The following is a lightly edited transcript of Episode 8 of* The Future of HIV Care, *a monthly podcast from TheBodyPro about the issues and initiatives that are changing the way we approach HIV prevention, treatment, patient care, and services in the U.S. You can listen to this episode using the player below, by following The Future of HIV Care on Spotify, or by searching for it and subscribing within your podcast app of choice.
Juan Michael Porter II: For this episode, we are looking at the monkeypox outbreak, which has disproportionately affected people living with HIV. Our conversation will take an honest look at the stigma and homophobia among medical professionals that has prevented people within the community from accessing care.
Rather than compile the litany of complaints, we will discuss the facts of monkeypox transmission and causality while digging into lessons that were learned from the AIDS crisis and tap into solutions that will help medical professionals address and overcome any biases or fears that they may have.
My guest, Gregorio Millett, M.P.H., is here to help us navigate this conversation. Greg is a vice president at amfAR, the Foundation for AIDS Research, as well as the director of amfAR’s [Washington,] D.C.-based Public Policy Office. Previously he served as a senior scientist with the CDC’s Division of HIV/AIDS Prevention and the senior policy advisor of the Office of National AIDS Policy in President Obama’s White House—where, among many things, he was one of three principal writers of the National HIV/AIDS Strategy and helped to eliminate the HIV entry ban that prevented people living with HIV from traveling to or seeking residency in the United States.
Thank you for being here, Greg. How are you?
Gregorio Millett: I’m doing well, Juan Michael. Thank you for the invitation to speak.
Echoes of Homophobia in Health Care: From HIV to Monkeypox
Porter II: I’m so happy to have you here, of all people, not only because of your expertise, but because the two of us are both living with HIV. And I think that we have seen how stigma manifests and also watched how it affects policy.
I’m curious: When you were thinking about monkeypox and the fact that it is affecting so many people living with HIV, what are some of the things that you think about when it comes to speaking to people about overcoming any sort of biases they may have against our community and anyone else who is affected by monkeypox?
Millett: You know, there are two things that I think immediately came to mind when the data became very clear that monkeypox was disproportionately affecting gay and bisexual men.
The first one really was the stigma that’s associated with having monkeypox. It reminded me of the HIV/AIDS epidemic in the ’80s and the ’90s, growing up in New York City and seeing so many dying in New York—particularly in Greenwich Village, where my dad worked; he worked at St. Vincent’s Hospital, which was sort of Ground Zero for the HIV epidemic [in New York City] back then. The stigma was so pervasive in the degree to which gay men were considered vectors of disease.
[I feel] a little bit [of] that, as well, with monkeypox. If you take a look at some of the message boards that are online with any of the articles around monkeypox, there’s a lot of homophobia that’s associated with it, when they talk about the fact that this is primarily affecting gay and bisexual men. And I think it hearkens back to what we’ve had to deal with, with HIV, as well.
So I think a new generation is experiencing this homophobia in health care—this view from society, generally, that you are a bearer of some disease—and really trying to grapple with some of that and some of the stigma that’s associated with it.
Porter II: This reminds me of the ongoing conversation about language: that we use people-first language, such as people living with HIV, instead of referring to human beings by their health conditions or calling them infected. By using dignified language, we know that we can empower people and help them to achieve optimal health outcomes, instead of pushing them away and treating them like vectors of a disease.
Data tells us that men who have sex with men are overwhelmingly affected by this outbreak. We also know that homophobia remains a problem within medical spaces. Greg, have you seen occasions where a medical professional has commented that “I don’t know why these gays can’t get their things together”? Or have you encountered other misunderstandings about why monkeypox is manifesting within our community?
Millett: You know, there’s a couple of things that I hear. And hearkening back, as well, to your original question, I forgot to mention the second thing that I saw: The second thing that I see that’s a parallel to HIV is the fact that there’s a lot of shame that’s associated with getting monkeypox.
