Integrating Mpox care into HIV programs as a global health imperative

Abstract The 2025 mpox clade IIb outbreak in Sierra Leone highlighted critical limitations of vertical disease control approaches. Facility-level data reveal high HIV co-infection prevalence, reaching up to 83% in one national referral hospital. Within this cohort, advanced immunosuppression was the norm, accounting for 82% of mpox-related deaths. A significant disruption in the HIV care continuum, evidenced by one-third of co-infected patients interrupting antiretroviral therapy, likely contributed to adverse outcomes, suggesting that mpox may function as an opportunistic infection in advanced HIV in this context. Current responses are undermined by programmatic silos, therapeutic inaccessibility, and stigma. In this Perspective, we argue that integrating mpox surveillance, prevention, and care into the foundational infrastructure of national HIV programs is a clinical and economic imperative. Learning from the Ebola-HIV syndemic, we propose a four-pillar framework: (1) institutionalizing routine bidirectional screening (2), adapting context-specific co-management guidelines (3), formalizing coordinated care pathways, and (4) prioritizing targeted operational research. Leveraging the robust platform of HIV services achieves cost-efficiency, improves early detection, guarantees care continuity, and builds a resilient health system capable of safeguarding vulnerable populations from converging syndemic threats.