Monkeypox Claims First US Victim: What You Need to Know

The first death from monkeypox in the US has been confirmed in Los Angeles County, according to the US Centers for Disease Control and Prevention. The individual, whose identity has not been made public, was reportedly severely immunocompromised and had been hospitalized.

According to the LA Department of Public Health, the announcement underscores the heightened risk the virus poses to individuals with compromised immune systems, including those with HIV, and the importance of seeking medical care if infection is discovered or suspected.

The Texas Department of State Health Services reported last month that a Houston resident with monkeypox died, but the virus' role in the death hasn't been confirmed.  

There have been more than 22,630 cases of monkeypox reported in the US as of Sept. 13, according to CDC data. Though cases appear to be tapering off, "a downward trend can be the most dangerous time if it opens the door to complacency," World Health Organization Director-General Tedros Adhanom Ghebreyesus warned during a Sept. 7 press conference.

The US declared monkeypox a federal public health emergency on Aug. 5, adding funding and resources to address the health crisis. 

That announcement followed similar emergency declarations by California, Illinois and New York. All three states are home to large gay communities and, to date, men who have sex with men are the largest sector of the population impacted by the outbreak. Of the known cases of monkeypox in the US, roughly 98% of those are among gay/bisexual men.  

Monkeypox isn't limited to LGBTQ people: Most cases in Africa, where the disease is endemic, aren't among gay men, the WHO reported.

Transmission can occur via direct skin-to-skin contact with infected lesions, rashes, scabs or fluids. It can also be passed on by touching surfaces, clothing or other objects used by someone with monkeypox, and via large respiratory droplets, such as through coughing or sneezing.

When the WHO declared the disease a global health emergency on July 23, Tedros underscored the importance of adopting policies that protected the dignity and civil liberties of affected communities. 

He cautioned that "stigma and discrimination can be as dangerous as any virus."

Here's what you need to know about monkeypox, including whether it's a sexually transmitted infection, how it's impacting the gay community and how the virus could interact with HIV.

For more info on monkeypox, check out resource pages from GMHC, the Human Rights Coalition, the WHO and the CDC.

What is monkeypox?

Monkeypox is a virus in the same family as smallpox, though it is milder and rarely fatal. It was first documented in humans in 1970 and is endemic in parts of Central and West Africa, especially the Democratic Republic of the Congo.

The first reported cases of monkeypox in the US were in 2003, all linked to infected prairie dogs being kept as pets.

Monkeypox can present as a rash or individual sores that look like pimples or blisters. They can appear almost anywhere on the body, including the hands, face, chest, groin and inside the mouth or anus. 

Fatality rates are very low, between 1% and 10% depending on the strain, and deaths usually occur in young children and those with compromised immune systems.

As of Sept.14, one confirmed death has been connected to monkeypox in the US, while another fatality is still not confirmed as being related to the virus.

Is monkeypox a sexually transmitted infection?

When the outbreak was first reported, medical experts were careful not to classify monkeypox as a sexually transmitted infection. The concern was that framing monkeypox as an STI -- and perpetuating the idea that it's a threat only to gay/bi men -- would lead to stigma.

"The monkeypox rumors are harmful because they isolate and seem to 'blame' a particular group of persons for spreading this infection," Dr. Michelle Forcier, a clinician with the LGBTQ-affirming wellness site FOLX Health told CNET's sister site Healthline in July.

Forcier also said that "calling the monkeypox virus an STI and linking it to our culture's view of sex as scary or shameful may keep persons exposed or infected from getting medical attention."

It may also lead individuals to mistakenly think precautions used for STIs will stop monkeypox. Condoms may help prevent transmission, but according to the CDC, "condoms alone are likely not enough to prevent monkeypox."

According to the WHO, the virus can spread through any close skin-to-skin contact. That does include oral or penetrative sex with someone who has symptoms, but it can also include coughing, sneezing, hugging or using contaminated towels, clothing or bedding.

Still, most cases have been linked to sexual activity. David Harvey, executive director of the National Coalition of STD Directors, told CNN that his office refers to monkeypox as a "sexually associated" infection.

"With the data that is available now, we know that the primary mode of transmission is sexually associated -- contact that is of a sexual nature," Harvey said. "Technically, a sexually transmitted infection is defined as an exchange of genital fluid that have a virus or bacteria that is associated with a sexually transmitted infection." 

He added that more research needed to be done on whether monkeypox could be passed by semen or genital fluids to definitively label monkeypox an STI.

