A hallmark of the outbreak of monkey pox ongoing is that most cases are linked to sexual activity, and this has sparked debates over whether to describe the disease as a sexually transmitted infection (STI).
“Many infectious diseases, although we classify them as one form of transmission, have multiple transmission mechanisms,” said Amesh Adalja, a senior scholar 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’s clearly spreading through close, nonsexual contact, too.
“I think we don’t have enough information at this point to classify the disease. I think there are some suggestions, but there are more studies that need to be done,” Adalja said.
“There are other infections — for example, syphilis — that spread in ways other than sexual transmission,” he said. “The Zika virus is transmitted by mosquitoes, but it can also be transmitted sexually. The point for me is making sure we’re clear about what’s going on physiologically before you make those kind of claims.”
Some experts argue that labeling monkeypox as an STI can be not only misleading, but potentially harmful to public health.
“One downside to suggesting smallpox is an STI is that people who aren’t having sex immediately think, ‘OK, I’m not getting it,'” said Atlanta-based primary care physician Saju Mathew and health expert. public.
“What a lot of people will think is it’s like herpes or gonorrhea or chlamydia — which means you have to have sex to get it. This is not true, it is disinformation,” she said. “It is transmitted by sex in most cases, but is not transmitted exclusively by intimate contact . You can also catch the disease through non-intimate contact.”
David Harvey, executive director of the National Coalition of STI Directors, said he and his colleagues refer to monkeypox as a “sexually associated” infection for a while.
“With the data available now, we know that the main mode of transmission is sexually associated – contact that is sexual in nature.
Technically, a sexually transmitted infection is defined as an exchange of genital fluid that has a virus or bacteria associated 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 this is still not very clear, which is why we’re calling the disease sexually associated.”
What constitutes an STI
STIs, also known as sexually transmitted infections, are transmitted from one person to another through sexual contact, such as vaginal, oral, or anal sex. In some cases, these infections can also be spread by intimate skin-to-skin contact, such as herpes and HPV.
The long history of STIs dates back to archaic times. Some studies suggest that migrations from modern human ancestors may be associated with HPV, herpes types, and other related diseases.
In modern times, a study from Nigeria was one of the first recent reports to describe the possible sexual transmission of smallpox from monkeys. This country experienced a major outbreak in September 2017, and the study was published in PLOS One magazine in 2019. Previously, human-to-human transmission was thought to occur primarily through saliva or respiratory droplets, or direct contact with the pus or crust of the lesions.
“There is no formal process for labeling an infection as an STI,” Kristen Nordlund, a spokeswoman for the US Centers for Disease Control and Prevention (CDC), wrote in an email to CNN on Monday (15th).
“Experts usually determine, scientifically, whether a pathogen [agente causador de doença] can be transmitted through sex, in which case it is called ‘sexually transmitted’. And the frequency with which the infection is referred to as an STI is related to the proportion of transmissions accounted for by sex. versus some other avenue – but there is no ‘headline’ that is used to guide this determination”.
She said monkeypox can more accurately be described as “sexually transmitted” as sex is one of the ways the virus can spread – but not the only one.
“Sex is human behavior. If the stigma were not associated with sexually transmitted infections, there would be less concern about the implications of saying that monkeypox is an STI for people who are most affected,” Nordlund wrote.
“It’s also important to look at this issue globally – and keep in mind that the implications for this label vary depending on where you are in the world. For example, there are countries where homosexuality is penalized with imprisonment or even death. Labeling monkeypox an STI could have far-reaching consequences in these countries.”
The smallpox virus can be spread during skin-to-skin contact, direct contact with a rash or crusts from an infected person, or direct contact with their respiratory secretions. Scientists are still researching whether monkeypox can be transmitted through semen or vaginal fluids.
While the risk is low, there is also some potential for the virus to spread through items or surfaces such as clothing, bedding, or towels that have been used by someone with the disease.
Mathew said that the skin lesions caused by a smallpox infection can be mistaken for a common STI, such as herpes or syphilis, and in some cases, a person with smallpox can have co-infections with common sexually transmitted diseases.
When he treated his first monkeypox patient in Atlanta, Mathew immediately noticed that the person had the typical lesions on his face. But the 25-year-old also had pain in his buttocks, Mathew said. “He ended up having another STI besides smallpox,” which was herpes.
Mathew added that about 25% of monkeypox patients in the US have had STI co-infections.
Harvey said that “when diagnosing monkeypox, you need to test for monkeypox, but you also need to do the variety of other STI tests to make sure they are ruled out or diagnosed as well.”
“We have the highest sexually transmitted infection rates in the US, basically in American history. So it’s not surprising that we’re diagnosing more STIs in the context of the current monkeypox outbreak,” he said. “Anecdotally, we’re hearing from some of our clinics across the country that they’re seeing 15% to 40% rates of co-infections with other STIs, but we don’t have national data on that at this time.”
CDC clinical guidance tells healthcare providers: “It is important to comprehensively evaluate patients who present with genital or perianal ulcers for STIs. However, coinfections with monkeypox and STIs have been reported and the presence of an STI does not exclude monkeypox.”
Fighting stigma
Any effort to call monkeypox a sexually transmitted infection “will only increase stigma and ignore other means of transmission,” wrote Jason Farley, nurse scientist and inaugural chair of Leadership and Innovation at the Johns Hopkins University School of Nursing, in an e-mail. email to CNN .
“The virus is spreading between close contacts and sexual networks within gay, bisexual and other men who have sex with men communities. We have also seen the spread, although limited so far, within households with cases in men, women and children. The latter is likely transmission through skin-to-skin contact of parents and children, but environmental contamination resulting in transmission is also possible,” wrote Farley.
“If you look at how the AIDS response unfolded, for example, it took nearly a decade for the heterosexual community to pay attention and realize that HIV was not a gay disease,” he wrote. “We cannot allow the same form of inaccurate information to guide our public health practice today.”
Harvey of the National Coalition of STI Directors said stigma is something STI clinics fight daily and worries that the smallpox outbreak is stigmatized in the context of being a sexually associated disease.
“We don’t want people to consider this a sexually transmitted infection, but on some level it adds to the stigma of sexually transmitted infections,” he said. “And so for those of us who work in this field full time and deal with these issues every day, we want to do everything we can to end stigma, especially around sexually transmitted infections. to ensure that people are tested and treated without shame or fear.”
Overall, whether or not monkeypox is designated an STI, Harvey said the outbreak response is straining sexual health clinics.
“STI and sexual health clinics across the country are bearing the brunt of responding to testing and treatment needs now – and they don’t have additional funding to handle the influx of patients. We are also seeing other testing of sexually transmitted infections and care already being discontinued,” Harvey said.
A survey of more than 80 clinics by the National Coalition of STI Directors July 26-29 revealed that 63% received referrals from other healthcare providers for suspected cases of monkeypox, 52% saw people who were refused by others. services, and 40% incurred unforeseen expenses for supplies or personnel due to the disease response.
In addition, 65% of clinics had to modify workflows to manage smallpox, such as moving from no appointment to appointment only clinics, and 22% had to reduce symptomatic or asymptomatic screening for other STIs to prioritize services. from monkeypox.
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, for testing, to pay for tests, they need additional staff hours and other types of capacity to help support the response to this outbreak.”
Source: CNN Brasil
