Mpox coinfections and clinical manifestation in Africa: a systematic review and meta-analysis.

BACKGROUND

Mpox remains a significant public health challenge in Africa, where endemic transmission persists alongside a high burden of other infectious diseases. Although the epidemiology and clinical impact of coinfections with human immunodeficiency virus (HIV) and varicella-zoster virus (VZV) remain poorly understood across the continent, these coinfections may influence clinical presentation, disease severity, and diagnostic accuracy. This aimed to describe the coinfections (VZV and HIV) patterns among confirmed mpox cases and characterize the trend of clinical presentation of mpox patients in Africa.

METHODS

Following PRISMA guidelines, we registered our protocol in PROSPERO (CRD420251133960) and conducted a systematic review and meta-analysis. We searched multiple electronic databases and grey literature through 27 February 2025, identifying observational studies from Africa that reported mpox coinfections (VZV and/or HIV) and associated clinical symptoms. Random-effects models were used to calculate pooled prevalence, while subgroup analyses and meta-regression explored sources of heterogeneity across WHO regions, countries, study designs, settings, and participant types.

RESULTS

A total of 23 studies conducted across African countries were included. The pooled prevalence of VZV-mpox coinfection was 8.73% (95% CI: 2.05-30.43; 10 studies; n = 2,681; I 2 = 75.7%), while HIV-mpox coinfection prevalence was 4.29% (95% CI: 1.78-9.96; 9 studies; n = 1,939; I 2 = 88.4%), both of which had significant heterogeneity. Coinfections were far more prevalent in hospital-based environments than in community-based research. The rash was observed across all clades, but the clinical manifestations varied by viral clades, with clades I and Ia linked to more severe systemic symptoms than clade II.

DISCUSSIONS: HIV and VZV coinfections with mpox pose a major yet possibly underestimated burden in Africa and are linked to more severe clinical presentations, particularly in hospital environments. The necessity of including clinical, epidemiological, and genomic in mpox monitoring systems is underscored by observed clinical differences across clades. Improving patient management and outbreak preparedness across the continent requires strengthening diagnostic capacity and routinely screening for coinfections.

SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251133960, identifier CRD420251133960.