Pan American Health Organization · 1st edition, 2022
Communication guidance to prevent stigma and discrimination while addressing the monkeypox outbreak concentrated in gay and bisexual men
- Issuer
- Pan American Health Organization
- Edition
- 1st edition, 2022
- Audience
- Health authorities, health workers, LGBTIQ+ organizations, media, communicators, policy makers
- Evidence
- Expert consensus based on outbreak data as of 20 August 2022
- Reviewed
- 18 Oct 2026 · GMJ
What this guideline says
GMJ summary
This PAHO communication guide addresses the May 2022 multi-country monkeypox outbreak, which has disproportionately affected gay and bisexual men (98% of cases). It provides comprehensive guidance on how to discuss monkeypox in ways that reduce stigma and discrimination while effectively communicating prevention, diagnosis, and treatment information to affected communities and the general public.
The guide covers clinical aspects including incubation periods (typically 6–13 days, but often under one week in this outbreak), symptom presentation, transmission routes, and management. It emphasizes that while 95% of transmission occurs during sexual activity, monkeypox is not classified as a sexually transmitted infection but spreads through close contact with lesions, body fluids, respiratory droplets, and contaminated materials.
Central to the guidance is the principle of community engagement, inclusive language, and avoiding fear-based or punitive messaging. It stresses collaboration with LGBTIQ+ organizations, appropriate media communication, understanding of contemporary sexual practices including chemsex, and addressing the intersection with HIV services where many cases are first identified.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Incubation period typically 6–13 days, but consistently under one week in current outbreak; symptoms last 2–4 weeks and are usually self-limiting
- Clinical presentation includes fever, lymphadenopathy (distinguishes from chickenpox), followed by rash evolving from macules to papules, vesicles, pustules, and scabs; in current outbreak, genital lesions may appear first, before fever
- Diagnosis: PCR testing of swabs from skin lesions, scabs, vesicles, or pustules is preferred; blood PCR often inconclusive due to low early viremia; 17–27% of cases have concurrent STIs, especially syphilis
- Treatment is supportive; tecovirimat, brincidofovir, and cidofovir available under emergency use authorization but should be used within clinical trials or expanded indication protocols with safety monitoring
- Isolation recommendations: separate room, no bed-sharing, separate bathroom (disinfect after each use), wash linens at >60°C with bleach (50–100 ml), maintain good ventilation, avoid sharing utensils
- Vaccination: Modified Vaccinia Ankara (MVA) vaccine approved in 2019, administered in two doses four weeks apart; approximately 85% protection reported from older smallpox vaccines; mass vaccination not recommended, target high-risk groups
- Contact tracing is critical for outbreak control; presented as a right to know exposure status, not persecution; search for symptomatic cases can be integrated into existing HIV/STI prevention services for key populations
- Risk reduction messaging should avoid abstinence-only approaches (proven ineffective with HIV); focus on clear information enabling autonomous decision-making, early symptom recognition, and reducing close physical contact during symptomatic periods
Comprehensive health intervention packages for gay men and men who have sex with men (MSM)
Table extracted from the guideline
| Category | Interventions |
|---|---|
| Essential for impact: Interventions that facilitate change | Eliminate punitive laws, policies, and practices; Reduce stigma and discrimination; Empower the community; Address violence |
| Essential for impact: Health interventions | Prevent HIV, viral hepatitis, and STIs; Distribute free condoms and lubricants; Post-exposure prophylaxis for HIV (PrEP); Post-exposure prophylaxis for HIV and STIs (PEP); Prevent vertical transmission of HIV, syphilis, and HBV; Hepatitis B vaccination; Address chemsex |
| Diagnosis | Test for HIV; Test for STIs; Test for hepatitis B and C |
| Treatment | Treat HIV; Detect, diagnose, treat, and prevent tuberculosis associated with HIV; Treat STIs; Treat hepatitis B virus (HBV) and hepatitis C virus (HCV) |
| Essential for overall health: Health interventions | Protect anal health; Protect mental health; Detect and treat dangerous and harmful consumption of alcohol and other substances |
Source: Pan American Health Organization, Silence can be damaging: How to talk about monkeypox without doing harm. Reproduced in summary form.
