Sexually transmitted diseases have recently experienced significant development and have occurred in at-risk populations such as the Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Intersex, Asexual, Two-Spirit, and LGBTQIA2S + populations [1]. In 2022, people worldwide were shocked by zoonotic diseases that reappeared in countries that are not endemic and are known as Mpox (formerly Monkeypox) [2]. In addition to the increasing number of reported cases, the emergence of this disease has raised public health concerns. The WHO has declared a global health emergency that must be addressed quickly and appropriately [3]. Mpox is transmitted through mpox viruses of the Orthopoxvirus family. Rapid progression of the disease poses a high risk of person-to-person transmission mediated by various sources, such as direct contact with infected animals (especially rodents), consumption of undercooked meat from infected animals, and close contact with respiratory secretions, skin lesions, or objects contaminated with the virus, including clothing or bedding [4–7].
To date, nonendemic countries have reported the presence of this infection in their countries. At least 115 countries have reported the presence of mpox in their countries with and without symptoms, and most have been reported to travel to endemic areas of the disease and interact closely with infected individuals [8–10]. The simultaneous emergence of three or more diseases has raised new problems in handling and treatment management. Several case reports and field surveillance results reported in countries with this disease report the presence of three diseases among people who have a risky sexual orientation, such as LGBTQIA2S+, who do not use condoms, change partners, use needles and illegal drugs, and have oral, vaginal, and anal sex with infected people. On average, they realize that they are infected with the disease 2–3 weeks after taking risky action [11–14]. A widely reported triple-burden disease is a mpox infection accompanied by sexually transmitted infections (STIs) in the form of genital and perianal lesions and HIV positivity [6, 15, 16]. Individuals who belong to the LGBTQIA2S + community, especially those involved in commercial or other sex work, are at risk of becoming infected with mpox, STIs, and HIV simultaneously [10, 17].
This disease's high burden and prevalence pose threats, obstacles, and challenges to efforts to suppress the occurrence of cases and eradicate them quickly [18]. These triple-burden diseases can mutually affect and worsen individual health with significant social and psychological impacts. A holistic approach to prevention, education, and stigma reduction must be adopted to overcome this triple burden and protect the LGBTQIA2S + community from this complex disease. This review aimed to identify the threats and barriers to triple-burden disease, including mpox infection, STIs, and HIV infection, simultaneously in LGBTQIA2S + populations. Hopefully, it will clarify the prevention, control, and elimination efforts and policies built for stakeholders. A bibliometric study approach was used to map these three diseases' research journeys and findings worldwide. The results of this study contribute to the development of research in the present and future.
Monkeypox (Mpox)
Mpox, a viral disease, is a member of the Orthopoxvirus genus and is similar to smallpox [19, 20]. The disease was first identified in 1958 following outbreaks among monkeys used for research. Since the initial report of sporadic cases and outbreaks worldwide, Mpox has remained a persistent threat, particularly in endemic countries located in tropical rainforests, such as those in Central and West Africa. The re-emergence of this disease at the beginning of 2022 has been a cause of concern. As of October 11, 2023, reports indicated that the cumulative number of cases has reached 90,656 across 115 countries, with 161 reported deaths in 23 countries. Figure 1 provides a comprehensive overview of the cumulative number of cases and deaths from Mpox. [2].
Mpox is primarily transmitted to humans through direct contact with infected animals, such as rodents or monkeys; close contact with infected individuals' respiratory secretions, blood, and body fluids; or meat consumption undercooked and infected [21, 22]. The incubation period for mpox ranges from 7 to 14 days, after which the symptoms manifest. These may include fever, headache, muscle aches, and fatigue, followed by a rash that progresses through different stages, including the development of fluid-filled blisters that crust over and eventually scab. The rash typically begins on the face and spreads to other body parts [19, 23]. In severe cases, complications, such as pneumonia, encephalitis (brain inflammation), and eye infections, can occur. Mpox is generally a self-limiting disease; most cases resolve without specific treatment. Supportive care, including pain relief, hydration, and the management of complications, is typically provided. However, in some instances, antiviral medications may alleviate symptoms and shorten the duration of the illness [14, 24, 25].
Human immunodeficiency virus (HIV)
Human immunodeficiency virus (HIV) is a viral infection that attacks the immune system by targeting CD4 cells, which are crucial in defending the body against infections and diseases [26, 27]. Over time, HIV weakens the immune system, making it more difficult for the body to fight opportunistic infections and diseases, ultimately leading to AIDS [27]. HIV can be transmitted through certain body fluids, including blood, semen, vaginal fluids, and breast milk, primarily through unprotected sexual intercourse with an infected partner; sharing needles or syringes contaminated with the virus; or from an HIV-positive mother to her child during pregnancy, childbirth, or breastfeeding. HIV cannot be transmitted through casual contact such as hugging, shaking hands, or sharing utensils [28].
