Confronting stigma as a core intervention in the Mpox-human immunodeficiency virus syndemic

Abstract The ongoing mpox outbreak in Sierra Leone exposes a lethal syndemic with HIV, where available clinical correspondence suggests that a large proportion of mpox-related deaths have occurred among people with HIV (PWH). While severe clinical manifestations in immunocompromised patients present a clear biomedical challenge, delayed care-seeking behavior, potentially driven by stigma and fear, is a plausible contributor to poor outcomes. This perspective argues that stigma should be considered a critical and underexamined pathway through which poor outcomes may arise within the mpox-HIV syndemic, rather than a peripheral social concern. Stigma operates at multiple levels: individual fear of disclosure discourages timely presentation; community ostracization and speculation deter care-seeking; and structural factors like weak confidentiality safeguards magnify risk. These forces may delay diagnosis and care-seeking, interacting with pre-existing advanced HIV disease and poor treatment continuity to undermine survival. Drawing on lessons from HIV programming, we propose a multi-level agenda integrating stigma reduction into the core of outbreak response. This includes the integration of mpox and HIV services within stigma-aware clinical settings, community-led communication strategies emphasizing reassurance, policy reforms to protect confidentiality, and operational research to evaluate stigma-mitigation interventions. Unless deliberately addressed, biomedical advances including antivirals, vaccines, and improved clinical guidelines may fail to reach the patients most in need, particularly in settings with inequitable access to HIV and mpox services. Confronting stigma is therefore not a charitable add-on but a cost-effective and ethical imperative for effective public health response.