More than two years into the pandemic, people are ready to party, but COVID-19 is still with us, and the emergence of monkeypox among gay and bisexual men presents a new health threat. Health officials don't advise canceling events or closing venues, but taking basic precautions can help maximize fun while minimizing risk.
"Coming out of the pandemic, people want to celebrate, and I think they can," Dr. Andrea Tenner of the San Francisco Department of Public Health told the Bay Area Reporter. "The risk [of monkeypox] to the general public is low — it's really more about gauging your risk as an individual and trying to modify risk behaviors."
COVID isn't over
COVID cases in San Francisco are at a relatively high but seemingly stable level after the largest-ever peak in January, attributable to highly transmissible omicron coronavirus variants. After rising steeply in April, cases numbers and hospitalizations have plateaued since mid-May.
Intensive care admissions and deaths are currently low, which experts attribute to the city's high vaccination rate and the availability of the antiviral medication Paxlovid. Nearly 90% of San Francisco residents ages 5 and up have completed their initial vaccine series, and the federal Food and Drug Administration recently authorized vaccines for the youngest children. Keeping up to date with boosters further reduces risk, and immunocompromised people who don't respond well to vaccines may benefit from pre-exposure prophylaxis using Evusheld.
But compared with earlier variants, omicron is better at evading immunity from prior infection or vaccination, and reinfection is increasingly common. Some people still get very sick and die, even after vaccination, and long COVID remains a poorly understood risk.
Yet as the nation has grown weary of restrictions and mandates, COVID prevention strategies have shifted toward individual risk assessment and personal precautions.
San Francisco and other Bay Area counties no longer require face masks, with the exception of Alameda County, which reinstated its indoor mask mandate on June 2. Nonetheless, local health officials recommend wearing a well-fitted mask indoors when community transmission is high — loose cloth and surgical masks provide little protection — and many residents are still heeding this advice.
With Frameline46 returning to a full schedule this year for the first time since 2019, the San Francisco International LGBTQ+ Film Festival is checking to see that attendees have been vaccinated. Audiences for all its indoor film screenings are required to wear a mask, and volunteers have ones to give people who forget to bring one of their own.
People who want to minimize their risk can avoid indoor and crowded outdoor gatherings. Meet people outdoors, if possible, and when indoors open windows to improve ventilation. Health officials urge people to stay home if they're sick, and self-testing before events can reduce the likelihood of transmission.
Monkeypox update
In early May, an outbreak of monkeypox was first reported in countries outside Africa, where the virus is endemic. As of mid-June, the U.S. Centers for Disease Control and Prevention had identified 100 cases in the United States and global health authorities had reported more than 2,000 cases in non-endemic countries, with numbers rising daily.
While anyone can get monkeypox through close personal contact, most cases in the ongoing outbreak have been gay, bisexual, and other men who have sex with men. Some reported international travel, and many visited saunas or attended large gatherings, including a Pride festival in the Canary Islands and a fetish festival in Belgium. Speaking during a webinar hosted by InterPride, an organization of Pride event producers, James Krellenstein of PrEP4All expressed concern that the full extent of community spread is unknown due to limited testing.
The monkeypox virus is transmitted from animals and from person to person through skin-to-skin contact, kissing, and contact with contaminated clothes, bedding, or surfaces. It also can be transmitted through respiratory droplets at close range, but it does not spread through the air over longer distances like the coronavirus that causes COVID-19.
The CDC recently clarified that the monkeypox virus "is not known to linger in the air and is not transmitted during short periods of shared airspace." It can be transmitted between people who live in the same household and to caregivers, but it does not spread, for example, via casual conversation, passing someone in a grocery store or touching doorknobs, agency officials said.
Most experts do not consider monkeypox a sexually transmitted disease in the traditional sense. It is not known whether the virus is transmitted in semen or vaginal fluid, but it can spread through contact with sores or face-to-face contact during sexual encounters. Dr. Demetre Daskalakis, a gay man who's director of the CDC's Division of HIV/AIDS Prevention, calls it a "sexually associated" — rather than a sexually transmitted — infection.
The predominance of cases among gay and bi men has spurred a concerted effort to raise awareness in the most affected communities while guarding against the kind of stigma that surrounds HIV. Monkeypox is not a "gay disease," health officials and advocates stress, and associating it with gay men could trigger homophobia, discourage people from seeking care, and lead other groups to think they're not at risk.