Journalist Stephen Thrasher, author of The Viral Underclass, which explores how inequality fuels epidemics, says tiptoeing around the term does more harm than good.

"Naming who is being affected and how transmission is happening is not homophobic or racist," Thrasher wrote in Scientific American in August. "Rather not naming, researching, preventing and addressing how transmission is happening will keep people from understanding how to prevent infection, allow unnecessary worry, and exacerbate racist and homophobic social determinants of health."

Lao-Tzu Allan-Blitz, a global health specialist at Brigham and Women's Hospital, told NBC News that considering the medical evidence, "it looks very clear to us that this is an infection that is transmitting sexually the vast majority of the time."

How can I protect myself against monkeypox?

Vaccination is the best protection against infection, though access to Jynneos, the two-dose shot approved by the Food and Drug Administration, is still limited.

In addition, given that the virus can be passed on surfaces, health officials recommend frequent cleaning of bedding, sex toys and fetish gear.

On July 27, the WHO recommended that gay and bisexual men limit their sexual partners during the outbreak, especially while the availability of the vaccine is still limited.

"For men who have sex with men this includes, for the moment, reducing your number of sexual partners, reconsidering sex with new partners, and exchanging contact details with any new partners to enable follow-up if needed," Tedros told reporters.

That messaging has divided some in the community.  

"We know from 40 years of experience with the AIDS epidemic that information that makes people feel ashamed about their sexual behavior doesn't lead to good public health outcomes," said Jason Cianciotto, vice president of policy and communication at GMHC, a leading LGBTQ health organization in New York.

GMHC began in the early 1980s as a grassroots AIDS organization formed by Larry Kramer and others who felt government officials were failing to act swiftly in the face of a virus targeting gay and bisexual men.

With monkeypox, Cianciotto told CNET, his organization is urging people to take care of themselves and each other. 

"That means making smart choices, recognizing someone who might have symptoms and having a conversation with a potential sexual partner," Cianciotto said.

At the same time, he added, because the vaccine is still so scarce, "people do need to consider the choices they make."

The CDC website recommends avoiding intimate, skin-to-skin contact if you or the other person have an illness or rash -- even if it isn't confirmed to be monkeypox. The agency suggests virtual sex and masturbation at a distance of at least six feet as alternatives to in-person intimate contact, to prevent the spread of the virus.

How is the gay community responding to monkeypox?

Adam Baran hosts a monthly sex party in Brooklyn. Given the spread of the monkeypox virus, he canceled the July gathering. 
"I'm hoping, cautiously, that we might be able to have a party in August," Baran said. "But I've definitely had to adopt a 'wait and see' approach."

It's difficult to know how many precautionary measures to take, said veteran New York nightlife promoter Daniel Nardicio, especially after more than two years of COVID lockdowns and isolation.
Nardicio hasn't stopped his weekly underwear party on Fire Island, a popular gay beach getaway about two hours outside Manhattan. But he has included information on monkeypox in social media posts and event emails.

"With COVID we just stopped everything," said Nardicio. "With this, we're monitoring things closely. Beyond that, I don't think we're in a position where [we're] going to have to stop events yet."

Nardicio is not bothered by WHO's recommendations for men who have sex with men. "It's not slut-shaming to tell someone to limit your partners when there's an outbreak," he said. "This is a community that is used to jumping into action and taking health crises seriously." 

Baran, Nardicio and Cianciotto all say they've seen massive interest in getting vaccinated in the gay community, far outstripping the availability of Jynneos.
"The desperation for the vaccine and the failure of the government to take care of this is a big topic of conversation," Baran said. "Almost everyone I know is trying desperately to get vaccinated. In fact, the only people I know who aren't running to get the shot are monogamous couples who feel like, 'We're not the highest risk group -- we're not gonna take someone else's spot.'"

Over the summer, pop-up monkeypox vaccination sites launched on Fire Island. Nardicio credited Eddie Fraser, vice president for corporate relations with Northwell Health and a Fire Island regular, for helping make it happen. 

How can I get the monkeypox vaccine?

Many gay men feel frustrated with the rollout of the monkeypox vaccine, which fell to the federal government, and inadequate access to testing.
It wasn't until nearly two months after the first cases were reported in New York that 300,000 doses of a vaccine owned by the US were finally shipped from a warehouse in Denmark. 