With HIV, for many years, even to this day, if you disclose that you’re HIV positive or newly have HIV, there’s a lot of shame that’s associated with it that people work through. Shame, where other people in the community are telling you, “Well, how did you get this? You should have known better.” Or even shame from your family members and others.
You’re getting a lot of that, as well, with monkeypox, where people who are diagnosed with it, some are ashamed to speak about it. Some of them are ashamed to tell their friends or their family members about it; ashamed to tell their employers. I mean, you have to isolate for as much as two to three weeks. What are some of the implications there of having to tell your employer? So you’re seeing a lot of these same parallels that are taking place.
That feeds into the question that you just asked, as well, in terms of the attitudes of providers. We’re seeing some really disturbing things from some providers, some of whom are saying rather homophobic things, in terms of, “Well, why can’t these gay men just stop doing this?” As if all gay men are doing a particular thing, even though all gay men are not.
But more beyond that, it’s really not about what they’re doing. It’s about the environment that’s promoting this disease, the networks that it’s passing through, and everything else. So that’s something that’s problematic.
I think the other thing that’s problematic, as well: As I mentioned a little bit beforehand, the degree to which gay men are becoming a bogeyman, in some ways, again. Some public health officials, for quite some time, tried to thread the needle by not labeling this as a gay disease—because it’s not. It’s primarily affecting gay men, but it’s not a gay disease.
My cousin lives in Nigeria, where monkeypox is endemic. And it affects primarily heterosexuals there. But the way that it’s manifesting now, in this new outbreak with this new strain, is that it got into a network of gay men. That’s why it’s spreading within these networks globally.
But with any other disease that primarily or disproportionately impacts a particular community—and particularly with infectious disease—the first thing that you see is blame and stigma. We saw it with HIV for gay men. We saw it in terms of the Haitian community; people who inject drugs; as well as now, with African Americans and Latinos. We saw the same thing with COVID-19, with the type of backlash that unfortunately we continue to see against Asian Americans across the United States.
We are now seeing exactly the same thing with monkeypox, where this particular group that has it is being demonized in some ways, despite the fact that many public health officials would not like that to happen. It really bespeaks that, as far as we’ve come in terms of rights and civil liberties and attitudes towards LGBT people, that we’re still just one disease away from all of these biases coming back.
That’s why it’s so important that we not only have culturally competent medical providers, but that we actually have value in teaching cultural competency within medical schools and schools that are providing health care training.
Porter II: This makes me think about something [HIV policy advocate and population health expert] Ace Robinson told me: that gay sex is not driving the monkeypox outbreak. Rather, it is driven by a lack of access to health care and a lack of knowing how to access that health care.
To your point about networks, we saw a [meningitis cluster] earlier this year at [Florida State University in Tallahassee], and it was understood that college kids weren’t driving that event, but that the outbreak was linked to a specific event and set of behaviors: that it was introduced during spring break among younger people who were engaging in closer contact than normal to celebrate the end of winter.
How Medical Providers Can Thread the Needle on Monkeypox Messaging
Porter II: With monkeypox, I think it is essential that we pay attention to specific behavior in relation to an event—as well as causality—instead of flattening it out into a rule about all men who have sex with men.
With that in mind, how does one actually address this outbreak that is affecting our specific community at greater rates, but without stigmatizing the whole?
Millett: I think that this is part of that $64,000 question that we had to deal with at the very beginning of the HIV pandemic, when there were elements of our society who were saying that we should take all people living with HIV and put them on an island somewhere, or completely segregate them from the rest of society. You saw gross instances of discrimination against children living with HIV, women living with HIV—and, particularly, gay and bisexual men living with HIV. It’s a shame that we have elements of that manifesting itself again in terms of some of the rhetoric that people have around this issue.
The best way to frame this, and for people to understand what’s happening, is that we’re at a moment right now where we’re living in a viral storm. There are many different infectious diseases that are manifesting in ways that we haven’t seen in over 100 years. We saw it first with COVID-19, but now we’re seeing monkeypox; we’re seeing the meningitis outbreak; there’s also [polio that we’re seeing outbreaks of] in New York, as well as in London and in other places.