After being infected with HIV, an individual may experience symptoms such as fever, fatigue, sore throat, and swollen lymph nodes, similar to other illnesses. Therefore, many people may not know that they have HIV and may continue to spread the virus unintentionally. HIV infection has three stages, starting with acute infection, which occurs within 2–4 weeks of exposure and may present flu-like symptoms [29]. During the clinical latency stage, the virus replicates at a lower rate, and individuals may not experience any symptoms. However, the virus remains active and damages the immune system. If left untreated, HIV can progress to the third stage, AIDS, where the immune system is severely weakened and individuals are at risk of contracting opportunistic infections and certain types of cancer [30]. Although there is no cure for HIV, significant advancements have been made in its management and treatment. Antiretroviral therapy (ART) is currently the standard treatment for HIV and comprises a combination of medications that suppress the virus, decrease its replication, and slow disease progression. ART can effectively control the virus if administered consistently and correctly, allowing individuals to lead healthy lives. Pre-exposure prophylaxis (PrEP) is a preventive approach that involves regularly taking medication to decrease the risk of contracting HIV [31].
Sexually Transmitted Infections (STIs)
Sexually transmitted infections (STIs) primarily contract through sexual activities, including vaginal, anal, and oral sex. These infections can be caused by bacteria, viruses, parasites, or fungi, and affect both men and women [32]. If left untreated, STIs can have severe health consequences and increase the risk of HIV transmission [33]. There are numerous STIs, each with its own symptoms and treatment options. Bacterial STIs such as chlamydia, gonorrhea, and syphilis are common and can often be cured with antibiotics. However, if left untreated, these infections can result in complications such as pelvic inflammatory disease (PID) in women or infertility in both men and women [34, 35].
Chronic sexually transmitted infections (STIs), such as herpes and human papillomavirus (HPV), may be managed with antiviral medications and other treatments but cannot be cured. HPV infection can also be prevented through vaccination. In contrast, HIV attacks the immune system and, if not adequately managed with antiretroviral therapy, can lead to acquired immune deficiency syndrome (AIDS) [27, 34]. Parasitic STIs, such as trichomoniasis and pubic lice, can be treated with medication but can be easily transmitted through sexual contact. Many STIs may be asymptomatic, making regular STI testing essential, particularly for those who are sexually active or engage in high-risk behaviors [36]. Safe sex practices, including consistent and correct use of condoms, can significantly reduce the risk of transmission. Open and honest communication with sexual partners regarding STIs and prompt medical care is also crucial if any symptoms arise.
Mpox, HIV, and STIs in the LGBTQIA2S+ community
Mpox has increased globally in recent years, with reported cases outside Africa, including the United States, Europe, and Asia [8, 11, 21, 22, 37–41]. These cases are often associated with travel from endemic areas or contact with infected animals [42]. Importantly, human-to-human transmission is a concern in areas where the virus has been introduced, although it is typically less efficient than that in endemic regions. Additionally, most countries report Mpox incidence in LGBTQIA2S + communities, which tends to be distributed [22, 43, 44].
The LGBTQIA2S + community faces unique challenges with Mpox because of various factors, such as sexual behaviors, limited access to healthcare, and stigma [6]. The community encompasses individuals identified as lesbian, gay, bisexual, transgender, queer, intersex, asexual, two-spirit, and other diverse sexual orientations and gender identities. Members of this community often face health disparities, including higher rates of mental health issues, substance use, and limited access to health care services. As a result, mpox transmission within the LGBTQIA2S + population can significantly burden global health systems, exacerbating the impact of the disease and potentially leading to further disease spread and outbreaks [3, 8].
Mpox can be transmitted within the LGBTQIA2S + population through sexual activities involving close contact, such as unprotected sexual intercourse and skin-to-skin contact. Like other sexually transmitted infections (STIs), engaging in high-risk sexual behaviors such as having multiple partners or engaging in skin-to-skin contact activities can increase the risk of transmission [9, 26, 45, 46]. Additionally, individuals using preexposure prophylaxis (PrEP) for HIV prevention may mistakenly believe they are protected against all STIs, including Mpox, potentially leading to higher-risk behaviors and vulnerability to infection. Socioeconomic factors also affect Mpox transmission within the LGBTQIA2S + community [6]. Poverty, limited access to healthcare, and unstable housing can hinder access to preventive measures, early diagnosis, and appropriate treatment [47]. Discrimination and stigma further complicate this issue, making it difficult for individuals to seek healthcare services and contributing to the spread of infectious diseases. Mental health and substance use issues are common in the LGBTQIA2S + community (März et al. 2022; Tanne 2022).
Individuals facing mental health challenges or substance use issues are likely to engage in risky behaviors that can spread Mpox, such as not following preventive measures [49]. It is essential to provide tailored mental health support and substance-use interventions to reduce the risk of infection and improve overall health. The impact of Mpox on the LGBTQIA2S + community goes beyond individual health outcomes, as this community is already marginalized and faces barriers to accessing healthcare. This can lead to more undiagnosed and untreated cases, further spreading the disease and potentially overwhelming healthcare resources and systems [50, 51].