HIV, mpox, and stigma in West Africa - a case for integrated person-centred syndemic management

Abstract

Across West Africa, HIV, mpox, stigma, and health-system barriers may interact in ways that compound clinical and social harms and challenge disease-specific models of care. This commentary proposes a practical, tripartite harm-reduction framework for integrated, person-centred syndemic management, designed not only to reduce morbidity associated with HIV and mpox but also to reduce harms arising from stigma, criminalization, inadvertent disclosure, and discriminatory health services. We propose: [1] integrated clinical pathways that provide HIV, mpox, and mental health services through co-location or discreet referral options while preserving voluntary access, confidentiality, and patient choice; [2] person-centred surveillance using ethically governed, de-identified data linkage to reduce fragmentation while protecting privacy and autonomy; and [3] funded, community-led interventions that address stigma, discrimination, criminalization, and exclusion from care through peer navigation, targeted communication, and legal and policy advocacy. We argue that this operational shift, supported by pragmatic implementation research, provides a testable approach to reducing clinical, social, and health-system harms associated with the syndemic. We encourage national health ministries, regional bodies, and global health partners to support the co-design, resourcing, and rigorous evaluation of pilot programmes in appropriate settings. Through integrated action that treats the whole person within their social context, this framework provides a testable approach to informing more equitable and resilient health-system responses in West Africa.

Clinical trial number: Not applicable.

Background

The syndemic theory provides a critical lens for understanding complex public health challenges in which two or more epidemics interact synergistically within a context of social and structural inequity, resulting in an excess burden of disease [1, 2]. This model moves beyond a simple biomedical approach to one that explicitly acknowledges how adverse social conditions, such as poverty and stigma, exacerbate disease clustering and outcomes [2, 3]. Across West Africa, HIV, mpox, stigma, and health-system barriers intersect in ways that may vary across countries, populations, and health-system contexts [4]. West Africa continues to carry a substantial burden of HIV, although the magnitude and distribution of that burden vary across countries and populations [5]. Concurrently, the 2022 global mpox outbreak revealed its disproportionate affected some populations, including men who have sex with men (MSM), while severe disease was particularly reported among people with advanced or untreated HIV [6, 7]. Stigma associated with both conditions may contribute to care avoidance, complicate engagement with contact-tracing activities, and create additional barriers to effective public health responses [7]. Despite calls for integrated, locally led action to address the intersection of mpox and HIV in Africa, health systems across the region remain substantially organized around vertical, disease-specific programmes [8, 9]. These siloed approaches may be less able to address the interconnected biological, social, and health-system factors that characterize a syndemic.

This commentary proposes a harm-reduction framework that brings together three functions that are often addressed separately in infectious disease programmes: integrated clinical care, ethically governed person-centred surveillance, and community-led action to reduce stigma and structural barriers to care. The distinctive contribution is not the individual components themselves, but their deliberate integration around a shared objective of reducing both disease-related and response-related harms. The framework therefore links service integration with confidentiality and patient choice, surveillance with privacy and community governance, and stigma mitigation with concrete action on discrimination, disclosure, criminalization, and exclusion from care. It further translates these principles into operational components and testable implementation and evaluation questions for resource-constrained health systems.

The syndemic problem: a vicious cycle of biology and society

The relationship between HIV and mpox can be understood as a bio-social interaction in which biological vulnerability, disease burden, and social and structural conditions may contribute to poorer health outcomes [10]. Immunosuppression, particularly in individuals with advanced or untreated HIV (low CD4 counts or unsuppressed viral loads), can significantly alter the clinical course of mpox [7]. Evidence indicates that these patients are at a markedly higher risk for severe and protracted disease, including the development of widespread, necrotic skin lesions, secondary bacterial infections, and systemic involvement [11, 12]. This altered clinical course can complicate management and is associated with poorer outcomes, including higher mortality among people with advanced or untreated HIV [13]. Conversely, mpox illness and associated stigma may disrupt continuity of HIV care, including attendance at appointments and access to ART, with potential consequences for treatment continuity and viral suppression [10, 12].

