Monkeypox Patients Living with HIV: A Systematic Review and Meta-Analysis of Geographic and Temporal Variations

This index meta-analysis estimated the pooled prevalence of human immunodeficiency virus (HIV) among individuals with monkeypox (mpox) globally. We searched seven databases: PubMed, Scopus, Web of Science, EMBASE, ProQuest, EBSCOHost, and Cochrane, for human studies published in English till 4 January 2023, as per International Prospective Register of Systematic Reviews (PROSPERO) registration protocol (CRD42022383275). A random effects regression model was used to estimate the pooled prevalence owing to high heterogeneity. The risk of bias in the included studies was assessed using the National Heart, Lung, and Blood Institute (NHLBI) quality assessment tool. The systematic search yielded 677 articles; finally, 32 studies were found eligible for systematic review and 29 studies for meta-analysis. The pooled prevalence of HIV infection was 41% (95% confidence interval [CI], 35–48). All studies were rated as fair or good quality. Studies from Europe and North America reported a high prevalence of HIV infection among individuals with mpox- 41% (95% CI 33–49) and 52% (95% CI 28–76), respectively, while studies from Nigeria, Africa reported a relatively low prevalence of HIV infection of 21% (95% CI 15–26). A history of sexual orientation and sexual partners in the last 21 days must be taken from individuals with mpox to identify the potential source and contacts for quarantining and testing them.


Introduction
Most mpox (previously known as monkeypox) cases were reported from central and west Africa in the past [1].However, in May 2022, the disease began to emerge across the world in multiple countries.It was declared a "public health emergency of international concern' by the World Health Organization (WHO) in 2022 [2].Among all known transmission routes, a potential sexual route has been reported among 82.1% (16,518/20,126) of individuals with mpox [3].Within mpox virus (MPXV), there are two distinct clades, namely clade I (formerly known as Central Africa strain) and clade II (formerly known as West African strain).Clade II encompasses two phylogenetically distinct subclades, IIa and IIb.The sub-clades are however distinct, with a differential evolution from an ancestor which dates back centuries [4].The 2022 multicountry outbreak of mpox has been attributed to clade IIb.Pre-2022 outbreak of mpox was mostly associated with close contact through the skin lesions and respiratory route of transmission [5].In contrast, sexual intercourse has been identified as a major risk factor for the 2022 multicountry outbreak.Close contact happening during sexual intercourse or as sexually transmitted infection due to the act are the potential routes of transmission implicated in the 2022 outbreak.This has led to the establishment and spread of MPXV among the communities with high-risk sexual practices, especially with the anal receptive sex.Semen samples have been reported to harbor a high load of MPXV [5].Human immunodeficiency virus (HIV) is another viral infection that is transmitted majorly through a sexual route [6].The burden of HIV is high, with prevalent cases of 39 million and 630,000 deaths in 2022 alone.Within these cases, Africa is the worst affected, with 2/3 of the people living with HIV (PLHIV) on the continent [7].Mpox is also endemic in African countries [8].
Considering the overlap in the epidemiology of HIV and mpox in the context of the 2022 multicountry mpox outbreak, it would be relevant to explore the relationship between these viral infections at the global and regional levels.The clinical manifestation of mpox is self-limiting, but the disease can be severe in a specific population, such as individuals with immunosuppressed, including PLHIV [9].Studies have reported poor outcomes among individuals with MPXV -HIV co-infection [10][11][12][13].In a retrospective study from Nigeria among 40 individuals with mpox, it was reported that individuals with MPXV-HIV were susceptible to an increase in the duration of the disease, more prominent lesions, and increased secondary bacterial infection [13].Uncontrolled HIV is associated with adverse outcomes, including deaths [12].
The epidemiological profile of mpox has shown considerable variation between continents, endemic/nonendemic countries, and the period of the cases (2022 multicountry outbreak vs. Pre-2022) in terms of mortality rates, clinical manifestations, and demographic characteristics of the affected population [14][15][16][17].Studies in Africa before the current outbreak reported a prevalence of HIV among mpox in the range of 18.75% to 25% [18,19].Studies in European countries showed varied HIV prevalence ranging from 15% in France to 64% in Spain [20,21].Thus, multiple studies from current and past outbreaks have reported varying HIV prevalence among individuals with mpox.However, based on our systematic search in multiple databases, we did not find an analysis reporting the pooled prevalence of HIV among the individuals with mpox, and the regional and temporal variations.
Hence, we conducted a systematic review and meta-analysis to determine the pooled prevalence of HIV reported among individuals with mpox, and to synthesise the epidemiological characteristics of individuals with HIV-MPXV co-infections.

