Mpox epidemiology, barriers to treatment and prevention, and perceived stigma: a cross-sectional study

Abstract

Background: The 2022 mpox outbreak in the United States primarily affected sexual minority men. Barrier to healthcare access, treatment, and vaccination against mpox are not well characterized. Stigma surrounding mpox has not been well quantified, and may significantly impede outbreak containment, compounding the public health challenges faced by marginalized populations.

Objective: This study aimed to assess the epidemiology of mpox in the U.S., explore barriers to treatment and vaccination, and evaluate stigma and its impact on individuals diagnosed with or at risk for acquiring mpox.

Methods: This cross-sectional You & Me Healthy Registry sub-study used multifaceted recruitment strategies including targeted recruitment through LGBTQ+-oriented app platforms. Eligible participants, including those who previously had mpox and those self-identified as at risk, with no prior mpox, completed an online survey of demographics, healthcare access, treatment, and vaccination behaviors, and mpox-related stigma. Stigma was measured using an adapted 12-item version of the HIV Stigma Scale. Descriptive statistical analyses and Chi-square comparisons of vaccination behaviors and stigma responses between those who previously had mpox and those at risk were conducted.

Results: Among 122 participants, 27 previously had mpox (22%). Participants were predominantly male (82%) and identified as gay (90%). The key barrier to treatment in those with confirmed mpox diagnosis was not being offered treatment (57%). Key barriers to vaccination included limited access to vaccines (30%) and stigma (14%). Stigma was pervasive, with 49% believing others would avoid them due to mpox and 43% expressing concerns about being perceived as "dirty." Overall, the highest rated stigma subscale score was for concerns about public attitudes subscale, with a median score 9 out of 12, [Q1 8, Q3 10]). Those who previously had mpox reported higher stigma levels compared to at-risk individuals, particularly within the stigma domains of disclosure concerns ("telling someone I have mpox is risky" median score of 3 [Q1 2, Q3 4] for those who previously had mpox vs. 2 [2, 2] for those at risk, with no prior mpox; p = 0.0002), and a trend towards higher stigma for the subscale evaluating concerns about public attitudes (p = 0.071).

Conclusion: Stigma surrounding mpox exacerbates healthcare disparities and may influence preventive behaviors. Public health efforts should prioritize stigma-reduction strategies, culturally competent care, and targeted community engagement to improve outcomes in persons with mpox and similar infectious disease outbreaks.

Keywords: Barriers to treatment; Barriers to vaccination; LGBTQ+; Mpox; Stigma.

Fig. 1

12-item Mpox stigma survey. The mpox stigma survey was adapted from the Reisner, et al. short version of the HIV Stigma Scale. Four subscales of stigma were evaluated, personalized stigma, disclosure concerns, concerns about public attitudes, and negative self-image. Each item was rated on a four-point Likert scale from Strongly Disagree (1) to Strongly Agree (4). Results are shown by mpox status (previously had mpox [n = 27], versus at risk, no prior mpox [n = 95]). The adapted mpox stigma scale showed overall good internal consistency, with a Cronbach’s α of 0.86 (95% confidence interval: 0.82, 0.89, Table 4). The personalized stigma subscale had low internal consistency (α = 0.44, 95% confidence interval 0.25, 0.59), but the other subscales were above a reasonably acceptable α value of 0.7