX for large festivals and other social and community gatherings planned for the summer, did not differentiate events like Glastonbury from Pride. 
As part of the wider information on MPX provided by community organisations, i-Base has posted two recent Q&A resources that include information about reducing risk in sexual settings for the upcoming Pride events. [7, 8]
One suggests that the safest way to avoid MPX is to limit sex for four weeks. The second explains why we are not saying not to have sex.
i-Base and the UK-CAB have produced an online factsheet that is currently being updated every couple of days. 
- International Monkeypox case tracker. [Kraemer MUG et al. Lancet Inf Dis, DOI: 10.1016/S1473-3099(22)00359-0]
- EACS/YING. EACS Live! Journal Club webinar. (23 June 2022).
- Collins S. UK offers limited vaccine to gay and bisexual men at risk of monkeypox: full dose offered in NYC. HTB (21 June 2022).
- NIHR. Efficacy of Tecovirimat for the treatment of non-hospitalised patients with confirmed monkeypox – research brief. (30 May 2022).
- US CDC. Disinfection of the Home and Non- Healthcare Settings. (6 June 2022).
- WHO webinar. Monkeypox and mass gatherings. (24 June 2022).
- i-Base Q&A. How can I avoid monkeypox during Pride week? (24 June 2022).
- i-Base Q&A. Why is i-Base saying to not have sex during Pride? (24 June 2022).
- i-Base and UK-CAB. Monkeypox factsheet (updated at least weekly)
This article was first posted on 27 June 2022.