By guest contributors Boghuma K. Titanji MD PhD, Keletso Makofane, PhD and @neurofourier
In recent weeks multiple cases of confirmed and suspected monkeypox infections have been reported in three European countries. The initial cluster of cases which first appeared in the United Kingdom so far includes four men who identify as gay or bisexual or other men who have sex with men (MSM). The narrative emerging as this outbreak evolves to involve other European countries, Canada and the United States is sadly reminiscent of initial reporting on pneumocystis pneumonia clusters in gay men with AIDS forty years ago. Monkeypox is not a gay disease and neither are any other infectious diseases. It is unfortunate that this still needs to be said, highlighting how little we have learned from previous outbreaks.
Stigma directed at a particular group of individuals fuels fear and seriously impedes upon outbreak investigation, case identification and public health interventions. The repercussions of labelling HIV infection a homosexual disease led to untold suffering in gay communities in the 1980s who were blamed for the epidemic. Cases were under-reported in the early days of the epidemic as individuals who contracted the virus went underground instead of seeking medical care. This resulted in many missed opportunities to quickly learn about the infection, understand its transmission and importantly, provide targeted public health interventions to curb its spread. Instead, individuals in the group most affected at the time were blamed for their own suffering and ostracized as purveyors of disease.
It wasn’t until it became obvious that HIV infections were not confined to the gay community that more resources and a political will to seriously tackle the crisis were set in motion. Four decades later, the dynamic of the HIV epidemic has been completely transformed by highly effective treatment and prevention strategies.
Sadly, the ripple effects of stigma have been more difficult to erase and continue to negatively impact the ongoing response to the HIV pandemic. For example:
- In the Southern United States, the HIV epidemic continues to devastate communities of predominantly Black and Hispanic MSM largely due to enduring stigma. Minority MSM have lower rates of HIV preexposure prophylaxis uptake, frequently present with advanced HIV infection and are less likely to be connected to HIV care when diagnosed.
- In a 2011 Kaiser Family Foundation Survey of Americans on HIV/AIDS, despite downward trends, 40% of the surveyed population still perceive a good deal of discrimination towards those living with HIV and AIDS. . This discrimination still persists in Black communities where 57% have expressed discomfort of having food prepared by an individual who is HIV-positive. This is further exacerbated with 47% of the community who believe that homosexual behavior is morally wrong.
The initial homophobia associated with the HIV pandemic led to rhetorical strategies that made HIV appear to affect everyone equally instead of strategies that acknowledge heterogeneity in risk and burden. This not only disappeared gay men from the global HIV responses of the 90s and early 2000s, but IT also created an understanding of the pandemic among heterosexual people that is monolithic and missed opportunities to attend to the particular needs of sub-groups among heterosexual people. It is only recently that we target women of specific age in specific geographies, for example.
Similar patterns of targeted stigma towards a specific group have emerged in the COVID-19 pandemic. Initially we saw stigma directed at people of Asian descent following reports of the first cases of SARS-CoV-2 infection from China and more recently unjustified stigma towards southern African countries following the identification of the omicron variant highlighting intersections with racism. For example:
- In a Household Pulse survey led by the U.S. Census Bureau, Non-Hispanic Asian households were twice as likely as non-Hispanic White populations to report not having enough food during the pandemic due to fear of discrimination or hate crime.
These patterns are harmful, dehumanizing and unhelpful in the face of any outbreak response and need to be broken.
Monkeypox is a zoonosis with incidental infections occurring sporadically in humans living in forested areas of Central and West Africa. In recent years there have been several reports of limited outbreaks with human-to-human transmission in endemic countries and occasional imported cases in returning travelers from these regions. Transmission can occur through close contact with contaminated fomites or bodily fluids from infected individuals and through droplet transmission. Despite uncertain variables in transmission with the April-May 2022 cases, immediately attributing a clustering of cases among MSM to sexual networks is not only premature but also feeds into negative stereotypes of sexual promiscuity being to blame for an expanding outbreak.
As we seek to learn more about the ongoing outbreak of Monkeypox in Europe, and North America the focus must be on characterizing determinants of infections without judgment, providing support and guidance to the public without stoking fear, and grounding the response in empathy. The harsh lessons we learned from previous and ongoing outbreaks must drive how we develop and communicate the need for surveillance without inadvertently alienating or negatively targeting any communities. This is how we break the cycle of stigma in infectious disease outbreaks. We’ve seen its damaging effects enough times to know better and that should translate into us doing better.
About the authors:
Dr. Boghuma Kabisen Titanji (MD, MSc., PhD) is an infectious disease physician and virologist, at Emory University in Atlanta. Her clinical focus is people with HIV and her current research focuses on chronic inflammation as a mediator of cardiovascular disease in people with HIV. She is passionate about leveraging translational research to improve the care of people with HIV, global health equity and using science to influence health policy through science communication and advocacy.
Dr Keletso Makofane is an FXB Health & Human Rights Fellow. He is a public health researcher and activist who works in the global HIV response with a focus on sexual minority men in east and southern Africa. He is currently a member of the governing council for the International Aids Society, the Strategic and Technical Advisory Committee for HIV, viral hepatitis and STIs at the World Health Organization, and the board of LVCT Health, a leading HIV service organization in Kenya.