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BRIEF RESEARCH ARTICLE
Year : 2023 | Volume
: 67
| Issue : 1 | Page : 178-180
Why should the men who have sex with men population in India be vigilant for monkeypox infection?
Elangovan Arumugam1, Santhakumar Aridoss2, Nagaraj Jaganathasamy3, Malathi Mathiyazhakan3, Rajat Shurva Adhikary4, Manoj V Murhekar5
1 Scientist-G, Department of Computing and Information Science, ICMR-National Institute of Epidemiology, Chennai, Tamil Nadu, India
2 Consultant, HIV Surveillance, ICMR-National Institute of Epidemiology, Chennai, Tamil Nadu, India
3 Scientist B, HIV Surveillance, ICMR-National Institute of Epidemiology, Chennai, Tamil Nadu, India
4 National Professional Officer and Technical Lead - Prevention, Surveillance, Research, HIV, Hepatitis and STIs, Department of Communicable Disease Surveillance, WHO-India Country Office, New Delhi, India
5 Director and Scientist G, ICMR-National Institute of Epidemiology, Chennai, Tamil Nadu, India
Correspondence Address:
Elangovan Arumugam
ICMR-National Institute of Epidemiology, R-127, 2nd Main Road, TNHB, Ayapakkam, Chennai - 600 077, Tamil Nadu
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijph.ijph_1233_22
Abstract
Monkeypox (MPX) is a zoonotic infection caused by the monkeypox virus (MPXV) and is primarily characterized by rash or pox marks and lymph node enlargement. The recent MPX has quickly spread across the globe and is now declared a global public health emergency. Being a contact illness, sexual encounters have been identified as the most common mode of transmission in the 2022 multicountry MPX outbreak. Data suggest that MPX is highly concentrated in men who have sex with men (MSM) networks and among those who had a recent sexual encounter with one or more partners. In India, the estimated MSM population was 569,346 in 2019. An analysis of the sexual partnerships among MSM suggests a potential highly interconnected MSM network in India, increasing the risk of MPX burden. The viewpoint emphasizes the need for community-level awareness and surveillance for the early detection and prevention of MPX infection in India.
Keywords: India, men who have sex with men, monkeypox
Monkeypox (MPX) is a zoonotic infection caused by the monkeypox virus (MPXV) belonging to the genus Orthopoxvirus. MPX was first reported among humans in 1970 in Western and Central Africa and had been endemic to Africa for several decades.[1] Although contagious, the infection had relatively low human-to-human transmission rates, and in most cases, the infection was primarily acquired through animal exposure. The animal hosts of the MPXV include African rainforest squirrels, rodents, pigs, hedgehogs, monkeys, and opossums. The disease is primarily characterized by rash or pox marks and lymph node enlargement. Rashes occur all over the body, including the face, mucosal, or genital areas.[1] Smallpox vaccinations were found to be partially protective against MPX infections, and MPX re-emergence owing to the vacant niche following smallpox eradication of smallpox was speculated.[2] The recent outbreak of MPX has quickly spread to many countries, with incident cases being reported from nonendemic regions in newer settings among individuals without a travel or contact history with animals. MPX is now declared a global public health emergency by the World Health Organization. Till August 7, 2022, 27,814 confirmed cases and 11 deaths were reported from 89 countries.[3] In India, ten laboratory-confirmed cases of MPX and one death have been reported.[3]
Being a contact illness, human-to-human transmission in MPX predominantly occurs through physical proximity or close contact with infected or symptomatic persons.[1] Sexual encounters have been identified as the most common mode of transmission in the 2022 multicountry MPX outbreak.[3] The disease can be acquired through skin-to-skin contact during sex or being face-to-face or through kissing, touching, and oral or penetrative sex. In this context, the high-risk HIV population is at a higher risk of MPX infection. Available data on disease source and transmission modes suggest that MPX is highly concentrated in men who have sex with men (MSM) networks and among those who had a recent sexual encounter with one or more partners.[4] MSM is reported to be at a much higher risk of infection, owing to their highly interconnected sexual networks that enable frequent sexual encounters with multiple partners.[4] Despite the lack of high-quality evidence, a high proportion of MPX infections has been reported among MSM in Europe, the UK, and the US.[3] In this view, the WHO recommends limiting sexual partners and encourages positive health-seeking behaviors among MSM to reduce the spread of MPX.