Research Question & Selection Criteria
The present systematic review and meta-analysis were carried out based on the research question, 'What is the prevalence of HIV in individuals with mpox?' The systematic search and identification of eligible studies were centered on the criteria elaborated in the Appendix A. (Tables A1 and A2).The study population included laboratory-confirmed individuals with mpox, belonging to all age groups and sex.All suspected or probable individuals with mpox were excluded.The outcome of interest was the prevalence of HIV.All eligible human studies published in English that satisfied the above criteria were included in the analysis.The present meta-analysis was registered with the International Prospective Register of Systematic Reviews (PROSPERO), with reference ID CRD42022383275.

Databases included and Search Strategy
The search was carried out in seven databases: "PubMed, Scopus, Web of Science, EMBASE, ProQuest, EBSCOHost, and Cochrane", until 4 January 2023 (Table A2).We also searched the pre-print servers such as "medRxiv, arXiv, bioRxiv, BioRN, ChiRxiv, ChiRN, and SSRN".Furthermore, studies obtained by hand search in the references of eligible primary research papers and reviews, which met our eligibility criteria, were also included in the data extraction.The search keywords included "mpox" 'MPXV', 'monkeypox', 'AIDS', 'HIV' and 'PLHA'.The database-wise search strategy applied and the results obtained have been enumerated in Table A2.The Mendeley Desktop V1.19.5 software was used to import articles, manage the citations, remove duplicates, and coordinate the overall review process between authors.

Title-Abstract Screening
Four senior authors independently reviewed the title abstracts of the studies obtained from the above systematic search applying the eligibility criteria and identified articles for full-text screening.If there was a disagreement about including a study for full-text review, the co-authors conversed among themselves to build consensus and decided on eligibility.

Full Text Screening & Data Extraction
Eligible full-text articles were reviewed for suitability of data extraction by two authors, and data extraction was performed by them independently.Contradictions in the extraction of data between the authors were removed in a consensus meeting held at the end of the independent extraction.A final table was formulated that included information such as author's name, publication year, sex distribution, age, study where it was conducted, study design, total mpox-positive individuals, and PLHIV.The preferred reporting standard of systematic reviews and Meta-analysis (PRISMA) flow chart and checklist were utilised to report general search, screening, data extraction, systematic review, and meta-analysis conducted to ensure scientific precision (Figure 1 & Table A3).

Quality Assessment
The risk of bias in the included studies was independently evaluated by two authors (MAS&SM) using the National Heart, Lung, and Blood Institute (NHLBI) quality assessment tool for case series and cross-sectional studies [22].

Data Analysis
The pooled prevalence of HIV infection was estimated as a proportion by collating

Quality Assessment
The risk of bias in the included studies was independently evaluated by two authors (MAS&SM) using the National Heart, Lung, and Blood Institute (NHLBI) quality assessment tool for case series and cross-sectional studies [22].

Data Analysis
The pooled prevalence of HIV infection was estimated as a proportion by collating the total number of individuals with mpox and PLHIV.To address the risk of bias, we planned a sensitivity analysis by excluding poor-quality studies.Baujat plot, Leave-one-out analysis, radial plot, and diagnostic test were applied to identify the outliers and undertake sensitivity analysis.The I 2 test was applied to determine heterogeneity among the included studies.Depending on the I 2 value, heterogeneity can be declared low (25%), moderate (25-50%), and high (>50%).A random effect regression model with the DerSimonian & Laird estimator was used to evaluate the overall effect, as heterogeneity was high.We performed a subgroup analysis to identify the source of heterogeneity: (i) geography (continentwise), (ii) MPXV (endemic vs. non endemic countries), and (iii) 2022 vs. pre-2022 studies.Prediction interval (PI) for the outcome was calculated if the heterogeneity was high.Metaregression was performed to assess the effect of age and sex on the outcomes using bubble plots.The funnel plot and doi plot were used to evaluate publication bias.If the funnel plot depicted possible publication bias, a trim-and-fill test was planned to address publication bias, and the Eggers test to evaluate the effects of the small study was planned.A p-value of less than 0.05 was interpreted as statistically significant.All analyses and graphs were performed using R-programming (v4.0).

