True or false: Is COVID-19 still harming and killing people living with and affected by HIV at disproportionately high rates?
Answer: True
True or false: Is mpox still impacting people with HIV disproportionately and killing people living with HIV who are without societal support?
Answer: True
If you are reading this article, there is a good chance that you already know the answers to these questions because you work in or pay close attention to updates about public health. However, people outside of public health typically hear little about HIV and even less about mpox and COVID-19. This lack of knowledge has a grave impact, especially on the communities we serve.
Landscape of Blissful Viral Ignorance
Just like HIV and other preventable communicable illnesses, COVID-19 disproportionately killed Black, Indigenous, and other global majority people even when controlling for rates of acquisition. COVID-19 was the “great equalizer” that never was. It still is.
If you take a walk outside on any given day, in any place across the United States, you are unlikely to encounter people utilizing face masks. Society has decided that the epidemic is over.
Contrary to our collective apathy and insufficient attention from the media, public health epidemiologists remind us that the epidemic is far from over. According to the Centers for Disease Control and Prevention (CDC), in the past three months, over 4,000 people died from COVID-19 complications―with the caveat that even more COVID-related deaths probably occurred, though we’ll never know because of underreporting.
Despite these ongoing and preventable deaths, three of the six jurisdictions with the highest rates of COVID-19 mortality (North Carolina, New York, and California) have or are currently considering making face masks illegal when shopping indoors or attending political rallies and large gatherings like social justice protests―all events that are known to contribute to respiratory epidemics or devolve into “superspreader events.”
Just Because We Can’t See Mpox Doesn’t Mean It’s Gone
Like COVID-19, mpox is beginning to tick up again in the United States. What makes matters worse is that this variant of the virus is more deadly than the version we encountered two years ago. The majority of cases have been diagnosed in the Democratic Republic of the Congo. When combined with anti-LGBTQ+ legislation throughout Central Africa and its suppressive effects on health care access among men who have sex with men and other gender-diverse people, that presents the possibility of another problem: Silently increasing rates among already stigmatized people who cannot safely seek care or treatment.
Meanwhile back in the U.S., after months of hypervigilance, many queer communities have decided that everything is fine. If you enter a bar or social venue across the nation, you are unlikely to see updates on mpox―a stark change from a mere two years ago. Nor will you encounter information on what mpox is, its associated symptoms, or how to prevent and treat it. Perhaps that is because the mpox epidemic was countered by a precedent established by long-time HIV activists: quick, community-centered awareness and action, and constant demands for adequate financial support from the federal government.
Despite these successful efforts, mpox disproportionately impacted and killed Black gay men–especially unhoused Black gay men living with HIV who were not virally suppressed. This trend came as no surprise to Keletso Makofane, Ph.D., M.P.H., a global HIV and mpox expert and principal investigator for a seminal study on mpox and meaningful community engagement in NYC.
“As with many other health conditions, mpox will most severely affect people who do not have access to the resources they need to protect themselves and/or recover from infection,” he told TheBodyPro. “It will compound the health burden of Black gay men who are already disproportionately affected by HIV.”
History supports Makofane’s perspective. Instead of continued care, the response to mpox has followed a now familiar script:
Rates of diagnoses and newer infections expand.
Panic and associated stigma develop.
Subsequent empathy for those living with and impacted by the virus follows.
Tools to prevent and treat the infection are created.
The most impacted populations are ignored while less impacted populations usurp resources.
General awareness and resources to end the epidemic are reduced once less impacted populations (e.g., white gay men) have received appropriate levels of prevention and care.
Wash. Rinse. Repeat. The comparisons to HIV are impossible to ignore: Because most of us can’t see it or are currently unaffected by it, many of us have decided that the problem does not exist.
Preserving the Health of People Living With HIV
Beyond sexual health, the impact on the overall health of people living with HIV cannot be understated. As Michael Peluso, M.D., of the University of California, San Francisco, shared during a symposium on COVID-19 last year at the 2023 International AIDS Conference in Brisbane, Australia, there is always the threat of long COVID, which is “to develop for people living with HIV through numerous mechanisms: persistent COVID virus; reactivation of other viruses; changes in microbiome; persistent inflammation; and clotting issues.”
Though antiretroviral therapy means that people who are virally suppressed can live long and effective lives without having to worry about passing the virus on (#U=U), Peluso explained that living with the virus still bears a cost. “Treated HIV is associated with excess risk and death from multiple morbidities like cardiovascular disease, venous thromboembolism, COPD, cognitive dysfunction, depression, and frailty,” he said.
And to that point, he noted, we would not have this knowledge if people with HIV had been excluded in clinical trials focused on these morbidities.
“We need to learn to be focused on the post-acute phase of whatever pandemic might come next, as well as the acute illness,” Peluso explained. “Many of the early studies of treatments [for COVID-19] did not include long-term follow-up or did not allow participants to be recontacted later. This was a mistake. We need to learn that long-term follow-up should be built into studies from the beginning.”
A year later, his words still ring true; it’s too soon to decide that things are over. And our efforts to mitigate communicable diseases require due diligence not just locally, but globally.
“Global surveillance of [communicable diseases] must endeavor to understand patterns of contact and connection within cities,” Makofane explained. “And we must use that understanding to react quickly. We need to strengthen surveillance not just for the mpox outbreak, but also for future outbreaks of novel infectious disease in our community.”
To quote the powerhouse South African-based HIV activist Yvette Raphael, “It’s not over until it’s over for everyone.”
What Can Public Health Experts and Clinicians Do?
There are many ways to resolve these issues, though the real question is whether our society can muster the political willpower to mandate effective change. But even if that does not happen, advocates and physicians can get behind one key action: harm mitigation. For COVID-19, that means masking up and supporting vaccinations wherever you are, even if your peers oppose them.
While speaking about the low rates of COVID-19 vaccinations across the U.S., Demetre Daskalakis, Ph.D., M.D.―the director of the CDC’s National Center for Immunization and Respiratory Diseases who previously led the White House’s mpox response―told TheBodyPro, “[COVID and long COVID are] serious issues, especially for long-term survivors who are at a higher risk of hospitalization and other severe outcomes―especially when not up to date with their COVID-19 vaccine. Receiving an updated booster will be required again this fall to stay on schedule and protected.”
Many of us are preparing to travel to the 25th International AIDS Conference in Munich, Germany, where this year’s theme is “putting people first.” Considering the large number of people living with HIV who will be attending, one of the best ways to follow that theme will be making sure our COVID-19 vaccinations are up to date and, barring that, by wearing masks as often as possible.
And when we return home, we can continue with IAS' theme by reminding our peers that providing health care means caring about other people’s health and adopting the lessons we’ve already used during our ongoing epidemics.