A Call to Plan

This is not a joke. In the middle of a world out of control, it’s time for the CDC to review the science on monkeypox (MPX) and recommend that all sexually active gay and bisexual men, regardless of their HIV status, get the MPX vaccine. NMAC makes this request to trigger the development of national, state, and local plans. Between the World Health Organization’s (WHO) declaration and the data in the New England Journal of Medicine (NEJM), where 41% of the people who got MPX are also living with HIV, it’s time to move from monitoring to planning.

Last weekend the WHO declared monkeypox a public health emergency of international concern. There are over 16,500 cases in 74 countries. In the US, there are 2,800 cases in 44 states, DC, and Puerto Rico. A recent article quoted the NEJM that said 95% of MPX cases were transmitted through sexual activity. Ninety-eight percent of the people who got MPX were gay or bisexual men. Forty-one percent were living with HIV. The declaration and science cannot be ignored. There needs to be a new standard of care that recommends and implements initiatives so all sexually active gay and bisexual men get the MPX vaccine.

While the recommendation prioritizes sexually active gay and bisexual men, vaccination targets may need to be expanded if we are unable to control MPX. Plans should include the transgender community, sex workers, and staff who work where there is sexual activity (bathhouses, saunas, and sex clubs). Due to shortages, there is not enough vaccine. This failure will not be forgotten. Hopefully, the system will be fully stocked in September. The next 45 days should prioritize planning. Vaccine equity and overcoming vaccine hesitancy are key. NMAC is particularly concerned about reaching people of color. The COVID vaccine roll-out showed it’s not enough to just make the vaccine available. There are too many who are unaware of MPX and/or who do not trust the system. Plans must prioritize hard to reach communities.

The WHO declaration validates the need for leadership and funding from the White House. Since the White House’s MPX response is coordinated by the National Security Agency (NSA), it’s time to bring everyone together to plan how to plan. Vaccine equity and overcoming vaccine hesitancy may create new pathways to educate about PrEP and/or U=U. While MPX and HIV impact the same communities, we don’t know much about the specific impact the virus that causes HIV has on MPX. Does viral load impact MPX outcomes? Since there are different versions of the MPX vaccine, is there a need to recommend a specific vaccine for people who are immune compromised? While there is a shortage, should we prioritize getting at least one MVA vaccine?

Why is HIV getting involved in MPX? These viruses impact the same communities and HIV has the infrastructure to support this huge lift. However, it is too big a task and requires coordination across multiple movements. Vaccine experts may not understand how to reach the target communities. The data and experience of vaccinating all sexually active gay men could support efforts to end the HIV epidemic. While many health departments have already started, there needs to be a coordinated national response. The sooner we vaccinate, the better our chances of stopping MPX from becoming another epidemic. It starts with an emergency transfer of $100 million to be drawn broadly from HHS. Federal guidance to health departments to reprogram HIV and COVID funds. Support for the National Coalition of STD Directors request for $100 million in new federal funding. But we can’t wait for Congress.

This is too much and our plates are already full. I really hoped to avoid this burden, but the virus had other plans.  The thought of vaccinating all sexually active gay and bisexual men is overwhelming. This is a very heavy lift that is going to take money, planning, and coordination across multiple sectors.

I got the monkeypox vaccine (MPXV)! Normally I would not share this information, but there is too much slut shaming, particularly from other gay men! I’m shocked I tell you. It’s a vaccine, not a lifestyle. Getting it says I care about my health. It’s the same smallpox vaccine that has been around for decades. Many older Americans got the shot; however, routine vaccinations stopped in 1972. If you don’t recall getting the vaccine, it is OK to get another dose. Talk to your doctor.

There are multiple versions. I got the MVA vaccine which is built around a weaker version of the virus and is much safer. The ACAM2000 vaccine contains active virus and is not recommended for immune compromised individuals. Are PLHIV considered immune compromised if they have an undetectable viral load? Once again, the role of treatment education is critical to our field.

Like the COVID vaccine, MPX vaccines needs to be free. Given the large percentage of PLHIV who might also get MPX, HRSA needs a MPX strategy for Ryan White clients. Can their infrastructure be used to vaccinate sexually active PLHIV? What about gay men who are HIV negative? While the data is clear, more science is needed. Hopefully, answers and strategies will be shared at the International AIDS Conference and/or the National Ryan White Conference. NMAC’s Treatment Division will have MPX updates at the 2022 United States Conference on HIV/AIDS. We will also try to get vaccines onsite at the meeting.

I got my MVA vaccine in Canada. It’s free, even for tourists. Why does Canada have enough MVA vaccines, even for tourists, but we have to wait until September in the US? You’ve got to love the Canadian healthcare system. Mobile vaccine clinics are set-up in the Gay Village of Montreal. A handsome young man in scrubs asked me to talk about monkeypox (MPX). I said, “I’m a tourist”, he said “it didn’t matter.” For folks going to the International AIDS Conference in Montreal, schedule an appointment and visit the mobile clinics in the Village. The site is in French, so click on the FR language icon in the upper right corner and it will change to English. When putting together plans, think outside the box. Set-up clinics in the places where gay and bisexual men gather.



Thank you to the National Council of STD Directors for their leadership on this issue. For more information on MPX go to their Command Center. There is also a letter from community to Secretary Becerra that outlines multiple requests. Also check out the O’Neill/amfAR brief on Monkey and Meningococcal Disease Outbreaks that more fully outlines concerns.

The White House needs to lead with community to develop a domestic strategy to stop MPX before it becomes another epidemic. Sexually active gay men, regardless of their HIV status, need to get the MVA vaccine. Because there is a vaccine, MPX might go away quickly, another in a long list of faded viruses, but right now no one knows. Unfortunately, this is not a joke.

Yours in the Struggle,

Paul Kawata

Paul Kawata