The syndemic mechanism proposed here operates across these biological and social pathways rather than through a single causal chain. Advanced or untreated HIV may increase vulnerability to severe mpox, while mpox illness may disrupt continuity of HIV care. At the same time, stigma, discrimination, concerns about disclosure, and barriers within health services may discourage timely care-seeking or continued engagement with services. These processes can interact: poorer health or prolonged illness may increase contact with health and social systems, while anticipated or experienced stigma may make such engagement more difficult. The resulting accumulation of clinical, social, and health-system barriers may compound individual and population-level health needs. This framework therefore conceptualizes the syndemic as an interaction between biological vulnerability and social and structural conditions, rather than as a simple one-directional pathway.

However, a solely biomedical account is insufficient because the burden of HIV and mpox is shaped not only by biological and epidemiological processes, but also by stigma, discrimination, criminalization, and barriers within health and social systems. The stigma associated with both HIV and mpox is complex, rooted in fears of contagion, associations with sexual transmission, and, in many contexts, moral judgment and criminalisation toward key populations [14]. Stigma can function as an important social determinant of health by contributing to barriers to service access at multiple levels: internalised stigma may contribute to symptom concealment; fear of ostracization may discourage disclosure and care-seeking; and discriminatory experiences within healthcare settings may reduce engagement with services [15]. These barriers can therefore interact with the clinical pathways described above by delaying diagnosis, reducing continuity of care, or limiting access to appropriate services. Internally, individuals may experience shame and self-blame, leading them to hide symptoms. At the community level, fear of gossip, social ostracization, and violence can be overwhelming. Structurally, healthcare providers may hold discriminatory attitudes, and policies may lack inclusivity [15].

These barriers may contribute to delayed or avoided care-seeking.For example, concerns about HIV disclosure, stigma, or being associated with a stigmatized group may discourage some individuals with symptoms suggestive of mpox from seeking timely care. Similarly, stigma or concerns about disclosure may affect continuity of HIV care among people diagnosed with mpox. Delayed or avoided care may contribute to poorer individual outcomes and can create additional challenges for timely diagnosis, treatment, and public health response [7, 16]. Taken together, these pathways suggest a syndemic pattern in which biological vulnerability, disease burden, stigma, and social and structural inequities may interact to compound health needs, while fragmented disease-specific services may leave some of these intersecting needs insufficiently addressed.

A harm-reduction approach to this syndemic must address not only the clinical consequences of HIV and mpox, but also the harms that can arise from stigma, criminalization, discrimination, inadvertent disclosure, and exclusionary health services. In this framework, integration is therefore a means of reducing preventable harms rather than an end in itself. Services should be voluntary, non-coercive, confidential, and rights-based, with safeguards that protect autonomy and allow individuals to choose how and where they receive care. This includes minimizing unnecessary disclosure of HIV or mpox status, avoiding stigmatizing service labels and practices, and ensuring that clinical and public health measures do not increase exposure to discrimination or legal and social consequences. The framework consequently treats the reduction of both disease-related and response-related harms as a core objective of syndemic management.

An operational framework for syndemic management

Rather than proposing integration as an end in itself, we frame syndemic management as a harm-reduction strategy in which clinical integration, ethical surveillance, and community-led structural interventions reinforce one another. The framework is organized around three interdependent pillars: [1] integrated clinical pathways designed to reduce access barriers and protect patient choice and confidentiality; [2] person-centred surveillance and data linkage designed to reduce fragmentation while protecting privacy and community trust; and [3] community-led stigma mitigation designed to reduce discrimination, disclosure-related harms, criminalization, and exclusion from care. The core components and proposed operational examples are summarized in Table 1.

Table 1.

Core components of an integrated syndemic management framework for HIV and Mpox in West Africa