This is about infectious disease, and [about] viruses that are really taking opportunities to exploit anything to their advantage. So when we see these outbreaks taking place in any of these different groups, it’s not that there’s something unique to these groups that is placing them at risk for these viruses. Viruses exploit opportunities, and if there are opportunities that are related to the environment that these groups are in, then that’s where you’re going to see this manifested.
I think that that’s the best way to really try and help couch this so people understand that for many of these different outbreaks, they’re all affecting different groups of people. But you don’t necessarily always see us demonizing some of those groups of people.
For instance, with the polio outbreaks that we’re seeing, it’s people who are immigrants; also people who come from specific religious communities. It was the same thing with the measles outbreak a couple years ago in New York. You don’t want to see people demonizing those groups for that.
We actually had a monkeypox outbreak back in the early 2000s in the United States, where about 30 people became infected with monkeypox. A lot of that was associated with people who were owners of guinea pigs and other small rodents who were infected with monkeypox because they were transporters with animals from Central and Western Africa who had monkeypox. At that time, I didn’t see the United States going around where everybody was intrinsically blaming someone who had a type of guinea pig for monkeypox, and people screaming around saying, “Well, if you have this guinea pig, we need to segregate you from the rest of society.”
We can’t do that, as well, for gay and bisexual men.
Again, it goes back to what I mentioned earlier: When these things take place in communities that are marginalized—even if there’s growing acceptance of these communities, even though we are more accepting of diversity—that it brings us backwards as a society to catering to the most base instincts of people: of fear, of fear of the other, of fear of contagion, of fear of people being vectors of disease.
[Fear is] really not helpful to contain an outbreak. Because once you have that fear, fear produces stigma, and stigma makes it much easier for people not to seek access to care. People will not come in and see the doctor, even if they believe that they might have monkeypox. That can accelerate transmission to other people in other communities, if people are afraid to talk about it. And that’s exactly what you do not want to do as a society or as health care professionals.
It’s been great to see CDC, as well as many departments of health, really try and thread that needle; to not stigmatize these communities that are at highest risk for monkeypox.
Taking Stock of Our Implicit Biases in Medical Care
Porter II: This makes me think about how a clinician or a medical professional engages with their own biases and recognizing that they’re there. For instance, I was—I’m going to speak to myself—but when I was diagnosed with HIV after being, like, “Well, that’s impossible,” my immediate thought was, “Well, how could this possibly be me?”
And then I started to think, “Oh, OK. There’s something going on here that I am deciding that it isn’t possible for me to acquire HIV because of who I am.” Not even beyond the behavior, but just my idea that HIV does not happen to someone like me. In fact, this is the first time I’m saying that publicly, but I’d said that before to myself many, many different times. The fact of the matter is, this is not a virus that discriminates against people based upon who they are. And yet, that was built within my head.
In interviews [I’ve done] with some medical professionals who are incredible, there have been times when off the record they’ve shared, “You know, I had to overcome a bit of my own stigma and stop when someone who was close to me was affected, and suddenly I saw this as not just happening to my patients—‘those people’—but something that happens to all of us.”
I’m curious if you have seen that sort of working through to understand how one could possibly engage with that internal bias that is fed to us on a daily basis—those people, those people, those people—to get through to actually doing the job and helping.
Millett: Absolutely. This is an area that, thankfully, many social scientists and others have been studying for quite some time. It’s this whole issue of implicit and explicit bias and what it’s related to, in terms of health-seeking behavior, as well as the type of health care that people are given.
There was an amazing study that was published in the American Journal of Public Health about seven years ago where they looked at 20,000 health professionals. They basically sent them surveys every year between 2008 and 2012. [Editor’s note: Participants accessed and completed the survey voluntarily on a rolling basis from 2006 through 2012.] And what they found was high levels of implicit bias towards people who were LGBT. These health professionals were implicitly predisposed to have better notions around people who were heterosexual, or patients who were heterosexual, rather than those who were LGBT.
