The Impact of HIV Coinfection on Mpox Patients: A Systematic Review and Meta-Analysis.

A substantial proportion of mpox cases occur in people coinfected with HIV. However, the extent to which HIV coinfection and HIV-related immune status influence clinical outcomes, including disease severity and coinfections, remains incompletely characterized. We systematically searched PubMed, Cochrane, EMBASE, and Web of Science from database inception to March 2025 for observational studies comparing clinical outcomes between mpox patients with and without HIV coinfection. The random-effects model was prespecified to pool effect sizes. Dichotomous and continuous outcomes were summarized as risk ratios (RRs) and standardized mean differences (SMDs) with 95% confidence intervals. Post hoc exploratory subgroup analyses were conducted on the basis of economic development level, HIV viral suppression status, and the proportion of participants with advanced HIV disease (AHD). A total of 29 studies involving 15,522 mpox patients were included, of whom 52.43% were coinfected with HIV. In the primary analyses, HIV coinfection was associated with significantly higher hospitalization rates [RR = 1.50, 95% CI (1.17, 1.93)] and mortality [RR = 4.54, 95% CI (2.11, 9.77)]. Mpox patients with HIV coinfection were more frequently coinfected with syphilis, HBV, and HCV and more commonly presented with fever, proctitis, malaise, rectal irritation syndrome, diarrhoea, skin and soft tissue infections, and pneumonia. Pooled blood test results revealed lower levels of albumin, calcium, and haemoglobin, and higher CK-MB levels in the coinfected group. Skin lesions in the perianal region were more common among coinfected patients. HIV coinfection is associated with substantially greater clinical severity, greater risks of hospitalization and death, and greater rates of sexually transmitted coinfections among mpox patients. Exploratory subgroup analyses further suggest that suboptimal HIV suppression may be a clinically relevant determinant of adverse outcomes, and that skin lesion severity may depend substantially on host immune status. All subgroup findings are post hoc and hypothesis generating and are limited by the aggregate nature of the data. Clinicians should consider intensified monitoring and comprehensive supportive care for mpox patients with HIV coinfection, particularly those with suboptimal suppression. Strengthening vaccination and health education in high-risk populations and optimizing strategies for ART initiation remain crucial for mitigating the public health impact of MPXV.