Recommendations and guidelines for syringe services programs and other stakeholders
What is monkeypox?
The monkeypox virus is a rare orthopoxvirus that displays similar symptoms to, but less severe than, smallpox. It is a virus that is generally spread through close or intimate contact, with symptoms including a fever and rash. Prior to 2022, the monkeypox virus had been reported in several countries in central and western Africa; however, an ongoing outbreak of the viral disease was reported in May 2022, beginning with a cluster in the United Kingdom. Cases have mainly been detected among men who have sex with men, but not exclusively. It is important to note that anyone can catch the disease, particularly if they are in contact with a symptomatic person.
While the monkeypox virus outbreak and data are still evolving, our immediate focus should be on providing the public with accurate information to communities that are impacted and at risk for monkeypox. This resource document was developed by AIDS United’s Harm Reduction Team to provide information pertaining to the monkeypox virus for people who use drugs, people who engage in sex work, men who sleep with men, as well as the various stakeholders — particularly syringe services programs and AIDS service organizations — that work with these communities.
Monkeypox transmission
The monkeypox virus is transmitted from person to person through avenues such as:
- Direct contact with the infectious rash, scabs or body fluids.
- Respiratory transmission during prolonged, face-to-face contact, or during intimate physical contact, such as kissing, cuddling or sex.
- Touching items (such as clothing or linens) that previously touched the infectious rash or body fluids.
- Pregnant people can spread the virus to their fetus through the placenta.
Monkeypox symptoms
Monkeypox can spread from the time symptoms start until the rash has fully healed and a fresh layer of skin has formed. The illness typically lasts two to four weeks.
- Fever.
- Headache.
- Muscle aches and backache.
- Swollen lymph nodes.
- Chills.
- Exhaustion.
- A rash that can look like pimples or blisters that appear on the face, inside the mouth, on or inside the genitals, or other parts of the body.
Monkeypox myth vs. facts
Myth
Monkeypox is a STD.
Fact
- Monkeypox is not an STD. While monkeypox can be spread during intimate physical contact with someone with a rash, evidence does not currently suggest the virus can be transmitted specifically through semen, vaginal fluids or other sexual transmission routes. (Centers for Disease Control and Prevention, World Health Organization)
Myth
MSM and the LGBTQ community are the only people at risk for monkeypox.
Fact
While cases have been identified in LGBTQ individuals, anyone can get monkeypox in regions where the virus has been detected. Health care workers and household members of people infected with monkeypox are at increased risk. (WHO)
*See “Reducing Stigma Surrounding Monkeypox Communication” below for more information.
Myth
Like COVID-19, monkeypox is contagious even if someone does not have symptoms.
Fact
Monkeypox can only spread once symptoms start to appear. The virus can be spread until the rash has healed (meaning all scabs have fallen off and a new layer of skin has formed). (CDC)
Myth
Monkeypox is a new virus and only affects people from African countries.
Fact
This has been a common trend on social media, where news sources that are covering monkeypox have used images of people of color — particularly Black people with monkeypox. A person of any race or ethnicity can contract monkeypox if they encounter someone who has contracted the virus. While monkeypox has been most common in the central and western African regions, it does not mean that it only affects people living within those countries.
Myth
Monkeypox cannot be distinguished from smallpox or chickenpox.
Fact
Monkeypox can be distinguished from smallpox or chickenpox based on the symptoms and laboratory tests. (CDC)
Myth
There is no treatment available for monkeypox.
Fact
There are no treatments specifically for monkeypox virus infections. However, because of genetic similarities in the viruses, antiviral treatments used for smallpox are used to treat monkeypox infections. (CDC)
Myth
Monkeypox is fatal.
Fact
New cases of monkeypox are rarely fatal. Over 99% of people who get monkeypox are likely to survive. However, people who are immunocompromised, children under eight, people with a history of eczema and people who are pregnant or breastfeeding are likely to become ill. Please consult with your health care provider on your potential risk factors. (CDC)
General prevention strategies
- Avoid close, skin-to-skin contact with people who have a rash that looks like monkeypox.
- Do not handle or touch the bedding, towels, or clothing of a person with monkeypox.
- Wash your hands often with soap and water or use an alcohol-based hand sanitizer.
Sexual health and prevention strategies
Note: Be mindful of your environment and identify potential risk factors for transmission. Sex parties or other enclosed spaces (circuit parties, cruising clubs, bathhouses, or saunas) that require minimal clothing may have a higher likelihood of contracting monkeypox.