Eligible Studies
Figure 1 shows the article selection process as PRISMA flow chart.The systematic search yielded 468 articles after removing 209 duplicates.After the title abstract selection, 170 articles were eligible for full-text selection.In the full-text screening, 139 articles were excluded due to non-reporting of HIV status (96), incorrect study design (27), and incorrect patient population (16).Two new studies were included from the hand-search of the references from the included studies.Finally, 32 studies were found eligible for systematic review.Among them, two studies included individuals with MPXV-HIV co-infection as their study population, and one study had a data duplication.Hence 29 studies were included for data extraction in the meta-analysis.

Risk of Bias
The quality assessment of the findings of the included study is illustrated in the supplement file (Table A4), with all studies (30) rated as fair or good quality.The Doi plot was symmetrical with an LFK index of 0.91, indicating no publication bias (Figure S1).
The layout of the funnel plot also showed a symmetric funnel, indicating no publication bias (Figure S2).

Sensitivity Analysis
Sensitivity analysis enables the improvement of the robustness of the pooled estimates by eliminating or reducing the heterogeneity between the studies.In order to undertake sensitivity analysis, diagnostic tests were applied [46].One of the studies (Miller et al. [44]) was identified as an outlier by the diagnostic test (Figure 3).However, leave-one-out analysis did not yield a significant change in the pooled estimate or heterogeneity (Figure 4).

Risk of Bias
The quality assessment of the findings of the included study is illustrated in the supplement file (Table A4), with all studies (30) rated as fair or good quality.The Doi plot was symmetrical with an LFK index of 0.91, indicating no publication bias (Figure S1).The layout of the funnel plot also showed a symmetric funnel, indicating no publication bias (Figure S2).

Sensitivity Analysis
Sensitivity analysis enables the improvement of the robustness of the pooled estimates by eliminating or reducing the heterogeneity between the studies.In order to undertake sensitivity analysis, diagnostic tests were applied [46].One of the studies (Miller et al. [44]) was identified as an outlier by the diagnostic test (Figure 3).However, leaveone-out analysis did not yield a significant change in the pooled estimate or heterogeneity (Figure 4).
The bubble graph showed that age had an inverse relationship and that the proportion of males in the study had a directly proportional relationship with HIV prevalence among individuals with mpox.(Figures S6 and S7) However, the relationships were not significant.Similarly, metaregression did not show a significant effect of sample size on HIV prevalence.(Figure S8).
The bubble graph showed that age had an inverse relationship and that the proportion of males in the study had a directly proportional relationship with HIV prevalence among individuals with mpox.(Figures S6 and S7) However, the relationships were not significant.Similarly, metaregression did not show a significant effect of sample size on HIV prevalence.(Figure S8).