It speaks to the fact that over the last couple years, we were talking about COVID-19 and the racism in health care communities, as well as medicine. There’s many other isms and issues that we also have to deal with in terms of health care, as well. Obviously, [for example,] sexism. There’s [also] issues in terms of the way we treat people who are not from our culture or our country; xenophobia. But we also have this homophobia that still exists, as well, where we haven’t been doing as well.
I just want to quote some quick statistics to you. There was another study done, from UCLA, where they found that only 9% of U.S. academic medical practices knew how to connect patients who were LGBT to LGBT-competent physicians, and that only 4% had policies identifying those physicians. And only 15% had lists of LGBT-competent physicians. So, we are really not doing that well in the medical sphere in trying to combat some of these biases around homophobia.
There’s another study that was done a couple years ago looking at health care personnel and attitudes towards gay and bisexual individuals. They found that the correlations of homophobia were really associated with specific variables, such as gender—particularly LGBT people who are more likely to be male, where you had these higher levels of homophobia. It was related to religion. It was related to occupation, the person or the health care personnel who had homophobia. It was related to knowledge level. And it was also related to education level. Those are some of the other issues that we’re seeing that are factors that predispose.
A lot of this is unfortunately something that we still see in HIV. So, for instance, in HIV the CDC said that as many as 34% of primary care doctors and nurses had never heard of PrEP—which is crazy. But a lot of that bespeaks to the point that, you know, LGBT health is not necessarily valued enough within these spaces among primary care physicians, that something as important to the toolkit of preventing HIV is something that many of these doctors have not heard of.
It’s unfortunate because, when you take a look at the degree to which LGBT health is, in many cases, not culturally understood and where we don’t see a lot of culturally appropriate health in the U.S., it certainly has manifestations. And one of the manifestations that we see from that is the degree to which we see greater anxiety among LGBT people in seeking health care.
LGBT people are less likely to go to preventive care. They’re less likely, when there is something wrong, to go see a health care provider, as compared to those who are not [LGBT]. And there’s still these psychosomatic aspects of it, as well, where there’s been studies: one by David Huebner found that LGBT people’s negative reactions with health care providers actually produce an increased level of cortisol, which is part of the stress hormone. We know that cortisol, when it’s accumulated over time, is associated with elevated heart rate, blood pressure, as well as infectious disease. This is something that has negative effects overall.
If we’re not able to provide culturally competent care, it means that the care that we’re providing is keeping people away from health care providers. And particularly in times like this, where we have an outbreak and it’s this specific population, you want to make sure that they are coming in for care and being recognized for that care.
More importantly, it has a negative effect on the population itself, because if they’re not coming in for care then they’re more likely to die of certain conditions. They’re more likely not to get the care that they need. They’re more likely to have all these other conditions that accumulate over time that really make their health care poorer overall compared to heterosexuals.
This is something that—as much as we’ve come forward with gay marriage, as much as we’ve come forward with not firing people who identify as LGBT—that our society is still not perfect yet. People still have fear of coming out to their health care providers.
That fear is something that is very clear, particularly if you live in the southern part of the United States, or if you live in the central part of the United States, as compared to the coasts. That fear could be different depending upon how much income that LGBT person has or doesn’t have, or whether or not they have access to health care. That fear could be different depending upon whether it’s a man or a woman or a transgender individual. And that fear is also different depending on the race or ethnicity of that individual, as well. So there’s still a long way for us to go.
All of that, unfortunately, is part of the mix of what’s taking place right now with monkeypox. It’s in the stigma we’re seeing against monkeypox and gay men.
Eliminating Bias in Monkeypox Testing and Treatment: Combating Discrimination With Data
Porter II: That makes me think about legislation in certain states that allows doctors to deny care to LGBTQ people based upon moral grounds. And to me, what automatically comes to mind is the idea that, well, if one associates monkeypox with gay and bisexual men, and a provider or doctor is in disagreement with that, that they can then deny tests.
