Marina Klein, research director and professor of medicine at the Division of Infectious Diseases at McGill University, left, and Sharon Lewin, International AIDS Society president-elect, speak during a roundtable discussion on monkeypox at the International AIDS Conference in Montreal, on July 31.Graham Hughes/The Canadian Press
As monkeypox continues to spread worldwide – 22,485 cases in 79 countries at last count – public health officials are unanimous on one point: We can’t afford a repetition of the AIDS debacle.
The foot-dragging and homophobia that greeted the new virus in the early 1980s created the perfect opportunity for what has become one of the worst pandemics in history, with more than 40 million dead and 38 million more living with HIV.
Yet the parallels in the response are eerily similar. To date, 98 per cent of monkeypox cases are in men who have sex with men. When AIDS emerged 40 years ago, it was labelled the “gay plague.”
The focus on the sexual practices of those being infected is a double-edged sword: It creates stigma, discouraging people from coming forward for testing and treatment, allowing the virus to spread; it also creates the false impression that no one outside the community is at risk.
Monkeypox has the added challenge of emerging two-and-a-half years into the COVID-19 pandemic. “We got caught flat-footed because everyone working in infectious disease is exhausted,” said Marina Klein, senior scientist in the global health program at the Research Institute of the McGill University Health Centre in Montreal.
Montreal was one of the first and hardest-hit cities by monkeypox. It recorded a first case on May 12, and has recorded more than 300 cases to date. The city is also being praised for its response.
Montreal Public Health has made it easy to get vaccinated, even opening a pop-up clinic on the street in the heart of the Gay Village. Many delegates to the 24th International AIDS Conference have taken advantage of the easy access to get shots, and visitors to the city’s Pride Week, which begins Monday, are expected to do the same.
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One week ago, the World Health Organization (WHO) declared the monkeypox outbreak to be a global health emergency. Since then, New York State and the city of San Francisco have also declared emergencies.
There are three major challenges in reining in the outbreak, according to Meg Doherty, director of the Department of Global HIV, Hepatitis and Sexually Transmitted Infection Programmes at the WHO: shortcomings in testing, vaccination and treatment.
There is no rapid test for monkeypox and many labs are not set up to test for the until recently rare disease. This likely means many undetected cases.
There is one principal manufacturer of the monkeypox vaccine and only 16.4 million doses available worldwide, raising fears of hoarding and inequity. The U.S. has distributed 310,000 doses and Canada 20,000 but there are no doses available anywhere in Africa.
There is only one treatment specifically for monkeypox, a drug called Tecovirimat (TPOXX for short) but it has only ever been tested in monkeys and rabbits, so it’s not clear how well it works in humans. The recommended 21-day isolation period is punishing.
Monkeypox causes pus-filled lesions on the skin. Symptoms are often not too bad but it can be extremely painful in some cases, or even deadly. To date, in the current outbreak, there have been eight recorded deaths: three in Nigeria, two in the Central African Republic, two in Spain and one in Brazil.
Chloe Orkin, a professor of HIV medicine at Queen Mary University in London, said because most of those infected are men who have sex with men, researchers are interested in any link with HIV. Her team published a study of 528 men with monkeypox, in which they found 41 per cent had HIV, and 57 per cent were taking PrEP (pre-exposure prophylaxis to prevent HIV infection). What this means is unclear. It could simply be that men with HIV are more likely to seek care when they have genital lesions.
Traditionally, monkeypox lesions appear as a rash on the hands, feet and face but, in the current outbreak, they are appearing in the genital, anal and oral areas. It’s not entirely clear why, other than this is where skin-to-skin contact occurs when men have sex with men. The monkeypox virus can also be spread by respiratory droplets or by touching the same surfaces as someone who is infected, like bedsheets.
At this point, can the outbreak be contained? That’s unclear.
Dr. Keletso Makafane, a fellow at the FXB Center for Health and Human Rights at Harvard University, said the most troubling aspect is that the early response to monkeypox has been worse than it was for AIDS.
“We have a huge multi-country outbreak and no co-ordinated global response,” he said. “Everything now needs to happen quickly.”
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André Picard