- If you or a partner has monkeypox, the best way to protect yourself and others is to avoid sex of any kind and avoid kissing or touching each other’s bodies while you are sick, especially any rash.
- Avoid kissing or touching the rash during sex. Touching the rash can spread it to other parts of the body and may delay healing.
- Remember to wash your hands, sex toys and any fabrics (bedding, towels, clothing) after having sex.
- Wearing clothes during sex can reduce the chance of transmitting monkeypox to an individual.
- If lesions are present in genital areas, use protective barriers to reduce risk of transmission (dental dams, condoms).
- Masturbating (preferably at a six-foot distance) with a partner can be an effective way to reduce transmission risk, as there is no opportunity for skin-to-skin contact.
- Try alternative methods to sexual intercourse such as virtual sex and/or phone sex.
- Limit or reduce the amount of sexual partners in one setting.
Considerations for people in the sex trades
Note: Depending on the circumstance or setting, some sex workers will be able to decrease their risk of transmission more than others. If you are doing in-person services, it is vital that you are clear about your boundaries with your clients. Avoid accepting clients who are experiencing any rashes, fever or other flu-like symptoms. Additionally, try to avoid kissing, cuddling, hugging or massaging your client if possible.
If you are able to do any of the following, this will decrease the likelihood of contracting monkeypox:
- Examine your clients for unusual scars, lesions or rashes — especially on the hands and face.
- Avoid brushing your teeth before or after seeing clients, as this can cause small cuts in your gums, increasing your risk of transmission.
- Use a towel or top sheet on the bed and be sure to change these between clients.
- Wash your bedding, towels and sheets on high heat, preferably between client visits.
- Check in with regular clients to see if you can upcharge in-person services for nudes, sexting or camming.
- Use condoms or dental dams when performing sexual intercourse or oral sex (fellatio, anilingus, cunnilingus) on your clients and vice versa.
Prevention and response in congregate settings
Note: For people experiencing homelessness, linkages and access to permanent housing should remain a priority, in addition to addressing the risks associated with monkeypox.
- Provide clear, fact-based information and messaging to residents, staff and volunteers.
- Allow flexible, non-punitive sick leave policies for staff and volunteers who have monkeypox to isolate until fully recovered.
- Identify and monitor the health of residents, staff and volunteers who may have had close contact with someone with monkeypox.
- If possible, contact tracing using exposure risk assessment recommendations can be effective in preventing cases.
- In settings where contact tracing is not feasible, folks who spent time in the same area as someone with monkeypox should be considered to have low to intermediate degree of exposure, depending on the setting characteristics (e.g., level of crowding).
- Provide access to hand washing or hand sanitizer with at least 60% alcohol.
- Wash hands or use hand sanitizer immediately after touching lesions or clothing, linens or surfaces that may have made contact with lesions.
- Provide residents who test positive with isolation spaces (on-site, if possible, or off-site based on setting capacity).
- Isolation spaces should include a closeable door and a dedicated bathroom.
- Multiple residents who test positive may share a room, if appropriate and spacing allows.
- If residents in isolation must leave the isolation space, skin lesions should be covered with long pants and long sleeves, and residents should wear a disposable mask over their nose and mouth.
- Clean and disinfect spaces where people with monkeypox have spent time
- Do not vacuum, dry dust, sweep or use fans for cleaning, which could spread dried material from lesions or scabs.
- Disinfect using an EPA-registered disinfectant with an Emerging Viral Pathogens claim, which may be found on EPA’s List Q.
- Linens and soiled clothing can be washed using regular detergent and warm water.
- Provide all necessary personal protective equipment for residents, staff, and volunteers
Reducing stigma surrounding monkeypox communication
- Creating spaces where people feel welcome to come forward to their medical provider about having monkeypox is essential to prevent community spread. Insinuating that gay or bisexual men are at increased risk of acquiring monkeypox only stigmatizes LGBTQ individuals, an already marginalized group.
- Note: While it is important to identify the risk factors for people who engage in MSM, it is vital to approach LGBT-community members with facts, resources and empathy.
- Ensure your SSP is tailoring its messaging to ALL community members. Anyone, regardless of gender or sexual orientation, can get monkeypox. Fearmongering messaging about community spread among MSM and LGBTQ community members stigmatizes the population from seeking medical care. It also embeds a dangerous sense of security in individuals that do not identify as LGBTQ.