Discussion
Our review and meta-analysis revealed a pooled prevalence of HIV infection of 41.11% among individuals with mpox.However, the prevalence varied according to the cases' geography, endemicity, and period.Studies in an African country (Nigeria) and before 2022 reported a lower HIV prevalence of 21.22% and 22.05%, respectively.The significant difference in the HIV prevalence might be due to the predominant transmission mode during the pre-2022 multicountry outbreak, which was mainly through close contact with the skin lesions [5,18].The ongoing multicountry outbreak and nonendemic countries were found to have a higher prevalence of HIV infection among individuals with mpox (42.05% and 42.60%, respectively).The prevalence rate is very high compared to the prevalence of HIV among the general population in all included countries (African and non-African countries).However, the gap was more pronounced in nonendemic and non-African countries, with a study from Portugal reporting a difference of more than 100 times that of the general population [38].The shift in human-human transmission routes might explain this.The current outbreak, which is more concentrated in nonendemic European and American countries, has a disproportionate share of the MSM, bisexuals, and gay population [30], who are HRGs for HIV.Although the burden and prevalence are high in African countries, the proportion of HIV infection among individuals with mpox is relatively lower than in Europe and the Americas, where HIV prevalence is low.In contrast, mpox lesions can also aid and abate the transmission of sexually transmitted diseases, including HIV [38].
Mpox lesions in the primary areas of the body of sexual contacts have been suspected to be the transmission gateway in patients with high-risk behavior [24].Rectal and semen samples had shown 67-77% positivity for individuals with mpox.A series of cases with MPXV-HIV coinfection reported the presence of the MPXV in 90% of the rectal swabs [47].Although the viral load was lower, the median clearance of the MPXV from semen samples has been reported to be 13 days, extending up to 39 days among the majority of the patients [36].Asymptomatic individuals with MSM mpox from France had their samples tested positive for MPXV from anal swabs, indicating a possible shedding of the virus in the anal route [28].These might be a potential explanation for MPXV transmission among people with high-risk sexual behaviors.
Clinical characteristics varied according to HIV infection status, with MPXV-HIV coinfected individuals having significantly higher composite rash scores.A significantly higher rate of oral and perioral lesions was found among the PLHIVs [23].Acute coinfection with HIV and MPXV has been reported to lead to hospitalization [27].In a global case series, the hospitalization rate among the MPXV-HIV coinfected individuals was reported to be 28% [48].Severity varied according to the status of HIV control, with adverse outcomes reported in hospitalized individuals with poor HIV control [44].A study from Spain reported the most severe mpox infection in the PLHIV with poor disease control (CD4 = 265), than in the other individuals with HIV-MPXV [32].Studies from nonendemic countries reported good HIV control status among most individuals with HIV-MPXV coinfection [13,28,30,31,35,45,49].A study from mpox endemic Nigeria reported a low CD4 count among the individuals with MPXV-HIV coinfection [18].A study from the USA reported that poorly controlled HIV status had a longer duration of hospitalization than HIV-negative individuals with mpox [40].A study in Nigeria reported poor clinical results among MPXV-HIV coinfected individuals but did not report the control status of HIV [11].Individuals with asymptomatic mpox who were found to have HIV coinfection (61.54%) had it under good control [28].It was also found that, irrespective of HIV infection, individuals with mpox were able to elicit a T cell response against the mpox virus [20,31].
We also found that, during the review, all African studies reporting HIV status in individuals with mpox were from Nigeria.However, none from the Democratic Republic of the Congo (DRC) reported a HIV status.This is of great importance because, while Nigeria had clade II MPXV, the mpox cases in the DRC were due to the more severe and fatal clade (Clade I).Additionally, the current multicountry outbreak in the endemic countries is primarily driven by clade IIb, thus limiting information on the interaction of HIV with the more severe clade of mpox virus (Clade I).A better understanding of the MPXV-HIV coinfection in the endemic African context, especially in the DRC, requires all future studies to report the HIV status of individuals with mpox.

