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Why calling monkeypox an STD is more than just a label


“I don’t think we have enough information at this point to fully classify it. 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 are spread by other routes than sexual transmission,” he said. “Zika virus is a mosquito-borne disease, but it can also be sexually transmitted. The issue for me is more about making sure we are clear on what is going on physiologically before we make such a claim.”

Some experts say labeling monkeypox as an STD could not only be misleading but potentially dangerous to public health.

“One downside to suggesting monkeypox is an STD is that people who don’t have sex immediately think, ‘OK, I’m not going to get it,'” said primary care physician Dr. Saju Mathew based in Atlanta and public. health specialist.

“What a lot of people will think is that it’s like herpes, gonorrhea or chlamydia, which means you have to have sex to get it. That’s not true. C “That’s why it’s dangerous to suggest it’s only transmitted sexually. That’s misinformation,” he said. “It’s transmitted sexually in the majority of cases, but it’s not not exclusively transmitted by 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 refer to monkeypox as a “sexually associated” infection for now.

“With the data currently available, we know that the primary mode of transmission is sexually associated – contact of a sexual nature. Technically, a sexually transmitted infection is defined as an exchange of genital fluid containing a virus or bacteria that is associated with a sexually transmitted infection,” Harvey said. “We need the science that definitively shows that this is an infection that can be transmitted through semen or genital fluids, and the science on this doesn’t is not entirely clear yet, which is why we call it sexually associated.”

What makes an STD

STDs, also known as sexually transmitted infections or STIs, are infections that are passed from person to person through sexual contact, such as vaginal, oral, or anal sex. In some cases, these infections can also be spread through intimate skin-to-skin contact, such as herpes and HPV.

The long history of STDs goes back to archaic times. Some studies suggest that modern human ancestor migrations may be associated with HPV, types of herpes, and other sexually transmitted diseases.
In modern times, a study conducted in Nigeria was one of the first recent reports to describe the possible sexual transmission of monkeypox. This country experienced a major outbreak of monkeypox in humans in September 2017, and the study on this was published in the journal PLOS One in 2019. Previously, human-to-human transmission was thought to occur primarily through saliva or respiratory droplets or direct contact with pus or crusted lesions.

“There is no formal process to label an infection an STI or STD,” Kristen Nordlund, spokeswoman for the US Centers for Disease Control and Prevention, wrote in an email to CNN on Monday. . “Experts usually determine, scientifically, whether a pathogen can be transmitted sexually, in which case it is called ‘sexually transmitted.’ to sex compared to another way – but there is no “rubric” which is used to guide this determination.”

She said monkeypox can be more accurately described as “sexually transmitted” because sex is one way the virus spreads, but not the only one.

“Sex is a human behavior. If stigma were not associated with sexually transmitted infections, one would care less about the implications of saying monkeypox is an STI for those most affected,” Nordlund wrote. . “It’s also important to look at this issue globally – and bear in mind that the implications of this label vary depending on where you are in the world. For example, there are countries where homosexuality is penalized by prison or even death. Labeling monkeypox as an STI or STD could have serious consequences in these countries.”

What is monkey pox?  Symptoms, risk factors, treatment and how the virus spreads

The monkeypox virus can be spread through skin-to-skin contact, direct contact with an infected person’s monkeypox rash or scabs, or direct contact with their respiratory secretions. Scientists are still investigating whether monkeypox can be spread through semen or vaginal secretions.

Although the risk is low, there is also some potential for virus to spread through objects or surfaces such as clothing, bedding, or towels that have been used by someone with monkeypox.

In the current outbreak, transmission is primarily through skin-to-skin contact, Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists, wrote in an email to CNN on Tuesday.

“The CSTE does not determine whether a disease or condition is classified as sexually transmitted. Regardless of the classification of monkeypox, it is very important to emphasize prevention messages,” Hamilton wrote.

“People should avoid close, skin-to-skin contact with those who have a rash that looks like monkeypox, avoid contact with object and materials used by people infected with monkeypox, and wash hands frequently. People exposed to monkeypox or those at greater risk of contracting monkeypox should get vaccinated.”

Mathew said the skin lesions caused by a monkeypox infection could actually be mistaken for a common STD like herpes or syphilis, and in some cases a person with monkeypox could have co-infections with sexually transmitted diseases. common transmissible.

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 sore buttocks, Mathew said. “He ended up having another STD besides monkeypox,” which was herpes.

Mathew added that about 25% of monkeypox patients in the United States have had STD co-infections.

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Harvey said that “when diagnosing monkeypox you need to test for monkeypox, but you also need to do the range of other STI tests to make sure these are either ruled out or also diagnosed.”

“We happen to have the highest rates of sexually transmitted infections in the United States, basically in American history. So it’s no surprise that we’re diagnosing more STIs in the context of the epidemic. current monkeypox,” he said. “Anecdotally, some of our clinics across the country tell us that they are seeing rates of 15% to 40% co-infections with other STIs, but we don’t have national data on this for the moment.”

CDC clinical guidelines tell health care providers, “It is important to thoroughly 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. “

Fight the stigma

Any effort to label monkeypox a sexually transmitted infection “will only increase stigma and ignore other means of transmission,” wrote Jason Farley, a nurse scientist and first president with leadership and innovation at the Johns Hopkins University School of Nursing, in an email to CNN. .

“The virus is spreading among close contacts and sexual networks within gay, bisexual and other men who have sex with men communities. We have also seen spread, although limited so far, within households. with cases in men, women and children. The latter is likely transmission by skin-to-skin contact from parents and children, but environmental contamination resulting in transmission is also possible,” Farley wrote.

“If we 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 homosexual disease,” he writes. “We cannot allow the same form of inaccurate information to guide our public health practices today.”

Harvey of the National Coalition of STD Directors said stigma is something STD clinics battle on a daily basis and he worries that the monkeypox epidemic be stigmatized in the context of a sexually associated disease.

“We don’t want people to see this as a sexually transmitted infection, but on some level it contributes to the stigma of sexually transmitted infections,” he said. “And so, for those of us who work in this field full time and who deal with these issues every day, we want to do everything we can to eliminate the stigma, especially when it comes to sexually transmitted infections. , so that we ensure that people are tested and treated without shame or fear.”

Overall, whether monkeypox is designated as an STD or not, Harvey said the response to the outbreak is weighing on STD clinics.

“STI and sexual health clinics across the country are bearing the brunt of responding to testing and treatment needs right now – and they have no additional funding to handle the influx of patients. We see also other sexually transmitted infection testing and care is already disrupted,” Harvey said.

A survey of more than 80 clinics, conducted by the National Coalition of STD Directors, between July 26-29 found that 63% were referred by other healthcare providers for suspected cases of monkeypox , 52% served people who were turned down. other providers, and 40% incurred unforeseen expenses for supplies or personnel due to the monkeypox response.

Additionally, 65% of clinics had to change workflows to manage monkeypox, such as moving from walk-in clinics to appointment-only clinics, and 22% had to reduce symptomatic or asymptomatic screening of other STIs to prioritize monkeypox services.

There’s “a lack of additional funding, a lack of federal funding, that can directly support these programs,” Harvey said. said. “These programs need support for supplies, testing, to pay for testing, they need additional staff hours and other types of capacity to help support the response to this outbreak.”

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