A hallmark of the ongoing monkeypox outbreak is that most cases are related to sexual activity, and this has led to some debate over whether or not to define the disease as a sexually transmitted disease.
“Many infectious diseases, although we will classify them in one mode of transmission, have multiple transmission mechanisms,” said Dr. Amesh Adalja, a senior scientist at the Johns Hopkins Center for Health Security at the Johns Hopkins Bloomberg School of Public Health. Monkeypox can spread sexually, he noted, but it also clearly spreads through nonsexual close contact.
“I don’t think we have enough information at this point to fully classify it. I think there are some suggestions, but more research needs to be done,” Adalja said.
“There are other infections — syphilis, for example — that spread in ways other than through sexual transmission,” he said. “The Zika virus is a mosquito-borne disease, but it can also be spread sexually. The question for me is more about making sure we’re clear about what’s going on from a physiological standpoint before making those kinds of claims.”
Some experts argue that labeling monkeypox as an STD can not only be misleading, but can also be harmful to public health.
“One negative point of suggesting monkeypox is an STD is that people who aren’t having sex immediately think, ‘Okay, I’m not going to get it,'” said Dr. Saju Mathew, an Atlanta-based family physician and public health specialist.
“What a lot of people will think is that it looks like herpes or gonorrhea or chlamydia – meaning you have to have sex to get it. That is not true. Therefore, it is dangerous to suggest that it is only transmitted through sex. That’s misinformation,” he said. “It’s transmitted through sex in most cases, but it’s not transmitted exclusively through intimate contact. You can also get it through non-intimate contact.”
David Harvey, executive director of the National Coalition of STD Directors, said he and his colleagues tentatively refer to monkeypox as a “sexually associated” infection.
“With the data now available, we know that the primary mode of transmission is sexually associated – contact that is of a sexual nature. Technically, a sexually transmitted infection is defined as an exchange of genital fluid with a virus or bacteria associated with with a sexually transmitted infection,” Harvey said. “We need the science to definitively show that this is an infection that can be transmitted through semen or genital fluids, and the science on that isn’t quite clear yet, so we call it sexually associated.”
STDs, also called sexually transmitted diseases or STIs, are infections that are passed from one person to another through sexual contact, such as vaginal, oral, or anal sex. In some cases, these infections can also spread through intimate skin-to-skin contact, such as with herpes and HPV.
The long history of STDs dates back to archaic times. Some research suggests that migrations of modern human ancestors may be associated with HPV, types of herpes, and other sexually transmitted diseases.
In modern times, a study from Nigeria was one of the first recent reports describing the possible sexual transmission of monkeypox. That country experienced a major outbreak of monkeypox in humans in September 2017, and the study was published in 2019 in the journal PLOS One. direct contact with the pus or crust of lesions.
“There is no formal process to label an infection as an STI or STI,” Kristen Nordlund, a spokesperson for the U.S. Centers for Disease Control and Prevention, wrote in an email to CNN on Monday. “Experts generally determine scientifically whether a pathogen can be transmitted through sex, in which case it is termed ‘sexually transmitted’. And how often the infection is called an STD is related to the proportion of transmissions caused by sex versus another route — but there’s no “heading” that is being used to direct this determination.”
She said monkeypox can be more accurately described as “sexually transmitted” because sex is one of the ways the virus can spread, but not the only way.
“Sex is human behavior. If stigma were not associated with infections transmitted through sex, there would be less concern about the implications of saying monkeypox is an STD for people more severely affected,” Nordlund wrote. “It is also important to address this question globally. – and remember that the implications for this label vary depending on where you are in the world, for example, there are countries where homosexuality is punishable by prison or even death. Labeling monkeypox as an STD or STD can be far-reaching in these countries. to have consequences.”
The monkeypox virus can spread through skin-to-skin contact, direct contact with a monkeypox rash or scabs from an infected person, or direct contact with their respiratory secretions. Scientists are still investigating whether monkeypox can be spread through semen or vaginal fluids.
While the risk is low, there is also some potential for the spread the virus through objects or surfaces such as clothing, bedding, or towels that were used by someone with monkey pox.
Mathew said the skin lesions caused by a monkeypox infection can actually be mistaken for a common STD like herpes or syphilis, and in some cases, a person with monkeypox may have co-infections with common sexually transmitted diseases.
While treating his first monkeypox patient in Atlanta, Mathew immediately noticed that the person had the typical lesions on his face. But the 25-year-old man also had pain in his buttocks, Mathew said. “He ended up getting another STD in addition to monkeypox,” which was herpes.
Mathew added that about 25% of monkeypox patients in the US have had STD co-infections.
Harvey said that “when diagnosing monkeypox, you have to test for monkeypox, but you also have to run the range of other STI tests to make sure those are either ruled out or diagnosed as well.”
“We happen to have the highest sexually transmitted infection rates in the US, actually in US history. So it’s not surprising that we’re diagnosing more STIs in the context of the current monkeypox outbreak,” he said. infections with other STDs, but we don’t have national data on that at the moment.”
The CDC’s clinical guidelines tell health care providers, “It is important to comprehensively evaluate patients with genital or perianal ulcers for STIs. However, co-infections with monkeypox and STIs have been reported and the presence of an STI does not exclude monkeypox.”
Any attempt to label monkeypox a sexually transmitted infection “will only increase the stigma and ignore other modes of transmission,” wrote Jason Farley, a nurse scientist and the inaugural Leadership and Innovation Endowed Chair at the Johns Hopkins University School of Nursing, in a statement. email to CNN.
“The virus is spreading through close contacts and sexual networks within the gay, bisexual and other men who have sex with men’s communities. We have also seen distribution, although limited so far, within households with cases in men, women and children. The latter is likely transmission through skin-to-skin contact from parents and children, but environmental contamination leading to transmission is also possible,” Farley wrote.
“For example, looking at how the AIDS response unfolded, it took almost a decade for the heterosexual community to take notice and realize that HIV was not a gay disease,” he wrote. “We cannot allow the same form of inaccurate information to guide our current public health practice.”
Harvey, of the National Coalition of STD Directors, said stigma is something STD clinics fight on a daily basis and he is concerned on the monkeypox outbreak being stigmatized in the context of a sexually related disease.
“We don’t want people to dismiss this as a sexually transmitted infection, but at some level it buys the stigma of sexually transmitted diseases,” he said. “And so, for those of us who work full-time in this field and deal with these issues every day, we want to do everything we can to break stigma, especially regarding sexually transmitted infections, so that we make sure that people are tested and treated without shame or fear.”
Overall, Harvey said the response to the outbreak weighs heavily on STD clinics whether or not Monkeypox is classed as an STD.
“STD clinics and sexual health clinics across the country are currently bearing the brunt of meeting testing and treatment needs — and they have no additional funding to handle the influx of patients. We also see other testing and care for sexually transmitted infections already being disrupted,” Harvey said.
A survey of more than 80 clinics conducted by the National Coalition of STD directors between July 26 and 29 found that 63% received referrals from other health care providers for suspected cases of monkey pox, 52% helped those rejected for other suppliers, and 40% incurred unexpected costs for supplies or personnel as a result of the monkeypox response.
Also, 65% of clinics had to modify workflows to manage monkeypox, such as changing walk-in clinics to appointment only, and 22% had to reduce symptomatic or asymptomatic screening for other STIs to prioritize monkeypox services.
There is “a lack of additional funding, a lack of federal funding, that can directly support these programs,” Harvey said. “These programs need support for supplies, testing, pay for testing, they need additional staff hours and other types of capacity to support the response to this outbreak.”