Leading experts and public health officials discussed national and global responses to the growing monkeypox outbreak at the 24th International AIDS Conference (AIDS 2022) this week in Montreal, but advocates say the world is not doing enough to address the crisis, which is primarily impacting gay and bisexual men.

Opening a hastily organized media roundtable on July 31, new International AIDS Society president Sharon Lewin, MD, said she hoped AIDS 2022 would drive a more equitable global response to monkeypox. “Having worked in HIV for so long, we want to make sure that some of the mistakes in the early response to HIV are not going to be repeated in this situation.”

As of August 2, the Centers for Disease Control and Prevention (CDC) has identified 6,326 monkeypox cases in all but two states. Worldwide, there are now more than 25,300 cases, most of them in countries where monkeypox had not been reported prior to this outbreak.

While anyone can get monkeypox through close physical contact, cases remain overwhelmingly concentrated among men who have sex with men three months into the outbreak, even as testing for other groups has increased.

“The epidemiology is becoming more clear as time goes on,” said Meg Doherty, MD, PhD, director of global HIV, hepatitis and sexually transmitted infection programs for the World Health Organization (WHO).

According to the WHO’s August 2 situation report, 99% of monkeypox cases are among men, of whom 98% identify as men who have sex with men. Sexual activity was the most common transmission route, reported in 92% of cases. Of cases with a known age, only 25 were children age 4 or younger. Five cases among children have been reported in the United States, presumably linked to household transmission.

Before the current outbreak, experts believed monkeypox was not easily transmitted from person to person. In Central and West Africa, case numbers have been low and stable for decades, often linked to contact with animals. In a 2003 outbreak in the United States, nearly 50 people were infected via contact with pet prairie dogs, but there was no confirmed cases of person-to-person transmission.

But sexual networks provide a favorable niche for rapid monkeypox spread—and this may not be a new phenomenon. Speaking by video at a monkeypox symposium on Monday, Dimie Ogoina, MBBS, of Niger Delta University in Nigeria, described the changing epidemiology in that country, where monkeypox is endemic. As NPR recently reported, Ogoina was among the first to observe that during a 2017 outbreak in Nigeria, monkeypox cases shifted to young urban men without traditional risk factors, suggesting the virus was spreading through sexual contact.

Unanswered Questions 

Reporters asked numerous questions at the media roundtable, but Marina Klein, MD, of McGill University in Montreal, acknowledged that many of them don’t yet have answers. We don’t know the exact mechanisms of transmission, whether the respiratory route is important or whether people can transmit the virus before they develop symptoms. What’s more, there’s little data showing how well the new Jynneos vaccine (also known as Imvanex or Imvamune) works or whether treatment with TPOXX (tecovirimat) reduces symptoms or lessens virus shedding, which has implications for the isolation period.

One area where more answers have come to light is symptoms, thanks to the efforts of frontline clinicians and patients who have shared their stories. Chloe Orkin, MBChB, of Queen Mary University of London, and a large team of collaborators recently published an analysis of more than 500 monkeypox cases, revealing previously unreported symptoms, including anal lesions and single sores that may resemble common sexually transmitted infections. Orkin is spearheading an effort to get the WHO and CDC to update their monkeypox case definitions to reflect these new symptoms.

In that case series, among those with a known HIV status, 41% were HIV-positive, most of them on effective antiretroviral therapy. Reassuringly, there were no differences in outcomes overall between HIV-positive and HIV-negative people, Orkin said.

However, people with HIV have a weaker response to the first dose of the Jynneos vaccine, suggesting they should be prioritized for second doses. One study (MVA-011) found that 67% of HIV-positive people and 83% of HIV-negative people had an adequate immune response four weeks after the first dose, rising to 96% and 98%, respectively, after the second dose.

Uncertainty about vaccine efficacy is reflected in the varying protocols across countries. The Food and Drug Administration (FDA) maintains that Jynneos is a two-dose vaccine, and people need both doses. Many cities and countries are administering one dose initially, to partially protect as many people as possible right away, but there is confusion about whether and when people will need to get the second dose.

“No one is saying anything about efficacy and no one is saying anything about time to protection,” said Simon Collins of HIV i-Base. “You have people who are stopping their behavior and are doing everything they can they get a shot in their arm, but most people are not being given any information at all. That could contribute to a worse epidemic because people will go out thinking they’re protected.”


Vaccine Access 

Health officials, clinicians and advocates agree that the global monkeypox vaccine supply is not keeping up with demand. Unlike AIDS and COVID-19, vaccines and treatments for monkeypox already existed when the new outbreak emerged because they have been developed, produced and stockpiled in case of bioterrorism involving smallpox, a related virus.

But critics say these tools have not been deployed efficiently. While Montreal has enough doses to provide to visitors—an offer many gay and bi conference attendees took advantage of—other countries have limited supplies. Even as gay and bi men in American cities wait in long lines for scarce doses, most countries, including the Africa countries that have been dealing with monkeypox for decades, don’t have access to the vaccine at all.

Demetre Daskalakis, MD, MPH, director of the CDC’s Division of HIV Prevention, said the supply and demand mismatch in the United States will probably continue through the summer and into the fall. On August 2, the White House announced that FEMA’s Robert Fenton has been appointed as the new national monkeypox response coordinator, with Daskalakis as deputy coordinator.

As Daskalakis started to speak at the symposium, dozens of protesters—including many veteran AIDS activists—stormed the stage, demanding wider and more equitable access to monkeypox vaccines and therapeutics in the United States and worldwide.

Although the United States owns the lion’s share of the global Jynneos supply, American advocates are particularly frustrated that some 800,000 finished doses sat unused for weeks at a factory in Denmark awaiting a delayed FDA inspection.

“We need to act now,” said James Krellenstein of PrEP4All, which has taken the lead on monkeypox advocacy. “We’re in a worsening outbreak that could have easily been prevented.”

The activists’ list of demands includes “decisive leadership” from WHO and the United Nations on global monkeypox vaccine and treatment access, including efforts to scale up production. Currently, only a single facility in Denmark can produce the Jynneos vaccine, with a production capacity of less than 50 million doses per year. They called for “immediate transfer of intellectual property, know-how and technology” to manufacturers around the world that can make vaccines, treatments and diagnostics.

The activists also demanded that higher-income countries make good on their commitment to be a “vaccine arsenal for the world.” Advocates are loathe to see a repeat of the situation with COVID-19 vaccines, where lower-risk people in some high-income countries may be getting their second booster while many high-risk people in low-income countries have not been vaccinated at all.

The protesters demanded that the global monkeypox response prioritize vulnerable populations and communities and called for funding and support for people who need to isolate. But, they emphasized, increased funding for the monkeypox response must not come at the expense of ongoing efforts to tackle HIV, tuberculosis, hepatitis C and sexually transmitted infections.

“We need to increase capacity rather than jeopardize the momentum we have to address today’s simultaneous pandemics and the ones to come,” said PrEP4All’s Emily Bass.

Click here for Mark S. King’s video report about the protest.
Click here for more reports from AIDS 2022.

Click here for more news about monkeypox.