Pillar	Key Components	Operational Examples	Outcomes to Evaluate
1. Integrated Clinical Pathways	Co-location of HIV, mpox, and mental health services	“One-stop” clinic within an existing ART facility.	Patient travel time, waiting time, and reported access burden.
	Simplified clinical algorithms	Algorithm for concurrent Tecovirimat and ART administration.	Time from presentation to mpox diagnosis and treatment initiation.
	Task-sharing & peer navigation	Nurse-led mpox assessment and community health worker follow-up.	ART adherence, retention in care, and continuity of HIV treatment.
	Robust infection control	Dedicated screening/triage area with PPE.	Clinical severity, complications, hospitalization, and mortality.
2. Person-Centred Surveillance & Data Linkage	Minimal person-level dataset	Unique identifier linking the mpox case ID to the HIV record.	Timeliness, completeness, and usability of linked syndemic surveillance data.
	Linkage of IDSR, HIV, & laboratory data	Dashboard for real-time identification of co-infected patients.	Timeliness of detection, interpretation, and use of surveillance findings for resource allocation and service decisions.
	Strong data governance & privacy safeguards	Community representatives participate in defining permissible data uses, reviewing governance safeguards, interpreting findings, and overseeing dissemination.	Community acceptability, perceived transparency, trust, and documented influence on data-use decisions.
3. Stigma Mitigation & Community Engagement	Community-led intervention design	Grants to local CBOs for anti-stigma campaigns.	Care-seeking intentions, timely presentation, and uptake of appropriate services.
	Peer navigation programmes	Peers provide escorts to clinics and support groups.	Changes in internalized, anticipated, and experienced stigma, measured using validated instruments.
	Advocacy for legal protections	Review of health facility policies for discriminatory practices.	Perceived availability, accessibility, and continuity of community and peer support.
	Integrated stigma measurement	Use of the HIV Stigma Scale in routine M&E.	Feasibility, acceptability, implementation fidelity, and documented use of stigma measures in programme improvement.

Integrated clinical pathways: flexible models of syndemic care

The first pillar translates the harm-reduction principle into clinical practice by reconfiguring the response around people’s needs rather than administrative disease categories. The establishment of “one-stop” syndemic clinics, integrated within trusted primary health facilities or HIV treatment centres, can maximize accessibility and reduce duplication [9, 17]. These clinics would co-locate three critical streams of care: (a) Comprehensive HIV Services: Routine testing, seamless antiretroviral therapy (ART) initiation and continuity. (b) Streamlined Mpox Management: Accessible PCR diagnosis, facilitated access to antivirals (especially for severe/advanced HIV cases), and supportive care, per WHO guidelines [18]. (c) Integrated Mental Health Support: Basic mental health triage and psychological first aid and referral pathways to address the compounded psychological toll [19]. Given the psychological burden associated with HIV, mpox, and stigma, mental health support should extend beyond initial triage to include routine assessment of psychological distress and stigma-related psychosocial needs, brief supportive interventions, and referral pathways for people requiring more specialized care. Pilot models should assess whether these services can be integrated into existing HIV and mpox care without creating additional disclosure, stigma, or access barriers. Operationalizing this model requires more simplified clinical algorithms for co-management and strategic task-sharing, empowering nurses and community health workers under supervision [20]. The inclusion of paid peer navigators from affected communities can support patient navigation and help strengthen trust between affected communities and the formal health system[21]. This approach also draws on lessons from the 2014–2016 West African Ebola outbreak, during which community engagement, trusted local leadership, and community-based health workers were important for building trust, addressing misinformation, improving service uptake, and strengthening links between affected communities and formal health systems. These lessons support the use of peer navigators as locally embedded actors, while recognizing that their roles should be adapted to the specific social and epidemiological context of HIV and mpox.

Integration should not require every service to be delivered in a single visibly designated clinic. Where co-location could increase the risk of inadvertent disclosure or stigma, programmes should offer discreet referral pathways, primary-care integration, or community-based options according to patient preference and local feasibility. The choice of service pathway should remain voluntary and confidential, with infection-prevention and control measures maintained across all models. The purpose of integration is therefore to reduce barriers and avoidable harms while preserving autonomy and minimizing the social risks that may accompany service use. Patients should be offered a meaningful choice among these models where feasible, with the preferred pathway determined jointly with the patient rather than assumed by the programme or provider.

Programme design should also avoid visibly identifying facilities, waiting areas, appointment systems, or patient records in ways that could reveal HIV or mpox status to other patients, community members, or unauthorized personnel. Where legal or criminalization risks exist, programmes should establish clear safeguards governing access to patient information by law-enforcement or other non-clinical authorities, consistent with applicable law, confidentiality obligations, and patients’ rights.

