In a waiting room at the Mortimer Market Centre, a sexual health clinic in central London, a slow but steady stream of men who have sex with men (MSM) are arriving to receive their first monkeypox vaccination. It is a sweltering afternoon, and all available slots have been filled, as they have ever since vaccines started to be delivered here in early July.
Few know much about the monkeypox virus itself, or how the vaccine works. But everyone at the clinic is acutely aware of how this unpleasant and potentially extremely painful disease has been sweeping through gay and bisexual men: according to the World Health Organization (WHO), they account for 98% of this outbreak’s cases. The 2,500 men who have so far passed through these doors now have some protection, although at what level – and for how long – remains uncertain. In very rare cases the disease can be fatal.
“I’ve been trying to get the vaccine for weeks,” says 20-year-old Callum Bowyer, after a nurse has administered a dose into his upper left arm. “I’ve got some friends who have monkeypox and it sounds really awful, with isolation of up to four weeks. I don’t want that. But finding out how to protect myself has been almost impossible.” A student in Guildford now back at the family home in Oxfordshire for the summer, he couldn’t find a clinic in either area that could offer him a jab, or any suggestion of where he could get one.
“I even had a monkeypox scare myself,” he says. It was right after London’s early July Pride celebrations. “When I had some spots appear on my body afterwards, I was told to travel to Soho from Guildford to get a test, so I had to sit on a busy train with a potentially contagious virus.” Bowyer eventually got the all clear. But even after this close call, finding a vaccine proved impossible. It was only after a tipoff from a friend that he managed to secure today’s appointment. Others I speak to describe similar struggles: phones going unanswered; apologetic NHS workers stating that they simply don’t have a supply to offer.
Despite being in a high-risk group, 63-year-old Ron Lithgo also had little luck with clinics in east London, where he lives. It was only after a referral from a cruising club that he nabbed a place here. “You can find out if you’re eligible very easily,” he says, as his name is called, “but nobody has a clue where to get one.”
By 4pm, the waiting room has cleared. With appointments over for another day, Kim Lombardi, the clinical lead for the vaccination team at Central and North West London NHS foundation trust, sets out just how high the demand has been. “At the moment,” she says, “we’re seeing up to 200 people a day. But we could see far more if we had supply to deliver.”
In some ways, staff say recent weeks in the clinic have felt reminiscent of the 90s. “In the evenings, when we’re delivering the vaccine, it feels a bit like a club,” Lombardi says. “Many patients know each other, and we put the music up; lots of the older staff say it feels like the old days.” But there are also more uncomfortable echoes of the HIV and Aids epidemic. “Some of the younger ones have been very anxious,” Lombardi adds. “They’ve inherited this history that’s alarming for them: something going around that nobody knows much about, that’s sexually transmitted. It’s scary for them.”
Lombardi has worked on and off in sexual health services since 2009, and in that time has never seen such demand for appointments. Once the vaccine centre was set up, regular patients who were eligible for the vaccine (those on pre-exposure prophylaxis medication (PrEP); HIV-positive patients; those who recently had STIs; men with multiple partners, who participate in group sex or attend “sex on premises” venues) were contacted. “The response has been massive,” says Lombardi. “As soon as we put appointments online, they’re going.” Within minutes, she says, 100 slots will have filled up. “People are clearly sitting there waiting.”
While booked appointments are still going ahead, with vaccines now in such short supply the clinic is unable to offer any new ones. As of this week, national rationing means jabs will also stop being routinely given to people after confirmed exposure to monkeypox through sexual contact. “When we tell some patients there are no appointments, they’re understanding,” she says. “Others get really upset, and you can understand why. So many people are presenting as being in the high-risk group. Whatever initial numbers were planned for centrally, it feels like a major underestimation.”
First identified in humans in the Democratic Republic of Congo 50 years ago, monkeypox is a relatively well-known virus. “It’s more generally observed in west and central Africa,” says John McSorley, a sexual health and HIV clinician, and a past president of the British Association for Sexual Health and HIV. “Its circulation in Europe and other continents beyond Africa – and this expanding outbreak – is unusual behaviour.”