The White House made more than 1.1 million doses available to states and cities, but officials told The New York Times that the Department of Health and Human Services waited too long to ask Bavarian Nordic, which makes Jynneos, to bottle and fill the vaccine orders already purchased. In a statement, the department told the Times that its "response has accelerated to meet evolving needs on the ground, and it will keep accelerating."

Read more: What You Need to Know about the Monkeypox Vaccine

In New York, the NYC Health portal offers appointments for vaccine sites around the city. Community-based organizations like GMHC that do direct LGBTQ health outreach, including the Callen-Lorde Community Health Center and Mount Sinai Hospital, are given a select number of appointment slots, usually prioritized for sex workers, queer people of color and other individuals in the highest risk categories.

Read more: New Monkeypox Symptoms: Here's What to Look For

San Francisco has a list of drop-in and appointment vaccination sites on the city government website. Illinois ranks third in the number of cases after New York and California, and most have been reported in Chicago. The Chicago Department of Public Health website has a list of vaccination sites and scheduling details.

Cianciotto said it's helpful that so many gay men are already engaged with health care and know where and how to access information. He said, though, that this doesn't necessarily ring true for lower-income communities of color, immigrants and trans and gender-nonconforming individuals. 

And he's worried that as monkeypox spreads to other parts of the US, the response might be worse. 

"Will Republican governors even request the vaccine?" he said. "We're being hit with another virus while my community is faced with what I believe is the most anti-LGBTQ era in US history. I'm concerned how this issue will be used to further the political goals of a minority of elected officials and theocratic nationals who employ fear and anxiety to win elections."

Can monkeypox be cured?

There's currently no cure or treatment specifically for monkeypox, but existing antiviral medications, especially tecovirimat (known commercially as TPOXX), have been used to treat some patients. But TPOXX's availability is limited and providers don't always know about it.

Are people with HIV more at risk for monkeypox?

People with HIV are considered a priority population for getting vaccinated against the monkeypox virus. In Europe, among the people with monkeypox for whom HIV status was known, 30%-50% were HIV-positive.

It isn't yet clear if HIV impacts the risk of being infected or developing monkeypox after exposure. According to the CDC, though, people with advanced or untreated HIV may be at higher risk of more severe or prolonged symptoms.

"Increasing HIV prevalence among persons with monkeypox over time suggests that monkeypox might be increasingly transmitted among networks of persons with HIV infection," the agency said. "Underscoring the importance of leveraging HIV and STI care prevention delivery systems for monkeypox vaccination and prevention efforts."
But Dr. Ina Park, a community medicine specialist at the University of California, San Francisco, said the numbers may not really mean HIV increases the risk of getting monkeypox. 

Individuals with HIV tend to be more engaged with the healthcare system, Park told Medscape Medical News.
"Persons with monkeypox signs and symptoms who have established connections with HIV or sexual health providers might be more likely to seek care," the CDC's Sept. 9 Morbidity and Mortality Weekly Report said, "and these providers might be more likely to recognize and test for monkeypox virus."

As far as the health risk to those who are HIV-positive, according to the CDC, individuals on effective antiretrovirals haven't shown a higher incidence of hospitalization or death. And the Jynneos vaccine approved by the Food and Drug Administration to prevent monkeypox has been proved to be safe and effective in people with HIV.

But individuals with an inadequately treated viral load (that is, a T-cell count of less than 350) have shown higher rates of secondary bacterial infections, as well as a greater likelihood of prolonged infectiousness and a continuous rash rather than discrete lesions. 
In addition, the rash associated with monkeypox can sometimes lead clinicians to mistake it for shingles, thrush, scabies, herpes or other rash diseases seen in people with HIV. 

So far there have been few reported negative interactions between tecovirimat and antiretroviral therapies for HIV. 

How is the Biden administration responding to the monkeypox outbreak?

The White House declared the outbreak a federal public health emergency in early August. In addition to increasing resources, that's expected to ease coordination between federal, state and local health officials. 
On Aug. 2, Robert Fenton, who helped lead the Federal Emergency Management Agency's COVID-19 vaccination campaign, was appointed to serve as White House coordinator to combat the spread of monkeypox.

Out physician Demetre Daskalakis, director of HIV/AIDS prevention at the CDC, was named deputy coordinator. 

Torrian Baskerville, director of HIV and health equity at the Human Rights Campaign, applauded President Joe Biden for tapping two public health officials with significant experience and expertise. 
"The reality, though," Baskerville said in a statement, "is that we need much more from our government and the window for immediate action is rapidly closing."