"Stigma distorts science. This virus transmits through close physical contact and it doesn't heed identities or social borders," Daskalakis said during the InterPride webinar, but it's important to offer culturally appropriate information to the networks experiencing increased transmission right now. "People are concerned that it's happening during Pride, but I can't imagine a better time to get the message out," he said.
Monkeypox prevention
Monkeypox, which is less severe than smallpox, causes flu-like symptoms, swollen lymph nodes, and a rash that can occur on the face, in the mouth or anywhere on the body. The virus has an incubation period of up to three weeks before symptom onset, and the illness typically lasts two to four weeks. Transmission can happen until the sores are completely healed and the scabs fall off.
But the new cases do not always follow the classic pattern. Some people have fewer and smaller sores, often on the genitals or in the anal area, and they may not have accompanying symptoms. The lesions can be "a bit more subtle" and might be missed if people aren't looking for them, Tenner said.
People concerned about monkeypox can take a harm reduction approach to lower their risk. The CDC has put together a fact sheet on social gatherings and safer sex that includes suggestions such as not sharing sex toys or fetish gear, having sex with clothes on to minimize skin-to-skin contact, and limiting the number of sex partners. While the United Kingdom Health Security Agency recommends condoms as a precaution, Daskalakis said they're unlikely to play a huge role in monkeypox prevention.
In addition to sex, crowded gatherings also present opportunities for transmission. "If you're in a place where you might be crammed in and can't avoid skin-to-skin contact, wear long-sleeved clothes and try to cover skin as much as possible," Tenner advises.
People who feel ill or have an unexplained rash are advised to refrain from sex and other close contact and avoid bars, gyms, and large gatherings. Those who are asymptomatic but think they might have been exposed should self-monitor for symptoms for three weeks. In addition, it's critical to inform known contacts and cooperate with contact tracing efforts, officials said.
"Take a pause from social activities and sex until you know what's going on," Daskalakis said. "If you see something, do something."
While monkeypox is circulating, gay and bi men should have a low threshold for seeking care and providers should have a low threshold for testing, even if symptoms are mild. Monkeypox lesions can resemble common STIs like herpes or syphilis, and some people have tested positive for both monkeypox and STIs, so clinicians shouldn't rule out monkeypox just because another STI is present, CDC director Dr. Rochelle Walensky told reporters during a recent media briefing.
In San Francisco, people who do not have a regular provider can contact City Clinic on Seventh Street or the San Francisco AIDS Foundation's Magnet sexual health center in the Castro.
Smallpox vaccination prevents monkeypox as well, and the virus can be contained through targeted vaccination of close contacts, a strategy known as ring vaccination. Because monkeypox has a long incubation period, vaccination can be given as post-exposure prophylaxis, ideally within four days after exposure. People over age 50 or so may have some immunity from prior smallpox vaccination, but they should not assume they're fully protected.
A recently approved vaccine called Jynneos is being administered to high-risk contacts of known cases. But contact tracing can be a challenge when people have casual or anonymous sex partners or attend large gatherings. As the vaccine supply ramps up, health officials hope to make it available to people who are at high risk for exposure and those who may have been exposed but don't have a known link to a confirmed case. In Quebec, Canada, the vaccine is already being offered to men who have had sex with two or more male partners within the past two weeks.
"I think that's the direction we're going in, but we have to make sure there's adequate supply to meet the demand," Dr. Phil Peters of the California Department of Public Health said during a June 16 webinar for LGBTQ organizations.
People diagnosed with monkeypox are advised to isolate at home for three weeks and avoid sex and other intimate contact. Wearing a mask can help protect household members and caregivers.
Most people with monkeypox recover without treatment, although antiviral medications used for smallpox can also be used to treat monkeypox. The new cases have generally been mild, with no confirmed deaths so far. But the sores can leave scars, and some people develop complications. Young children, pregnant women, and immunocompromised people are more likely to have severe illness. People with well-controlled HIV do not appear to be at greater risk, but those who are not on antiretroviral treatment and have a low CD4 count may have worse outcomes.
With Pride season in full swing, "now is a great time to make sure you're up to date with your sexual health [and] have your HIV prevention plan lined up, whether it's undetectable equals untransmittable or pre-exposure prophylaxis," Daskalakis said during a CDC briefing for the LGBTQ press. "To me, [Pride] is an important reminder of how important it is to take care of our mental and physical wellbeing as individuals and, by extension, as a community."
To contact City Clinic, go to https://www.sfcityclinic.org/ or call its new phone number, 628-217-6600. To contact SFAF's Magnet clinic at Strut, go to https://www.sfaf.org/programs/magnet/ or call 415-581-1600.
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