The virus appears to have been able to exploit the close networks and contacts of MSM. “In effect,” McSorley says, “this is a virus transmitted through close skin-to-skin contact. So it’s not obligatory to pass through sexual contact.”
Monkeypox usually presents with symptoms, and in the vast majority, McSorley says, these are at the “milder” end of the spectrum. “These less severe symptoms include poxes or spots which may last seven to 10 days, healing with mostly complete improvement. At the opposite end of the spectrum, in Europe 5-10% of people have had relatively serious complications often requiring hospitalisation, including multiple lesions in critical areas of the body such as in and around the mouth, neck and genital area or bottom, causing difficulty or pain when eating or excreting.”
For most, the infection will be over within 21 days. But for some, there are longer-term complications. “And in Africa,” McSorley adds, “it’s been established there can be fatalities with this virus, generally more frequent where it affects children and babies, pregnant women or people with significant underlying health conditions.” In 2022, the African Centre for Disease Control believes there have been 75 deaths across the continent.
“This outbreak beyond Africa tends to be spreading primarily in men who have sex with men aged 16-65, otherwise in relatively good health or with access to good healthcare,” McSorley continues. “The mortality level has been lower than our initial worries, but it’s still there: for example, two men in their 30s in Spain with no underlying health conditions died recently.”
The case for mass vaccination of those most at risk is crystal clear. Unlike Covid, where mutations allow for repeat infections, all evidence suggests this won’t be the case with monkeypox. “Given the family of viruses it comes from, it shouldn’t happen,” McSorely says. And the vaccination drive is showing results. Latest figures show that the outbreak is slowing, for now, with 3,195 cases across the UK: on average 20 cases are being confirmed a day, compared with 52 during the last week in June.
“This outbreak could be brought to a halt by replacing immunity through natural exposure with vaccination,” McSorley says. “And yet we’re about to run out of doses.”
He and other practitioners I ask all believe the government could be doing more. “They have the power to authorise things to move faster, or increase spending,” McSorley says. “We are not aware that there has been any variation in budget: as far as we can tell, all responses have had to be delivered from existing resources.” A Department for Health and Social Care spokesperson pointed the Guardian towards existing funding: “We are enabling local authorities to invest in essential frontline sexual health services by providing more than £3.4bn through the public health grant.”
According to the UK Health Security Agency (UKHSA), as of 17 August, close to 30,000 MSM had received their first monkeypox vaccination. If all goes according to plan, they should get a second shot – although it’s unclear when this will prove possible. They are getting modified vaccinia Ankara vaccine (MVA), also used to protect against smallpox. But there is still a long way to go. The UK government initially ordered 50,000 doses (the maximum, it says, that was immediately available), and a further 100,000 are expected to arrive in late September. This would be enough to treat 75,000 people. According to a coalition of sexual health experts, including representatives from the British Association of Sexual Health and HIV, the National Aids Trust, the Terrence Higgins Trust and the Association of Directors of Public Health, these numbers should be significantly higher: it calculated that at least 125,000-130,000 men would need the vaccine.
Global supply issues are a major problem: there is only a single supplier of the vaccine worldwide (Bavarian Nordic), and part of its production line is closed for refurbishment. The company recently said it is no longer certain it can meet demand on its own as case numbers escalate, although it is exploring whether doses that have passed their expiry date could help to bridge the gap.
But many British public health officials, practitioners and campaigners believe there have been failures closer to home. As one senior public health official put it, speaking on the condition of anonymity: “The global situation simply doesn’t explain or excuse the initial inadequate and shambolic response and rollout that we witnessed from central government and national agencies.
“I don’t think UKHSA or NHS England were terribly bothered by the outbreak at first,” the official adds. “They kept fighting with one another rather than working together. People in various agencies have quite literally said to me and colleagues: ‘If it ends up endemic in gay men, then so be it.’”
This is reflected, the official argues, in the vaccine response: “There could have been more vaccines here by now if the government had moved faster.”
Dr Andrew Lee, the UKHSA’s monkeypox incident director, rejects suggestions that the agency was slow to get to grips with the outbreak. “We acted immediately to tackle the spread of the monkeypox virus,” Lee says, “and have worked continuously with a range of stakeholders to investigate the outbreak, alert people to the symptoms and support those affected.”
