Monkeypox Considerations for Sexual Health Services

October 11, 2022

Dear Colleagues:

Thank you for your ongoing work to improve sexual health in U.S. communities, including addressing the current monkeypox outbreak in the U.S.

During the 2022 monkeypox outbreak, the main route of transmission has been through sexual contact, primarily affecting gay and bisexual men and other men who have sex with men and transgender women. Therefore, although transmission can, and has, occurred through non-sexual contact, many of the health communications, facilities, and programs that we use for STIs and HIV are applicable for monkeypox prevention and treatment.

The same populations that are disproportionately affected by STIs and HIV, are also experiencing the brunt of the monkeypox outbreak. Because of this overlap, consideration should be given to incorporating monkeypox diagnosis, treatment, and, per CDC’s updated recommendations, vaccination into existing sexual health services. This syndemic approach to addressing monkeypox and other infections that are sexually transmitted is better for patient care and is more programmatically efficient.

Monkeypox should be considered as part of the differential diagnosis during a sexual health visit.

The features of early monkeypox cases can be confused with other STIs, such as syphilis and herpes. It is important to comprehensively evaluate patients presenting with genital or perianal ulcers for STIs per the 2021 CDC STI Treatment Guidelines, as well as for monkeypox. Co-infection with monkeypox and STIs is common, with 41% of persons diagnosed with monkeypox reporting an STI in the prior year, and 38% having HIV at the time of monkeypox diagnosis. The presence of an STI does not rule out the potential for co-occurring monkeypox virus infection. Patients with a new rash or lesion, especially those who meet one or more of the epidemiologic criteria should be tested for monkeypox. Additional clinical information about monkeypox, including clinician FAQs, may be found on the CDC website.

As we work to prevent and control monkeypox, we have an opportunity to provide STI and HIV screening to populations who can most benefit from it. We can leverage that opportunity to provide routine STI screening, including HIV testing, and refer eligible patients to HIV pre-exposure prophylaxis (PrEP), or link people with HIV to HIV care and treatment. We cannot afford to miss the opportunity to provide holistic care to people affected by monkeypox as we know they may be disproportionately affected by other health conditions. CDC, HRSA, and SAMHSA have provided flexibility with many of their cooperative agreements that allows resources to be used to support monkeypox-related work when conducted in conjunction with provision of other services.

We recognize that this is a challenging time for everyone, and we appreciate all you do to prevent, diagnose, and treat sexually transmitted infections and to support sexual health throughout the nation.

Best regards,

/Jonathan Mermin/

Jonathan H. Mermin, MD, MPH
RADM and Assistant Surgeon General, USPHS
Director
National Center for HIV, Viral Hepatitis, STD, and TB Prevention
Centers for Disease Control and Prevention
Stay connected: @DrMerminCDC & Connections

/Leandro Mena/

Leandro Mena, MD, MPH, FIDSA
Director, Division of STD Prevention
National Center for HIV, Viral Hepatitis, STD, and TB Prevention
US Centers for Disease Control and Prevention

/Robyn Neblett Fanfair/

Robyn Neblett Fanfair, MD, MPH
CAPT, USPHS
Acting Director, Division of HIV Prevention
National Center for HIV, Viral Hepatitis, STD, and TB Prevention
US Centers for Disease Control and Prevention