Strengths and Limitations
This review included studies in multiple databases of published and unpublished literature to quantify and study the prevalence of HIV in mpox patients, globally and regionally.The risk of bias in the studies was assessed using standard tools.Subgroup analysis and metaregression (including multiple variables, such as sex, age, and sample size) were undertaken to explain the heterogeneity.A sensitivity analysis was performed methodologically, identifying and excluding outliers.However, the present analysis was not without limitations.There was significantly high heterogeneity among the included studies.The substantial heterogeneity observed in the study is hypothesized due to the global nature of the data in the review with varied patient characteristics in terms of "human immunodeficiency virus":ti,ab OR "human t cell lymphotropic virus type iii":ti,ab OR "lymphotropic virus type iii":ti,ab OR ("aids" NEXT virus*):ti,ab OR "acquired immune deficiency syndrome virus":ti,ab OR "acquired immunodeficiency syndrome virus":ti,ab OR "acquired immune deficiency syndrome":ti,ab OR "acquired immuno deficiency syndrome":ti,ab OR AIDS:ti,ab OR "people living with hiv aids":ti,ab OR PLHA:ti,ab OR HIV:ti,ab (TI "human immunodeficiency virus" OR AB "human immunodeficiency virus") OR (TI "human t cell lymphotropic virus type iii" OR AB "human t cell lymphotropic virus type iii") OR (TI "lymphotropic virus type iii" OR AB "lymphotropic virus type iii") OR (TI "aids virus*"OR AB "aids virus*") OR (TI "acquired immune deficiency syndrome virus" OR AB "acquired immune deficiency syndrome virus") OR (TI "acquired immunodeficiency syndrome virus" OR AB "acquired immunodeficiency syndrome virus") OR (TI "acquired immune deficiency syndrome" OR AB "acquired immune deficiency syndrome") OR (TI "acquired immuno deficiency syndrome" OR AB "acquired immuno deficiency syndrome") OR (TI AIDS OR AB AIDS) OR (TI "people living with hiv aids" OR AB "people living with hiv aids") OR (TI PLHA OR AB PLHA) OR (TI HIV OR AB HIV)  'human immunodeficiency virus':ti,ab OR 'human t cell lymphotropic virus type iii':ti,ab OR 'lymphotropic virus type iii':ti,ab OR 'aids virus*':ti,ab OR 'acquired immune deficiency syndrome virus':ti,ab OR 'acquired immunodeficiency syndrome virus':ti,ab OR 'acquired immune deficiency syndrome':ti,ab OR 'acquired immuno deficiency syndrome':ti,ab OR AIDS:ti,ab OR 'people living with hiv aids':ti,ab OR PLHA:ti,ab OR HIV:ti,ab 566,993 #3 #1 AND #2 154 ProQuest #1 (TI,AB(mpox)) OR (TI,AB(monkeypox)) OR (TI,AB(mpxv)) OR (TI,AB("monkey pox")) 555 #2 TI,AB("human immunodeficiency virus") OR TI,AB("human t cell lymphotropic virus type iii") OR TI,AB("lymphotropic virus type iii")OR TI,AB("aids virus*") OR TI,AB("acquired immune deficiency syndrome virus") OR TI,AB("acquired immunodeficiency syndrome virus") OR TI,AB("acquired immune deficiency syndrome") OR TI,AB("acquired immuno deficiency syndrome") OR TI,AB(AIDS) OR TI,AB("people living with hiv aids") OR TI,AB(PLHA) OR TI,AB(HIV) TITLE-ABS("human immunodeficiency virus") OR TITLE-ABS("human t cell lymphotropic virus type iii") OR TITLE-ABS("lymphotropic virus type iii") OR TITLE-ABS("aids virus*") OR TITLE-ABS("acquired immune deficiency syndrome virus") OR TITLE-ABS("acquired immunodeficiency syndrome virus") OR TITLE-ABS("acquired immune deficiency syndrome") OR TITLE-ABS("acquired immuno deficiency syndrome") OR TITLE-ABS(AIDS) OR TITLE-ABS("people living with hiv aids") OR TITLE-ABS(PLHA) OR TITLE-ABS(HIV)

Methods
Eligibility criteria 5 Specify the inclusion and exclusion criteria for the review and how studies were grouped for syntheses.4 and Table A1 Information sources 6 Specify all databases, registers, websites, organizations, reference lists, and other sources searched or consulted to identify studies.Specify the date when each source was last searched or consulted.

4,5 and Table A2
Search strategy 7 Present the full search strategies for all databases, registers, and websites, including any filters and limits used.Table A2 Selection process 8 Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, include details of automation tools used in the process.

Data collection process 9
Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, include details of automation tools used in the process.

Data items 10a
List and define all outcomes for which data were sought.Specify whether all results that were compatible with each outcome domain in each study were sought (e.g., for all measures, time points, and analyses), and if not, the methods used to decide which results to collect.
5, Table 1 10b List and define all other variables for which data were sought (e.g., participant and intervention characteristics, funding sources).Describe any assumptions made about any missing or unclear information.
5, Table 1 Study risk of bias assessment 11 Specify the methods used to assess the risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process.

4, Table A4
Effect measures 12 Specify for each outcome the effect measure(s) (e.g., risk ratio, mean difference) used in the synthesis or presentation of results.Describe the processes used to decide which studies were eligible for each synthesis (e.g., tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5)).
5, Table 1 13b Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions.

NA 13c
Describe any methods used to tabulate or visually display the results of individual studies and syntheses.Figure 1 13d Describe any methods used to synthesize results and provide a rationale for the choice(s).If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used.

5,6 13e
Describe any methods used to explore possible causes of heterogeneity among study results (e.g., subgroup analysis, metaregression).