From the guideline
Verbatim
“Stigma and discrimination connected with any disease, including monkeypox, are never acceptable; they can seriously impact health outcomes, and undermine the response to the outbreak by making people reluctant to come forward or seek medical care.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As we consider monkeypox preparedness in Georgia and the broader Caucasus region, this PAHO guidance offers a critical framework that extends beyond immediate outbreak response to address structural barriers in our health systems. The guidance's most important contribution for our context is its emphasis on integrating monkeypox surveillance into existing HIV and STI services—infrastructure Georgia has strengthened significantly through our hepatitis C elimination programme and expanding PrEP services. I would stress to Georgian clinicians the diagnostic point that 17–27% of monkeypox cases have concurrent STIs, particularly syphilis, meaning STI clinics and infectious disease services must maintain high clinical suspicion and not dismiss monkeypox based on another diagnosis. The realistic implementation challenge we face is healthcare worker sensitization and reduction of institutional stigma toward men who have sex with men: without addressing this systematically through professional associations and the National Center for Disease Control, even excellent clinical protocols will fail because affected individuals will avoid care. Georgia's experience with community engagement in our tuberculosis and HIV programmes provides a foundation, but we must be honest that LGBTIQ+ organizations operate under more constrained conditions here than in many settings where this guidance was developed.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 18 Oct 2026
Applicability
Georgia and the South Caucasus
For Georgia and the South Caucasus, this guidance is immediately relevant given the region’s established HIV programmes and emerging PrEP services that serve as entry points for monkeypox surveillance and response. The guidance’s emphasis on integrating monkeypox screening into existing HIV/STI services aligns with Georgia’s hepatitis C elimination infrastructure and universal health coverage framework. However, national programmes must consider the legal and social context: stigma against men who have sex with men remains significant in the region, and healthcare worker sensitization will be critical. The guidance’s framework for community-based organization engagement can build on existing civil society partnerships developed through Georgia’s HIV and hepatitis programmes, though outreach to LGBTIQ+ communities may require careful adaptation to local contexts where such organizations face constraints.
Questions this guideline answers
Quick answers
Is monkeypox a sexually transmitted infection?
Monkeypox has not been classified as an STI. While 95% of transmission in the current outbreak occurs during sexual activity, the virus spreads through contact with lesions, body fluids, respiratory droplets, and contaminated materials—not exclusively through sexual fluid exchange. Anyone can contract monkeypox through close physical contact with an infected person.
How long should someone with monkeypox isolate, and what precautions are needed at home?
Isolation should continue until all lesions have healed and scabs have fallen off (typically 2–4 weeks). At home: use a separate room and bathroom if possible; wash linens and towels in hot water (>60°C) with bleach (50–100 ml for whites); do not share utensils, which must be washed with hot water and detergent; disinfect surfaces with bleach solution (1:50 ratio) or 70% alcohol; maintain good ventilation; and both patient and caregiver should practice frequent hand hygiene.
Should gay and bisexual men be vaccinated against monkeypox?
The Modified Vaccinia Ankara (MVA) vaccine is approved for monkeypox prevention and is administered in two doses four weeks apart. Some countries are providing it to high-risk populations or contacts of cases. However, mass vaccination is not recommended at this time, and vaccine supply is limited. Vaccinated individuals should continue protective measures. Countries implementing vaccination should collect data on effectiveness.
Does having HIV increase the risk of getting monkeypox or having more severe disease?
There is no evidence that HIV infection predisposes someone to contracting monkeypox. The over-representation of people living with HIV in case reports likely reflects their better access to healthcare and more frequent medical visits, not biological vulnerability. In studies, 41% of monkeypox cases were people living with HIV, with 95% having undetectable viral loads on antiretroviral therapy. People with severe immunosuppression may be at increased risk of complications.
Related on GMJ
Interconnected resources
Dictionary of Public Health
Conditions A–Z
GMJ News coverage
Quality & accreditation
Other guidelines on this topic
- Guidance on Clinical Suspicion and Differential Diagnosis of Monkeypox
- Considerations on the Use of Antivirals, Monoclonal Antibodies, and Other Interventions for the Management of COVID-19 Patients in Latin America and the Caribbean
- Operational handbook on tuberculosis: Module 4: treatment and care
- Prevention of re-establishment of malaria transmission: global guidance
- Monitoring and epidemiological assessment of mass drug administration in the global programme to eliminate lymphatic filariasis: a manual for national elimination programmes, 2nd ed
- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- 1st edition, 2022
- Status
- Current
- Published
- 2022-01-01
- Languages
- English, Spanish
- Scope
- Communication guidance for monkeypox outbreak response
- Audience
- Health authorities, health workers, LGBTIQ+ organizations, media, communicators, policy makers
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- Expert consensus based on outbreak data as of 20 August 2022
- Next review
- Dynamic updates planned as outbreak evolves
- Record history
- Created 18 Oct 2026 · updated 18 Oct 2026 · next check Apr 2027
Pan American Health Organization. Silence can be damaging: How to talk about monkeypox without doing harm. Washington, DC: PAHO; 2022. (PAHO/CDE/IMS/Monkeypox/22-0017).GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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