Person-centred surveillance and data linkage

Syndemic surveillance should improve coordination without creating new privacy or disclosure-related harms. Current parallel systems, such as Integrated Disease Surveillance and Response (IDSR) for mpox and separate HIV registries, may limit the ability to examine intersecting patterns of disease and care [22]. We therefore propose carefully governed linkage of the minimum data necessary from relevant surveillance, HIV, laboratory, and clinical systems, with de-identification or pseudonymisation applied according to the intended use [23]. Any linkage should be subject to defined access controls, data-security procedures, retention limits, and safeguards against re-identification or unauthorized disclosure. Governance arrangements should also specify when, how, and by whom linked information may be accessed, including clear protections against inappropriate access by law-enforcement or other non-clinical authorities. These safeguards should be developed transparently with affected communities and relevant stakeholders to protect privacy, autonomy, and public trust while enabling appropriate monitoring of clinical outcomes and health-system performance [24]. Community representatives should also participate in decisions about which data are collected and linked, how they are interpreted and shared, and what safeguards govern their use. In pilot programmes, this participation should extend to oversight of data governance, interpretation of findings, evaluation, and decisions about adaptation or scale-up

Implementation should proceed incrementally. Programmes should first identify the minimum variables required for syndemic monitoring and assess their availability across existing HIV, mpox, laboratory, and routine surveillance systems. This assessment should consider fragmented data systems, digital infrastructure, interoperability, data quality, workforce capacity, and the governance requirements for linking information across systems. Where linkage is feasible and ethically justified, data should then undergo predefined quality and privacy checks before analysis. Findings should be translated through agreed decision pathways into patient-level referral or follow-up, community-level communication or outreach, and health-system actions such as service adjustment or resource allocation. Pilot sites should document the time and resources required at each stage and assess whether the resulting information is sufficiently timely, accurate, acceptable, and actionable to support coordinated syndemic responses.

Stigma mitigation and community engagement: the core social intervention

Therefore, reducing stigma-related and discrimination-related harms should be a core, funded, and measurable component of syndemic management programmes, with dedicated resources for interventions that improve access, protect confidentiality, and reduce exclusion from care [25]. Critically, these interventions cannot be designed in a top-down manner; to be effective and sustainable, they must be community-led, leveraging the expertise and trust of affected populations [26]. This requires direct, flexible funding and capacity-strengthening support for trusted civil society and community-based organizations (CBOs), which are best positioned to design and deliver contextually appropriate solutions.

Community participation should extend beyond delivery of interventions to shared decision-making. Affected communities should have defined roles in programme design, priority-setting, implementation oversight, interpretation of monitoring data, evaluation, and decisions about adaptation and scale-up. Where feasible, community representatives should hold formal roles in programme governance or advisory structures, with transparent mechanisms for documenting how community recommendations are considered and acted upon.

A harm-reduction approach also requires attention to harms that may arise from the delivery of health services themselves. Community-led interventions should therefore address confidentiality breaches, involuntary or unnecessary disclosure of HIV or mpox status, discriminatory treatment by health workers, criminalization and other legal or social barriers that may discourage care-seeking, and exclusion from appropriate services. The aim is not only to reduce stigmatizing attitudes, but also to reduce the practical and structural harms that stigma and discrimination can impose on people seeking care.

Key interventions they are uniquely equipped to lead include: (a) Targeted Social and Behaviour Change Communication (SBCC): Developing and disseminating messages that directly address and counter the specific misinformation, fear, and moral blame surrounding HIV and mpox transmission within local contexts. (b) Peer Navigation Programs: Formalizing the training, deployment and fair compensation of individuals from affected communities (for e.g., people living with HIV, mpox survivors, etc.) to provide practical, logistical, and emotional support, thereby operationalizing the community health worker model for syndemic care. (c) Advocacy for Legal and Policy Reform: Supporting policies that protect people from discrimination in healthcare and other essential services, strengthen confidentiality protections, reduce unnecessary disclosure, and address legal and structural barriers, including criminalization that may deter people from seeking or continuing care.

To ensure accountability, guide resource allocation, and enable continuous improvement, the effects of these interventions should be evaluated using mixed-methods approaches that combine validated quantitative measures of stigma and discrimination with qualitative assessment of lived experiences, implementation processes, and unintended harms.

