Assessing mpox knowledge and sexual behaviours within high-risk populations in the Democratic Republic of the Congo

Historically, the Democratic Republic of the Congo (DRC) has faced the greatest public health burden from mpox, including more than 70 000 probable cases from 1 January 2024 to 2 February 2025. However, there has been a relative paucity of investigation focused on mpox community engagement in DRC, including assessments of disease knowledge and risk perception.

Given the ongoing Clade I mpox public health emergency of international concern, and the linkage between sustained human-to-human transmission and dense sexual networks, we sought to investigate mpox knowledge and sexual behaviours among key populations. Between 20 March 2024 and 25 August 2024, we recruited 2794 participants distributed across Kinshasa, Kwango and North Kivu provinces, with a focus in urban centres where mpox risk was considered high.

Most participants were considered other at-risk populations (948; 33.9%), followed by men who have sex with men (MSM, 828; 29.6%) and sex workers (897; 32.1%). Mpox knowledge, including transmission routes as well as sexual and health-seeking behaviours, was evaluated through questionnaires led by peer educators. Overall, only 6.1% of all participants reported prior mpox knowledge. Among this participant subset, zoonosis ('direct contact with infected animals') and 'people living in high-risk areas' were the most frequently selected options in regard to mpox transmission and populations at risk, respectively. When considering at-risk behaviours for mpox, those who identified as sex workers reported significantly higher risk sexual activities, including multiple sexual partners (80.3% of sex work participants), engaging in transactional sex (84.7%) and anonymous sex (80.8%) compared with MSM. However, both sex workers (44.8%) and MSM (56.7%) reported the highest health seeking behaviours for a suspected sexually transmitted infection.

Our results highlight the need to evaluate knowledge in high-risk communities, especially in an endemic setting. Community engagement, which incorporates both mpox knowledge and risk perception activities, is inclusive of at-risk populations and is needed for ongoing mpox containment and mitigation efforts.