13f
Describe any sensitivity analyses conducted to assess the robustness of the synthesised results.5 Reporting bias assessment 14 Describe any methods used to assess the risk of bias due to missing results in a synthesis (arising from reporting biases).NA

Certainty assessment 15
Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome.NA

Study selection 16a
Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram.

16b
Cite studies that might appear to meet the inclusion criteria but were excluded and explain why they were excluded.For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g., confidence/credible interval), ideally using structured tables or plots.Was the participation rate of eligible persons at least 50%?Q4: Were all the subjects selected or recruited from the same or similar populations (including the same time period)?Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?Q5: Was a sample size justification, power description, or variance and effect estimates provided?Q6: For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?Q7: Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed?Q8: For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as a continuous variable)?Q9: Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?Q10: Was the exposure(s) assessed more than once over time?Q11: Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?Q12: Were the outcome assessors blinded to the exposure status of participants?Q13: Was the loss to follow-up after baseline 20% or less?Q14: Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)?

Figure 1 .
Figure 1.PRISMA flowchart for included studies in systematic review and meta-analysis of prevalence of HIV among the individuals with mpox.

Figure 1 .
Figure 1.PRISMA flowchart for included studies in systematic review and meta-analysis of prevalence of HIV among the individuals with mpox.

Figure 2 .
Figure 2. Forest plot of pooled prevalence of HIV prevalence in monkeypox virus.Figure 2. Forest plot of pooled prevalence of HIV prevalence in monkeypox virus.

Figure 2 .
Figure 2. Forest plot of pooled prevalence of HIV prevalence in monkeypox virus.Figure 2. Forest plot of pooled prevalence of HIV prevalence in monkeypox virus.

Figure 4 .
Figure 4. Sensitivity analysis by leave-one-out analysis.

1 ( 2 "
mpox[Title/Abstract]) OR (monkeypox[Title/Abstract]) OR (mpxv[Title/Abstract]) OR ("monkey pox"[Title/Abstract]) OR ("monkeypox"[MeSH Terms]) OR ("monkeypox virus"[MeSH Terms]) 2441 #human immunodeficiency virus"[Title/Abstract] OR "human t cell lymphotropic virus type iii"[Title/Abstract] OR "lymphotropic virus type iii"[Title/Abstract] OR "aids virus*"[Title/Abstract] OR "acquired immune deficiency syndrome virus"[Title/Abstract] OR "acquired immunodeficiency syndrome virus"[Title/Abstract] OR "acquired immune deficiency syndrome"[Title/Abstract] OR "acquired immuno deficiency syndrome"[Title/Abstract] OR "AIDS"[Title/Abstract] OR "people living with hiv aids"[Title/Abstract] OR "PLHA"[Title/Abstract] OR "HIV"[Title/Abstract] OR "HIV"[MeSH Terms] OR "acquired immunodeficiency syndrome"[MeSH Terms] ABS(mpox)) OR (TITLE-ABS(monkeypox)) OR (TITLE-ABS(mpxv)) OR (TITLE-ABS("monkey pox")) 2397 #2 statement of the objective(s) or question(s) the review addresses.4 (a) YOP: Year of Publication; Y: Yes; N: No; NA: Not Applicable; CD: Cannot Determine; NI: No Information; NIH: National Institute of Health.Q1: Was the study question or objective clearly stated?Q2: Was the study population clearly and fully described, including a case definition?Q3: Were the cases consecutive?Q4: Were the subjects comparable?Q5: Was the intervention clearly described?Q6: Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants?Q7: Was the length of the follow-up adequate?Q8: Were the statistical methods well described?Q9: Were the results well described?(b) YOP: Year of Publication; Y: Yes; N: No; NA: Not Applicable; CD: Cannot Determine; NI: No Information.Q1: Was the research question or objective in this paper clearly stated?Q2: Was the study population clearly specified and defined?Q3:

Table 1 .
Baseline characteristics of studies reporting proportion of HIV infection in individuals with mpox.

Table A2 .
The adjusted search terms as per searched electronic databases [as of 04.01.2023].

Table A4 .
(a) Quality assessment of the included case series with the use of the NIH quality assessment tool.(b) Quality assessment of included cross-sectional and cohort studies with the use of the NIH quality assessment tool.