- When showing people imagery of the rash for identification purposes, ensure that the images are of mild to moderate cases. Showing images of severely infected patients will cause panic, especially to someone who believes they have been infected by monkeypox.
- Attached below is a socio-ecological model outlining anti-stigma interventions. There are five levels in this model to implement anti-stigma interventions within your organization.
Examples of fact-based messaging about monkeypox
- Emphasizing prevention strategies, symptom recognition and the treatable nature of monkeypox to minimize fear and promote a sense of personal agency.
- Using inclusive language, such as ‘us’ and ‘we’ pronouns.
- “Monkeypox is a viral infection transmitted through close personal contact, including kissing, sex and other skin-to-skin contact.”
- “Cases have been detected among gay and bisexual men, but not exclusively.”
- “Anyone can get monkeypox. Blaming any single community may harm public health efforts and cause providers to miss monkeypox in other communities.”
Vaccination information
There are two FDA-approved vaccines in the US available for preventing monkeypox — JYNNEOS and ACAM2000. These vaccines were developed to protect against smallpox and can be used to prevent monkeypox infections since monkeypox and smallpox viruses are genetically similar. The CDC is currently collecting data on any side effects and whether the source of infection impacts the efficacy of vaccine protection.
JYNNEOS is a series of 2 injections, 4 weeks apart (though people who have received smallpox vaccination in the past may only need 1 dose).
- People are considered fully vaccinated two weeks after their second shot.
- While JYNNEOS can be given at the same time as other vaccines, people at increased risk of swelling of the heart muscle (myocarditis) should wait four weeks after receiving the JYENNOS vaccination before getting an mRNA COVID-19 vaccine.
- Vaccination is safe for people with HIV and atopic dermatitis.
- Animal data do not show evidence of reproductive harm (there is currently no data in people who are pregnant or breastfeeding).
ACAM2000 is a single shot.
- People are considered fully vaccinated four weeks after the vaccine is administered.
- People with the following conditions should avoid the ACAM2000 vaccine:
- Cardiac disease.
- Eye disease treated with topical steroids.
- Congenital or acquired immune deficiency disorders (including those taking immunosuppressive medications and people living with HIV).
- Current or history of atopic dermatitis/eczema or other acute of exfoliative skin conditions.
- Infants less than a year old.
- Pregnancy.
At this time, the CDC does not recommend widespread vaccination against monkeypox. However, the U.S. is currently using three vaccination strategies to protect people against the illness before or after a recent exposure:
- Monkeypox Vaccine Post-Exposure Prophylaxis (“standard PEP” for monkeypox): This strategy is recommended following exposure to monkeypox to prevent illness. Per CDC recommendation, vaccine for PEP should be administered within four days of the exposure to best prevent onset of the disease. Vaccine administration four to 14 days after exposure may reduce disease symptoms, but may not prevent monkeypox.
- Outbreak Response Monkeypox Vaccine Post-Exposure Prophylaxis: A more targeted approach to the current monkeypox outbreak, this strategy is aimed at reaching people with certain risk factors who are more likely to have been exposed to monkeypox, even if they have not had a documented exposure. This approach may help slow the spread of monkeypox in places with a high number of cases.
- Monkeypox Vaccine Pre-Exposure Prophylaxis: This strategy involves vaccinating someone at high risk for monkeypox, such as laboratory workers and clinicians. However, most clinicians and lab workers who are not performing diagnostic tests for monkeypox and other orthopoxviruses are not advised to receive monkeypox vaccine PrEP.
Vaccination is recommended for people who have been in close contact with people who have monkeypox, including:
- People who are aware that a sexual partner in the past two weeks has been diagnosed with monkeypox.
- People who had multiple sexual partners in the past two weeks in an area with known monkeypox cases.
- Health care and public health workers who may have been exposed to the virus.
Vaccine Distribution and Eligibility
Vaccines are currently being distributed locally. The United States Department of Health and Human Services has been shipping the JYNNEOS vaccine to jurisdictions across the country since late June. You can find weekly jurisdictional vaccine distribution information here.
Contact your state or local health department for questions regarding where to receive a monkeypox vaccine or on becoming a vaccine provider. Contact a health care provider or local health department to determine whether you are eligible for monkeypox vaccination.
Summary
Overall, when discussing monkeypox with your clients, it is important to provide timely and fact-based information on prevention strategies, symptom recognition and vaccination services for the condition. Additionally, reducing stigma during monkeypox communication through fact-based information is necessary, especially among MSM and LGBTQ communities.