While we haven’t heard cases of this, we have heard cases of [phlebotomists being told not to actually test] people who are suspected of having monkeypox. And, again, that association comes into play: “Well, I don’t have to treat you. I have been allowed not to.”
Something Dr. Melanie Thompson, who’s an HIV doctor based in Atlanta, pointed out to me is that [she has received letters from Quest Diagnostics] saying that they would not [test] people. So this isn’t just a theoretical thing; it’s actually occurring.
[If it’s kosher for us to post a screenshot, this would be where I’d love to put a screenie of Melanie’s tweet; will coordinate w/ Erica Snyder]
She also pointed out that because monkeypox requires a great deal of equipment when it comes to screening or testing, quite a number of facilities, labs, or clinics are declining to test people. And this starts to turn into a question of: Do we really know how large a deal this outbreak is, if people can’t actually get tested?
You worked in the Office of National AIDS Policy, and you’ve been involved in leadership in health and policy for many, many years. You have your eyes on the ground of what was occurring before you went in and spoke to your colleagues about, “Well, how do we address these issues?” Looking at the way that certain providers and medical professionals are denying care to people around monkeypox, I’m curious what you might say to someone who finds themselves in a space where they’ve been told, “We don’t have to do testings or screenings for monkeypox”—how they might activate and say, “Well, actually, we are required to provide care, and it’s incumbent upon us to actually see people, regardless of whatever fears we might have.”
Millett: It’s a good question. You know, there’s so much of this conversation that we’re having that ties back to HIV.
We know from HIV experience that all health care providers should be utilizing universal precautions in dealing with their patients. Universal precautions were adopted because of HIV, and since then they’ve become the standard of care. When you’re dealing with patients, there are just universally things that you do: PPE, washing of hands, other specific things that you do, ways that you handle sharps, etc. If you were following universal precautions, there’s no way for you to be afraid of any type of infectious disease, for a health care provider, that you might get it.
That’s part of what we’re seeing with phlebotomists, what we’re hearing from some of these labs; it’s really just based upon homophobia and looking at gay men, again, as vectors of disease. Because there is no way that these lab technicians or phlebotomists—or even people who are swabbing lesions—are able to get monkeypox. It’s just not possible.
In fact, the CDC has not reported one case of a health care provider who is taking care of a monkeypox patient getting monkeypox. I was just listening on a call with the European CDC last week to find out what was taking place in terms of monkeypox diagnoses across European countries, and they did disclose that there are about 70 of the 12,000 diagnoses of monkeypox among health care providers. When they looked into those health care providers to see what was taking place, none of those health care providers got it occupationally. Every single one of them were gay and bisexual men who got monkeypox through sexual transmission. So the health care providers really have no risk of getting monkeypox.
It goes to show, again, that we need to do a better job of really addressing some of the homophobia that others have to these specific communities. You know, when you are a health care professional, you take the Hippocratic oath. And the Hippocratic oath, of course, is to do no harm; you need to treat everyone the same and to do no harm.
This is not what we’re seeing with this subset of professionals. And quite frankly, it’s something that’s embarrassing. As a scientist myself, it’s embarrassing to see public health officials who are doing this.
It hearkens back a little bit, too—I trained on LGBT health at a prominent medical school in the Southeast in the early ’90s. And I remember trying to teach medical students about LGBT health, and just the overwhelming wave of homophobic comments that I received, along with my co-presenter who was a nurse, from some of the students. At the time, I tried not to take it personally, because the best way to defuse these types of comments is for people to be able to have the latitude to ask them—even if they ask it in a way that is derogatory—so that you could answer as factually as possible, and also model behavior in terms of: This is how you deal with this, and this is how you should be dealing with this with your patients.
It’s a shame that some of the things that I heard in the classrooms then are some of the things that we’re hearing now.
You mentioned the Office of National AIDS Policy, and some of the things that we can be doing or should be doing. One of the things that we really need is visibility. Part of the reason why we’re seeing this type of outbreak taking place, and the backlash that is taking place, is that we’re not doing a good job of even counting LGBT people. This is something that took place during the Obama administration, where we saw the first federal efforts to really institutionalize in many of our census surveys, other types of surveys, where they systematically put LGBT people into it. And then we saw the next administration systematically take them out again.