On the afternoon of 22 August, UKHSA announced a trial of fractional dosing across a limited number of vaccination sites. Trials suggest delivering one-fifth of the current amount of vaccine into a patient can yield the same results as the standard dose. If this is rolled out, access to the vaccine will grow rapidly. And Jim McManus, the president of the Association of Directors of Public Health, and the director of public health at Hertfordshire county council, believes there has been improvements.
“It’s extremely encouraging that there is now a clear consensus between organisations at every level that we are aiming to end the outbreak in the UK and stop it becoming endemic,” McManus says. “But there’s still much more to be done. We have no support package agreed by the government for men who have to isolate with monkeypox, and we are also still nowhere nearer national government funding for the extreme, unprecedented and unique pressure sexual health services are now under.”
The consequences of these failures could be severe: if monkeypox continues to spread as vaccine supplies dry up, there is a real risk it could become endemic. “That will worsen health inequalities for gay and bisexual men significantly,” McManus says, “and it will be very difficult to eliminate when it spreads across the wider community, the cost of which will be hundreds of times that of vaccinating everyone and eliminating it.”
Gay and bisexual men are loud advocates for their own health. Decades of being let down by central government and national health agencies has proved this to be a necessity. But while much has changed since the 1980s’ and 90s’ nakedly homophobic response to HIV and Aids, many still believe the government doesn’t care enough about MSM’s sexual health.
Greg Owen, a sexual health and HIV activist who now works with the Terrence Higgins Trust was a key figure in the fight for PrEP to be made available on the NHS, a drug that – if taken correctly – almost eradicates the risk of contracting HIV sexually. In July 2012, the United States Food and Drug Administration announced it was approving PrEP as a drug for this purpose. It took almost eight years – and tireless campaigning – for the treatment to be made routinely available in the UK, during which time more than 30,000 men were diagnosed HIV positive.
“Many gay and bisexual men really don’t trust the state to look out for their sexual health,” Owen says. “And honestly, I don’t blame them.”
Day and night, Owen is inundated with requests for help from those who are experiencing symptoms and others desperate for guidance on where to find a vaccine. For many, he says, this period has proved incredibly traumatic.
“Of course there’s a hangover from HIV and Aids,” he says. “I know people older than me are freaking out – seeing young, otherwise healthy gay and bisexual men turning up with lesions all over their faces. That’s a huge trigger for those who lived through that epidemic.” While medically there are few comparisons to be drawn between HIV/Aids and monkeypox, the inaction – Owen argues – feels alarmingly familiar.
“This is a community who are oppressed, ostracised and attacked for who they have sex with,” says Owen. “What does it say to that new generation that in 2022 there hasn’t even been extra money made available to deliver the vaccine or run a proper national information campaign? Right now some people won’t even know about the risk at all, and those who do but can’t get the vaccine are having to place themselves at risk, or abstain from sex indefinitely. It’s outrageous.”
This is precisely the situation facing 29-year-old Ryan Coleflex. Based in Sheffield, and eligible for a vaccine, he’s received no guidance on when he might receive a jab. “More and more,” Coleflex says, “I’m seeing peers post on social media of how they’re affected, often with graphic photos to highlight their struggle, which is heartbreaking and terrifying. And yet all I can do is sit and wait.”
Clinicians say the proximity of the monkeypox outbreak to Covid has had certain benefits. The overriding willingness of the public to present themselves for a vaccine – and to isolate when necessary – feels more normal now, two and a half years into the pandemic. For Owen, it’s hard, therefore, not to also compare the two vaccination programmes.
“We saw what happened with Covid,” he says. “Every resource possible was put towards ensuring the vaccine was available to those who needed it. People were asked to change their behaviour, with the promise they’d be called in as soon as possible. With this, we’re not waiting for clinical trials, or breakthroughs in science.” There is a vaccine, Owen says; we know it works. “Yet no agency or politician will even commit to providing access to everyone who wants a vaccine, when supply becomes available. Instead, this community is once again being placed at risk. It feels like there’s no urgency. I don’t believe it’s overt homophobia. It’s not the same as what happened with HIV and Aids. But the inaction, the muted response, feels far too similar.”