Risk of Monkeypox among Men Who Have Sex With Men in India 
In India, MSM is a core high-risk group for HIV and sexually transmitted disease (STD) infections, and the estimated population of MSM in India was 569,346 in 2019.[5] The national Integrated Bio-Behavioral Surveillance (IBBS), 2014–2015 among MSM indicates multiple sexual partnerships among MSM with varying partner types. During the national IBBS, data on sexual behaviors and partnerships were collected from 23,081 MSM across the country. The operational definition of MSM in IBBS was men aged 15 years or more who had anal or oral sex with a male/hijra partner in the last month. Nearly 60% had regular male or transgender (TG) partners, and the other common male partner types were paying male partners (48.4%), casual male or TG partners (37.2%), and paid male partners (26.5%).[6] Approximately 2–4 sexual partnerships and 3–4 sexual acts were reported on an average per week among MSM [Table 1]. Prabhu et al., in their recent study, reported 21,723 sexual partnerships among 8086 MSM.[7]
Table 1: Sexual behavior and partner types of men who have sex with men in India based on the national Integrated Bio-Behavioral Surveillance data and report[6]Similarly, the number of sexual partners per week among MSM was calculated for varying partner types from the IBBS data. A total of 55,031 sexual partnerships, including regular partners, were reported among 23,081 MSM per week [Figure 1]. Considering the estimated MSM population in India,[5] the total number of sexual partnerships among MSM per week is calculated as 1,357,466. This indicates a highly connected sexual network among MSM in India, which would probably increase if the TG networks were accounted for.
Figure 1: Sexual Partnerships of MSM in India based on the IBBS data.[6]. MSM: Men who have sex with men, IBBS: Integrated Bio-Behavioral Surveillance Need for Positive Health-Seeking Propagation among Men Who Have Sex With Men Globally, structural barriers such as self-identity, economic status, general stigma, stigmatization by the health-care system, and accessibility to health-care facilities hinder the health-seeking behavior of MSM. In India, despite legalizing homosexuality, their social acceptance is still debatable. IBBS reports indicate that about 13% of MSM perceive stigma and discrimination at health-care facilities, and about 17% perceive general stigma.[6] A recent small-scale community study in North India indicated that about 70% of the MSM sought health-care services for sexual health issues; however, a majority (~80%) preferred not to disclose their sexuality due to fear of stigma and discrimination.[8] Public health researchers indicate that the early reports of MPX could worsen the prevailing stigmatization of the community.[4],[9] The stigma associated with MPXV disease and MSM sexuality could further complicate and delay their health-seeking behavior.[4] Besides, the self-limiting nature of the disease with low mortality rates, could lead to dilatory health-seeking and further transmission. Reports also indicate possibilities of coinfection with other sexually transmitted infections, misdiagnosis, or delayed responses due to similarities in the presentations of the MPX rash and some STDs.[10] Hence, awareness and encouraging positive health-seeking behavior must be undertaken at the community level to facilitate early detection and isolation.
Need for Community-Level Surveillance in India Given the numbers, India might be at significant risk of MPX infection in the MSM and TG communities. The MPX incidence in such a hidden and dynamic population could quickly spread to their close contacts, which could remain largely undetected. Hence, establishing surveillance among high-risk groups (HRGs) to monitor the symptomatic individuals might be essential for MPX prevention and management. Such monitoring efforts would preferably involve the MSM and TG community, their peers, and private providers from whom they often seek health services. While the surveillance of MPX incidence among MSM and TG is inevitable, it is also to be informed that MPX is communicable through physical contact and is not associated with sexual orientation.[4] Hence, screening symptomatic individuals seeking sexual health-care services with appropriate data privacy and confidentiality protocols can be established considering the necessity of surveillance for the public good.
Financial support and sponsorship
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Conflicts of interest
There are no conflicts of interest.
References 
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