That’s a problem because, when we come to an outbreak like this that’s moving fairly quickly; when over three quarters of the data that’s coming back and that’s reported by states doesn’t have enough demographic information to understand who is becoming infected—even to the granular level about: Is this primarily gay men; is this primarily trans women—that’s something that’s a problem. We need more visibility in the collection of data.
The other issue, too, is the degree to which people know somebody who’s LGBT. We saw that with the marriage issue: If you knew somebody who was LGBT, you were more likely to be pro LGBT, more likely to be pro marriage. It’s the same thing with health care providers. As long as they know somebody who is LGBT, you see that stigma subsides in that group of people.
The other thing that’s helpful is we need modeling by health care providers. We need instructors in medical schools who model how you not only treat LGBT people overall—including their students—but how you treat LGBT patients. We’ve seen in many different types of studies that if you model these types of behaviors, you see a decrease in stigma against LGBT people.
And then last, we need to put a premium on diversity. If we see diversity and many different types of people and human experiences as strengths, rather than the other—rather than weaknesses, rather than something to be feared; if they’re strengths, then this is something that I think is much more cohesive and helpful for us overall as a society. To realize that we have strengths in our differences, and that these differences are beautiful and there’s nothing to be scared of. We are all human, overall.
So these are all different things that can and should be done. But unfortunately, as much progress as we’ve made, we’re still far away from getting to the point where we need to be on these issues.
Porter II: Your point about homophobia—this makes me think about how in 1987, the American Medical Association formally announced that it was unethical to refuse to treat people with AIDS. And then they published an actual blog on it in 1992.
We are still seeing this sort of reticence that is anti-science when it comes to providing care. And I think that you give a really wonderful guide for addressing that, looking at it, and then confronting one’s own stigma and saying that, “Even if I feel this way, I have taken the Hippocratic oath. And actually it is safe for me to engage with people. It does not harm me and, if anything, it helps society.” I think that’s something that every person listening to this podcast signed up for when they were younger at some point: that they wanted to help people to achieve optimal health outcomes.
Amid Heartlessness, Plenty of Room for Hope
Porter II: I wonder, when you think about the progress that you have seen during the course of your career, are there any things that give you hope when it comes to addressing the next viral outcome that we are not anticipating?
Millett: Oh, absolutely. I think one of the biggest things that gives me hope is just watching who is responding right now and countering all of the negativity around gay and bisexual men getting monkeypox; who is countering some of the narratives around this; who is challenging the government and making sure that testing and care is provided for gay men.
What’s been wonderful to see is that it’s not necessarily people my age or older. We’re seeing a lot of younger people who are really driving this narrative, people who were not around during the ’80s and ’90s where I was younger and protesting in ACT UP around HIV and AIDS. People who weren’t born yet.
To see that this muscle memory is there, passed down from one generation to another in the gay and bisexual community, where these younger people are demanding that the government does right; that they’re demanding that the government provides testing as well as care for gay men; that they’re in the news talking about some of the problems that they’re seeing, both at the federal and at the local level.
And it’s important to me that it’s not just among white gay men. We’re seeing young Black gay men who are doing exactly the same thing, as well as Latino gay men, who are routinely in the news talking about how this is affecting their communities, and how we believe that states as well as federal officials can and should be doing better.
We’re even seeing young gay men who are scientists early in their career, because of the data that we don’t have about the extent of the outbreak—exactly what you’d mentioned beforehand, that we’re just getting diagnoses data, and diagnoses data really are a fraction of the number of transmissions that are taking place. But you’re seeing these young gay men who are early in their careers—epidemiologists who are now connected to other epidemiologists in other cities—where they’re trying to do some seroprevalence surveys to try and find out what is the actual prevalence of monkeypox within their communities as compared to diagnoses; to just get a better idea of the magnitude of the outbreak, [and] more importantly, projecting ahead [to] how far we see this outbreak going.
