Re: action to prevent monkeypox in Iran: special attention to men who have sex with men.

To the editor

Until 9 September 2022, 57 527 cases of monkeypox were reported across 103 countries [1], prompting the World Health Organization to declare it a global public health emergency [2]. To date, its spread has disproportionately affected men who are gay, men who are bi-sexual and other men who have sex with men (MSM) [3] and who have no recent travel history to countries where monkeypox is endemic, suggesting its spread through intimate or sexual networks [4]. Sexual behaviours which confer the risk of human immuno-deficiency virus (HIV) acquisition increase the risk of acquiring other sexually transmitted infections [5], and the risk of contracting monkeypox is similarly increased. People with advanced and uncontrolled HIV infection are at a greater risk of severe or prolonged monkeypox disease when infected with the virus [6]. Social interactivity has contributed to a greater risk of monkeypox transmission and led to further suppression of homo-sexuality, especially in countries where it is illegal. One such country is Iran. Institutions in Iran remain strongly opposed to homo-sexuality, leading to negative propaganda, rejection by the society and families and internalization of this stigma by gay men, leading to an ego-dystonic mindset and the promotion of pseudo-scientific therapies by health professionals [7]. The government-led media in Iran has used the outbreak of monkeypox to promote hatred, which has intensified homo-phobia, discrimination and stigma against MSM. This, together with forthcoming mass gatherings, Hajj and Umrah 2022 in Saudi Arabia and Qatar World Cup 2022, has increased concerns among Iranian public health professionals about the spread of monkeypox.

Hence, we propose the need for the following in Iran:

Utilize 150 sites used for HIV infection treatment for epidemiologic surveillance, contact tracing and isolation of cases, testing, patient care and accurate provision of information on monkeypox.

Consider the diagnosis of monkeypox in all patients who are MSM with characteristic presentations and adopt a non-discriminatory, evidence-based approach for their management.

Adhere to World Health Organization and Human Rights Organization guidance in Iran that gay, bi-sexuals and MSM seek medical care and receive vaccinations without stigmatisation.

MSM should limit sexual contact to one partnership to significantly minimize monkeypox transmission.

Special consideration is given to people with HIV infection through surveillance and testing and through prioritization for receiving monkeypox vaccination.

Monkeypox should be aggressively managed in persons with HIV infection based on the severity of the disease and degree of immunosuppression.

Avoid stigmatizing language and re-inforcing homo-phobic stereotypes through the following:

A. Workshops, training and dissemination of policy guidelines and educational materials, such as posters on evidence-based infection control.

B. An integrated approach to health care based on a human rights framework and delivered in partnership as is done for people living with HIV infection.

C. Interventions in the health-care setting using interactive modular training focusing on medical ethics, limiting stigma and promoting infection control through regular contact as is done for people with HIV infection.

Transparency declaration

The authors declare that they have no conflicts of interest.

Author contributions

AK developed planned and conducted the content of this paper. AK and IN contributed to the writing of the finalised paper. AK is responsible for the overall content as guarantor.