Knowledge and attitudes to mpox among GBMSM in Australia

In a recent study posted to the medRxiv* server, researchers presented the results of a cross-sectional survey done in Australia between August and September 2022. This national-level survey assessed concerns regarding mpox virus (MPXV) infections in bisexual, queer, and gay people who self-identified as being non-binary and men. In particular, the team focused on assessing their inclination to make behavioral changes to reduce MPXV transmission risk and willingness to get vaccinated for MPXV.

Background

Gay and Bisexual and other Men who have Sex with Men (GBMSM) bore the brunt of MPXV in non-endemic countries, with over 95% of mpox cases being among them. Cases of MPXV peaked globally around August 2022, with ~1,000 cases daily but have diminished gradually. In Australia, there were 141 MPXV cases reported by November 2022, with nearly two-thirds of them acquired by people who traveled abroad.

Australia declared MPXV as a nationally notifiable disease in June 2022 and began acquiring the third-generation, modified Vaccinia Ankara (MVA) vaccine by August 2022. Based on their experience with coronavirus disease 2019 (COVID-19), the Australian government expected that GBMSM would follow public health guidance and change their social and sexual behavior to reduce the risk of MPXV transmission until receiving the vaccine.

For instance, they could indulge less in sex parties, attend fewer sex-on-premise venues, and have no or minimal contact with indiscernible sexual partners. So, they conducted this survey at the national level to assess the success of their public health guidance programs aimed at GBMSM and non-binary people to inform the Australian MPXV vaccination program.

About the study

In the present study, researchers invited ≥16-year-old gay, bisexual, or queer people, both men and non-binary, from across Australia to participate in an online cross-sectional survey through direct emailing, web advertising, and promotions through community groups. The team acquired 3,232 survey participants and collected data on their socio-demographics, physical wellness, and sexual encounters. They also enquired if these people had a history of sexually transmissible or human-immunodeficiency virus (HIV) infections. If yes, whether or not they received its pre-exposure prophylaxis (PrEP) or treatment.

More importantly, the team enquired about their smallpox or MOXV vaccination record, awareness and concern(s) regarding MPXV, and willingness to change sexual or social practices to reduce the risk of contracting MPXV and get a vaccination for it. Finally, the researchers used a logistic regression model to identify associations between behavioral change measures and willingness for vaccination, two dependent variables.

Study findings

Of 3,232 enrollees, 2,287 participants completed the study survey, i.e., the completion rate of this survey was 70.76%. The average age of the study participants was 40 years, and in 1,984 people who self-identified as gay, there were 2,189 men. Most participants belonged to New South Wales and Victoria (37.6% and 33.2%).

Regarding their vaccination history, nearly one-fourth, i.e., 541 of 2287 participants, had received a vaccination for smallpox or MPXV, and 64.1% (347/541) of them got vaccinated after May 2022. Of these 347 participants, 283 had received the vaccine before potential MPXV exposure and 15 afterward. While most (60.1%) had received an MVA vaccine, 5.2% had received a second-generation vaccinia vaccine. Most MVA vaccine recipients (320/325) had received only one vaccine dose. The 2268 participants in whom MPXV remained undiagnosed, 2,087, 1,977, and 1,647 identified skin lesions, skin rash, and fever as potential MPXV symptoms, respectively.

Expectedly, vaccinated participants were more knowledgeable and concerned about MPXV, though only 120 of 2268 undiagnosed participants have heard a lot about it. Media, interactions with family & friends, and community groups provided the most information about MPXV to these individuals; 1,904, 729, and 660 of 2,255 participants had heard from these three sources, respectively.

Regarding risk factors, 599 (26.19%), 1277 (55.84%), 1248 (54.58%), 804 (35.16%), and 731 (31.96%) participants had over 10 male sex partners, sex with other men without condoms, innominate sex, group sex, and sex in a sex-on-premises venue, respectively, in six months before this survey. Participants with over 10 partners in the past six months recognized more MPXV symptoms and transmission routes than those with fewer partners. Yet, most participants knew it spread through skin-to-skin contact, both prolonged and brief, and body fluids.

Among risk-mitigating behavioral interventions, participants accepted three most promptly, having fewer sex partners (64.64%), attending sex parties (65.87%), and going to sex-on-premises venues (66.40%). Though 93.03% of 2,268 undiagnosed study participants were willing to reduce contact with other people diagnosed with MPXV, they were unwilling to stop hugging people (19.62%), avoid densely populated sites (33.51%) and not kissing others (33.99%). Thankfully, 1457 of 1733 (84.07%) unvaccinated participants showed an inclination to receive a vaccination for MPXV, with 77.15% of them willing to take a shot immediately.

Multivariate analysis revealed an independent correlation of the concerns about MPXV and vaccination since May 2022 with greater acceptability of the three most acceptable risk-mitigation strategies. Moreover, participants with more recent sexual partners (over 10) were more willing, and bisexual participants and those unconcerned about MPXV were less willing to be vaccinated.

Conclusions

The current study highlighted the knowledge and attitude towards MPXV among GBMSM in Australia. The survey results confirmed these people were aware of MPXV's common clinical symptoms. Though mistaken beliefs about historical vaccination might prevent them from receiving a vaccination, addressing this issue through public education campaigns highlighting the protection offered by historical smallpox vaccination could help improve this situation.

GBMSM might be experiencing ‘pandemic fatigue’ as everyone did after COVID-19 restrictions in Australia, so they perceived changes to social behavior as less acceptable. A public health message should consider what behavior change to promote based on its acceptance in GBMSM during the 2022 MPXV outbreak for it to be effective. In this context, continuous surveillance of GBMSM sexual behavior, vaccine uptake, and behavior change in response to MPXV could be very effective.

The survey results highlighted an urgent need for targeted messaging for bisexual men, elucidating the benefits of vaccination and how it could be safely yet privately accessed. Such messaging might be particularly significant to increase MPXV vaccination rates before the commencement of World Pride, happening in Sydney in February 2023.

Most importantly, Australia and other nations where MPXV transmission is currently low should consider widely advertising acceptable MPXV infection risk reduction strategies among high-risk populations. Furthermore, they should ensure that those at high-risk should at least seek vaccination against MPXV as supply improve.

*Important notice

medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

Written by

Neha Mathur

Neha is a digital marketing professional based in Gurugram, India. She has a Master’s degree from the University of Rajasthan with a specialization in Biotechnology in 2008. She has experience in pre-clinical research as part of her research project in The Department of Toxicology at the prestigious Central Drug Research Institute (CDRI), Lucknow, India. She also holds a certification in C++ programming.