This can be achieved by integrating scales to measure experience, internalized, and anticipated stigma into the routine monitoring and evaluation frameworks of health programs, moving beyond anecdotal evidence toward data-driven decision-making [26]. Taken together, the three pillars constitute a single harm-reduction framework in which service integration, ethical information systems, and community-led structural action are intended to address interconnected clinical, social, and health-system harms rather than operate as separate programme components.

A pragmatic research and policy agenda

Implementing this operational framework must be intrinsically coupled with a focused, implementation-science-driven research agenda embedded within pilot projects. The goal is to generate local evidence on feasibility, implementation, preliminary effectiveness, and cost to guide iterative refinement and inform decisions about potential scale-up. Priority research areas should include: (a) Pragmatic Evaluation of Integrated Care: Conducting prospective or quasi-experimental operational research, where feasible, to compare integrated care models with existing service arrangements on outcomes such as time to mpox diagnosis, continuity of HIV treatment, patient-reported access barriers, stigma-related harms, and other contextually appropriate clinical and service outcomes. (b) Implementation Research: Investigating the how and why of implementation. Key questions include: What are the specific barriers and facilitators to task-sharing in mpox care management among HIV nurses? What are the most cost-effective and scalable models for funding and sustaining community-led stigma reduction? How can data linkage systems be maintained and utilized sustainably within existing health information architecture? (c) Health Economics and Governance Studies: Building the economic case can inform policy decisions and domestic resource mobilization. Cost-effectiveness and budget impact analyses of integrated syndemic management compared with existing care arrangements should be conducted where feasible. Concurrently, research on data sovereignty, security, and co-development of ethical, locally owned governance frameworks for integrated health data is paramount for sustainability and trust.

A robust Monitoring, Evaluation, Accountability, and Learning (MEAL) framework should be co-developed with communities and embedded within all pilot initiatives. This framework will support iterative improvement, inform evidence-based decision-making for mid-course corrections, and provide structured evidence to inform decisions about adaptation, continuation, or potential scale-up.

Conclusion

The intersection of HIV, mpox, stigma, and social and structural barriers presents an important challenge for health equity in West Africa, in which biological vulnerability and social adversity may compound health needs. Its complex bio-social nature highlights limitations that may arise when health systems remain organized around vertical, single-disease services. Addressing these intersecting needs may benefit from a person-centred, integrated model of care that considers the whole individual within the social context.

The operational framework presented here combines co-located clinical services, person-centred data systems, and community-led structural interventions into a proposed approach that can be tested and adapted in context. We encourage national ministries of health in West Africa, regional bodies such as the West African Health Organization (WAHO), and global health partners and funders to support context-specific co-design, piloting, and evaluation of syndemic management approaches. This includes supporting the co-design, resourcing, and rigorous evaluation of pilot syndemic management programmes in settings where such approaches are considered appropriate. With local leadership, meaningful power-sharing with communities, and continued generation and use of local evidence, such approaches can be adapted and evaluated to inform more equitable and resilient health-system responses.

Abbreviations

ART

Antiretroviral therapy

HIV

Human immunodeficiency virus

IDSR

Integrated disease surveillance and response

MEAL

Monitoring, evaluation, accountability, and learning

PCR

Polymerase chain reaction

MSM

Men who have sex with men

WHO

World health organization

CBOs

Community-based organizations

SBCC

Social and behaviour change communication

WAHO

West african health organization

Author contributions

AUB-S: Conceptualization, writing original draft, supervision, final approval. FSS: Writing, review and editing, critical revision, validation. JM: Writing, review and editing, conceptual input, validation. CSK: Writing, review and editing, literature synthesis, validation. YSC: Review and editing, clinical expertise, critical revision. RAN: Review and editing, clinical expertise, critical revision. CAO: Writing, review and editing, clinical expertise, critical revision. All authors read and approved the final manuscript.

Funding

This work received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable. This article is a commentary and does not involve human participants, human data, or animal research.

Consent for publication

Not applicable.

Declaration of generative AI and AI-assisted technologies

The authors used ChatGPT (OpenAI) exclusively for proofreading and grammatical refinement. The tool was not used to generate original scientific content, data, methodologies, or conclusions. All scientific content, intellectual contributions, and interpretations are solely attributable to the authors. The authors reviewed and approved the final manuscript and take full responsibility for its accuracy, originality, and integrity.

Competing interests

The authors declare no competing interests.