So what gives me hope is the fact that there’s a new generation that has been equipped to deal with this homophobia—to deal with some of the inadequacies that have happened in terms of the federal response—and are empowered to move things forward to make sure that LGBT communities are treated on equal footing as other communities. As somebody who’s in their mid-50s, who’s long in the tooth and has nothing but gray hair, I am just incredibly happy to see so many younger gay and bisexual men who are really picking up the mantle and moving these civil liberties and civil rights forward, particularly in terms of health care.
Porter II: Thank you. That was so beautiful.
To your point about people standing up—younger people, younger generations—I recall a time when watching TV, a person was identified as a gay man, his face was blurred out, and he had a voice disguiser because he was so afraid of people identifying him. And I recall being a teenager, watching Ellen DeGeneres on television come out, and then this sort of backlash to that, only to then come forward this many years later to see that one in five Generation Z adults identifies on the queer spectrum, while also understanding that what we think of as queer, gay, bisexual, or lesbian is not how other people perceive themselves. There are many people who may not accept that identity for political reasons or because it doesn’t serve them.
But we are out here. And if this is a virus that is affecting a community of people who are on the queer spectrum but they don’t identify as that openly, if we don’t make it safe for people to come forward and be who they are, we are actually making it impossible to address this virus that is affecting the universal community. I really want to thank you for pointing that out in terms of the progress, which then leads to greater progress of visibility and possibility of how we are all interconnected.
Expanding Our Concept of Sexual Networks, People at Risk, and “Sexual Transmission” of Monkeypox
Porter II: I’m curious. When we think about networks—for instance, that, yes, this is affecting predominantly gay and bisexual men—but the fact that we don’t quite know how far it is extending because of the lack of testing and stigma; are you concerned at all about [other] people who are within the network? For instance, women who are having sex with men who also have sex with men? People who are not necessarily at the forefront of who we think about as being vulnerable to this outbreak? Do you have any ideas about that?
I want to be clear that I don’t want to feed into any sort of hysteria. For instance, people who are worried about children who, of course, do not have high rates of acquisition or transmission.
Millett: No, absolutely. And I think, you know, for any infectious disease, that’s a valid question to ask: How do we project moving forward if there are other groups that might also be enveloped by this disease? It’s certainly something that I’ve thought about.
I released a document along with Georgetown last week, where we were talking about tackling monkeypox in Black and Latino communities. We really focused on what’s taking place among Black and Latino gay and bisexual men, where we’re starting to see disproportionate rates of monkeypox. But near the end of it we also started talking about other communities where we really need to make sure that there’s good sentinel surveillance, to make sure that monkeypox is not creeping into other parts of the Black or Latino community.
One of them that we’re worried about but looking at is homeless communities or incarcerated communities. The thing that people don’t seem to realize is that the LGBT community is everywhere. Men who have sex with men are everywhere—in detention centers, as well as homeless communities.
Here in Washington, D.C., we have been seeing some cases of monkeypox among homeless individuals. And that’s something that we need to make sure that we keep an eye on to see whether or not we’re going to see an increase in cases, or if these are just blips among homeless individuals who may have been men who have sex with men.
The other group that, of course, we want to make sure that there’s some sort of sentinel surveillance is sex workers. There are certainly individuals in the sex work industry who are men who have sex with men who have been very vocal about the fact that they have had monkeypox, trying to fight the stigma around monkeypox and trying to sound the alarm around monkeypox. We need to make sure that there’s some sort of sentinel surveillance within those communities, as well.
In addition, sex workers could be male or female. We need to make sure that, among women, we’re also monitoring what’s taking place with monkeypox.
As you mentioned, there are some men who are bisexually active. And the good thing that we know about bisexually active men is that when they have sex with their female partners, they’re far more likely to use condoms with their male partners. So it reduces the risk of HIV infection—far more likely to have fewer sex partners with men, so that also reduces the risk of HIV infection. But that’s for HIV infection.
