Last Spring, the nation was alarmed to hear of another infectious disease that was rapidly spreading. On the heels of the COVID-19 pandemic, public health officials, including the World Health Organization, declared Monkeypox, now called Mpox, a public health emergency of international concern.

While everyone could be impacted, a stark and glaring disparity clearly emerged. Mpox was disproportionately impacting gay and bisexual men. In fact, at one point, the Center For Disease Control announced that an estimated 1.7 million gay and bisexual men faced an elevated risk of acquiring Mpox.

The then CDC Director, Rochelle Walensky, repeatedly reinforced the responsibility to address the racial and sexual inequities highlighted by this outbreak. This approach and acknowledgment were applauded and admirable, especially considering the history of systemic neglect and governmental silence related to queer health issues, like HIV, in the past. Sadly, recent data released in April 2023 illuminated a somber reality; grave disparities persisted despite progress.

The median age of the deceased, 34.

The CDC’s Morbidity and Mortality Weekly Report summarized over a year of data. According to the report, there were about 30,000 cases of Mpox in the United States, mostly in cisgender men who have sex with other men. However, for the first time, this data revealed a vast disparity in the number of mpox-related deaths.

Of the 38 people who have had a Mpox-related death, in the United States, almost 90% were Black men who had sex with men, and most were also living with HIV, reporting a CD4 count of 50 or below. This translated to a median age of 34, meaning these Black queer men lived less than the estimated life expectancy of 79 years old.

Thirty-eight deaths may not seem significant, but context is crucial here. The latest data shows that there have been an estimated 148 deaths from Mpox in the world, meaning Black queer men in the United States make up nearly 20-25% of all current global MPox-related deaths.

Like Black Lives, Structural Factors Matter

Previous anecdotes have already highlighted the unequal distribution of the Mpox vaccine.  Initially, Mpox was often wrongly framed as a sexually transmitted disease. There was a narrative that Black queer men put themselves more at risk. Yet, when examining the impact of Mpox on Black queer men, it is essential to understand the distinctions between being “disproportionately impacted,”  "at risk," and "vulnerable.”

"Disproportionately impacted" emphasizes the unequal burden and higher rates of infection experienced by Black queer men compared to other populations.

Being "at risk" refers to the potential exposure or likelihood of contracting the disease. For example, in this context, Black queer men may be at higher risk due to various factors, including their dense sexual networks., but this does not equate to more sexual intercourse.

"Vulnerable" pertains to the increased susceptibility to severe health outcomes once exposed to the virus; this is where structural issues matter. Structural factors, including fluctuating healthcare coverage such as Medicaid, systemic medicalized homophobia, and limited access to vaccine resources, could render Black queer men more vulnerable to long-term ailments related to severe mpox cases.

Let’s assume one was to experience a breakthrough case of Mpox, an instance of testing positive despite receiving a vaccine. Multiple barriers would likely impact one’s ability to receive and stay engaged in care. Many communities lack access to healthcare facilities with flexible hours to accommodate various working schedules. They may not have close healthcare facilities within their insurance network, forcing people to travel long distances for potentially life-saving treatment. Public transportation options are limited and expensive, making it challenging for individuals to attend appointments or consistently receive treatment updates. Making matters worse, one could likely encounter Mpox specific racism or homophobia , yearning for more access to culturally competent healthcare providers.

Constant Concern For Comorbidities

Ample research and data in 2022 showed the dire disparity of Mpox cases, but the CDC’s recent report centers on something different-the importance of understanding HIV as a chronic condition that intersects with other illnesses.

Nearly all who passed from Mpox were immunocompromised and in advanced stages of HIV, but not on antiretroviral therapy (ART). Most patients did receive Mpox-specific treatment once they were in intensive care, but the treatment often occurred once the ailment progressed too far.

Boosting immune function via ART and avoiding immunosuppressives, such as steroids, are critical to Mpox recovery. However, this treatment protocol only works if one knows of both conditions. The report concludes that deaths were likely due to “a reduced capacity to respond to infection because of co-occurring immunocompromise.”

What lies ahead: The opportunity to do better

Similar to the alarms of last Summer, officials have again identified pockets of increasing Mpox cases, especially in major cities like Chicago. The CDC recently released a list titled "Potential for Recurrent Mpox Outbreaks Among Gay, Bisexual, and Other Men Who Have Sex with Men" that categorizes certain communities and jurisdictions based on their current risk of an elevated Mpox outbreak. 4/5 counties most at risk are in the South: Duval County (FL), Shelby County (TN), Bexar County (TX), and Dallas County (TX).

More data and insights create an inherent opportunity to work toward equity. By prioritizing racial justice and equity in the fight against Mpox, we can address underlying structural factors and ensure that Black queer men have equal access to prevention, treatment, and support.

1. Targeted Outreach: Implementing targeted outreach efforts to reach under-resourced communities and historically marginalized populations would be advantageous. Change where a health message is placed and view community collaboration as a long-term opportunity. Lean into community organizations, religious institutions, and trusted leaders to disseminate accurate information, address concerns, and provide access to vaccine clinics.

2. Culturally Aware Communication rooted in empowerment:  Cultural sensitivity refers to awareness and respect for communities’ cultural norms, values, and beliefs. It involves recognizing the diversity within the population and avoiding cultural stereotypes. Culturally responsive approaches go further by actively incorporating cultural knowledge into public health strategies. This includes tailoring interventions to reflect the cultural context, language preferences, and community practices. Culturally specific approaches are more targeted and directly address populations' cultural, social, and linguistic needs. They involve designing interventions and programs specifically created for and by the community, drawing on their unique strengths and assets.

3. Community-Based Vaccination Sites: Establishing community-based vaccination sites with pre-existing places of trust and/or use could be helpful. By bringing the vaccine directly to these communities, transportation, cost, and access barriers can be minimized, ensuring equitable distribution and treatment. The use of mobile vaccination clinics to reach underserved communities, including rural areas, low-income neighborhoods, and places with limited healthcare infrastructure, could also be fruitful. These clinics can provide on-the-spot vaccinations, removing barriers related to distance and transportation.

4. Equitable Appointment Scheduling: Implement appointment scheduling systems that consider the unique challenges of the working class, such as flexible hours, walk-in options, and extended clinic hours. This helps accommodate work schedules, childcare responsibilities, and other factors hindering access.

5. Integrate Wrap-Around Services: The individuals who passed from Mpox did so due to not being retained in consistent HIV care. Therefore, in this situation, retention in HIV care and viral suppression is also one of the best preventative tools against fatal cases of Mpox. A wrap-around approach for Black queer men could be helpful in this context. Wrap-around services are comprehensive, holistic support systems that provide coordinated services to individuals affected by HIV and Mpox. Wrap-around services may include access to healthcare providers, case management, mental health counseling, substance abuse treatment, housing assistance, transportation support, nutritional guidance, and peer support networks.

By integrating these services, individuals living with HIV and Mpox are more likely to receive treatment for both conditions simultaneously, a need outlined in the CDC report. When Mpox is suspected, providers should consider early treatment with Mpox-directed therapy, especially for patients with HIV who are at the highest risk for severe outcomes.