Monkeypox is different. You can get this from rubbing skin together. Even if bisexually active men are less likely to get HIV, if they do get monkeypox they could pass it on to their female partners. So of course you want to make sure that there’s some sort of sentinel surveillance to make sure that we are picking up any monkeypox outbreaks that may or may not be taking place among Black, as well as Latino, women.
Why that’s important is because we already see high mortality rates among Black women, as well as Latinas, among those who are pregnant. And monkeypox has some very severe consequences for women who are pregnant. So we want to make sure that we catch that as quickly as possible.
I think the last group that we just need to be aware of—but I do think that the risks are low, at least with this strain of the virus, which is sexually transmitted—are people who work in the hotel industry, people who are maids, people who work to clean rooms. And why I’m saying that is because in Central and West Africa, we’ve seen monkeypox outbreaks among people who are working with linens and cleaning hotel rooms and are touching towels, etc. That’s a different strain of monkeypox than the strain that we’re seeing now. But it’s still something that we should monitor, because we do know that communities of color in the United States are more likely to be in these positions, as maids or domestic workers, or changing linens in the hotel service industry. You just want to make sure that we’re not seeing any transmissions that are taking place there.
It’s incredibly unlikely because we’re not seeing those types of secondary transmissions. We’re not seeing it in the European data, which is months ahead of us and would have told us if that was likely. And we’re certainly not picking that up now. But it’s still something that you just want to monitor.
Porter II: Looking at the phrase “sexually transmitted”—and this is not to challenge you; it’s more clarification—is the strain now officially understood as being sexually transmitted?
Millett: The strain is sexually transmitted, but it doesn’t mean that it’s a sexually transmitted disease. I know a lot of people get hung up on this, and you really don’t want people to get hung up on it. But there are certain diseases that are diseases that you can get that are not STDs, but you can get them through sex.
One of them, for instance, is hepatitis C. For many years, it was understood that the highest rates of hepatitis C were among people who inject drugs, or people who use injection works in some fashion or other. And it’s true: You do see very high levels of hep C there. But about 10 years ago, we started to see high rates of hep C among men who have sex with men, particularly men who have sex with men who are living with HIV, in these networks in Europe. And then we saw the same thing taking place in the United States, where you’re starting to see this sexually transmitted hep C.
It’s the same thing that we’re seeing with this virus. It’s a virus that is not a sexually transmitted disease—in endemic countries it’s mainly skin-to-skin contact or other types of contact—but it has now taken advantage of a different environment of sexual transmission.
That’s why I want to be careful when we talk about what monkeypox is. It’s not a classic STD, but it can be transmitted through sex. Just like hep C is not a classic STD, but it can be transmitted through sex, as well.
Porter II: Thank you so much for that clarification, and also for all of this glorious data and information. It is always a pleasure to speak with you. Thank you for being here.
Millett: Thank you for the invitation, Juan Michael. And thanks for really helping demystify what’s taking place in terms of monkeypox and, unfortunately, some of the stigma that’s still rearing its ugly head, and a lot of the parallels that we see with HIV. We’ve come very far, but unfortunately, we still have far to go.
Porter II: As our conversation with Greg revealed, the universal standards of precaution, many of which were established during the AIDS crisis, ensure that medical professionals have no reason to fear monkeypox transmission, or really any infectious disease, while providing care.
If you find yourself resistant towards providing care to people who may have the virus, please remember your medical training and that you have everything you need to know to protect yourself and your patients. Just as importantly, hold on to the Hippocratic oath, as well as the many medical safety lessons we have learned over the past 40 years.
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Thank you to Greg Millett for his deep insights into history, structural issues, policy, and overcoming stigma. Additional thanks to our producers, Alex Portaluppi and Lucy Mueller; our project manager, Alina Mogollon-Volk; our content editor, Maria Elena Perez; and our executive editor, Myles Helfand.
I’m Juan Michael Porter II. And this is The Future of HIV Care.