There are limited data on the impact of coronavirus disease 2019 (COVID-19) vaccines on mortality among people living with human immunodeficiency virus (HIV) (PLHIV) across different severe acute respiratory syndrome coronavirus 2 variants. We assessed the impact of the COVID-19 vaccine in reducing in-hospital mortality among PLHIV across various severe acute respiratory syndrome coronavirus 2 variant waves. We analyzed individual-level data from 159,150 patients hospitalized with COVID-19 across 43 countries. Flexible parametric survival models were used to estimate the association between COVID-19 vaccination and in-hospital mortality, accounting for HIV status. Among HIV-negative individuals, COVID-19 vaccination reduced the risk of in-hospital mortality by 38 to 42% across all variant waves compared to their unvaccinated counterparts. In PLHIV, the protective effect of vaccination was less pronounced. Vaccinated PLHIV exhibited higher mortality risks compared to unvaccinated HIV-negative individuals: 41% higher during the Omicron wave (adjusted hazard ratio [aHR] 1.41, 95% confidence interval [CI] 1.05-1.89) and no significant difference during the pre-Delta and Delta waves. However, vaccinated PLHIV consistently showed lower mortality risks than unvaccinated PLHIV, with mortality reductions of 60% (aHR 0.40, 95% CI 0.31-0.51) during the pre-Delta period, 50% during Delta (aHR 0.50, 95% CI 0.33-0.75), and 54% during Omicron (aHR 0.46, 95% CI 0.36-0.59). While COVID-19 vaccination significantly reduced inpatient mortality among PLHIV, mortality risks remained elevated compared to HIV-negative individuals, particularly during the Omicron variant wave. Overall, vaccination still offered substantial protection against death for PLHIV compared to unvaccinated PLHIV. These findings underscore the need for targeted vaccination strategies, including booster doses, to protect high-risk populations such as PLHIV, in alignment with World Health Organization recommendations.

Conflicting information exists in the literature regarding the relationship between HIV viral load suppression and immune suppression among people living with HIV (PLHIV) with coronavirus disease (COVID-19) comorbidity. We evaluated risk of in-hospital mortality among PLHIV with varying levels of immunosuppression and viral load in South Africa. We analyzed retrospectively collected individual-level cohort data from South Africa shared in the World Health Organization Global Clinic Platform comprising 3,10,522 hospitalized individuals, including 8191 PLHIV on antiretroviral therapy. Advanced disease was defined as CD4 counts of <200 cells/µL. The primary outcome was in-hospital mortality, defined as death within 28 days of hospital admission. Royston-Parmar survival models were used to assess the association of viral load and CD4 counts with in-hospital mortality among PLHIV on antiretroviral therapy. Models were adjusted for demographic factors, COVID-19 severity, severe acute respiratory syndrome coronavirus-2 variants, and comorbidities. Among the 8191 PLHIV with available CD4 and viral load data, 77.2% had viral suppression, and 35.9% had CD4 counts < 200 cells/μL. Compared to HIV-negative individuals, PLHIV with CD4 < 200 cells/μL and viral load ≥1000 copies/mL had a significantly higher risk of mortality (adjusted hazard ratio [aHR] 2.73, 95% CI: 2.45-3.04). Elevated mortality risk was also observed in PLHIV with CD4 < 200 cells/μL and viral load < 1000 copies/mL (aHR 2.01, 95% CI: 1.84-2.20), and those with CD4 ≥ 200 cells/μL and viral load ≥ 1000 copies/mL (aHR 1.47, 95% CI: 1.20-1.81). PLHIV with CD4 ≥ 200 cells/μL and viral suppression had the lowest, but still significant, increased in-hospital mortality risk (aHR 1.27, 95% CI: 1.18-1.36). A substantial increased risk of in-hospital mortality occurs among PLHIV with advanced HIV disease and unsuppressed viremia hospitalized with COVID-19. These findings highlight the importance of prioritizing COVID-19 vaccination and COVID-19 therapeutics for PLHIV during the post-pandemic phase. Further research is however needed to understand the high risk of mortality in virally suppressed PLHIV with CD4 ≥ 200 cells/μL.

BACKGROUND:WHO has worked closely with member states to set baseline targets, monitor progress and gaps, and develop a strategy to achieve the elimination of viral hepatitis as a public health threat by 2030. This analysis aimed to use the latest data to assess global progress, identify gaps, and provide strategic support to countries and regions to scale up prevention and treatment services to meet global, regional, and country-level targets. METHODS:Data on key indicators for 2022 were collated in 2023, including prevalence, incidence, mortality, and the cascade of care for chronic hepatitis B virus (HBV) and chronic hepatitis C virus (HCV) infections. WHO country offices, regional offices, related departments, and partners were involved to verify and ensure the quality and completeness of the data. Data from 2022 were compared with historical data to monitor progress, and reported data were compared with expected data and targets to identify gaps in incidence and mortality. FINDINGS:As of June 30, 2023, WHO had received verified data reports from 187 of 194 countries and territories, including data contributions from collaborative partners. We estimated that, in 2022, globally, 254 million (3·27%) of 7758 million people were living with chronic HBV infection and 50 million (0·65%) people were living with HCV infection. Overall, five countries (China [83·7 million; 27·5%], India [35·3 million; 11·6%], Indonesia [18·9 million; 6·2%], Nigeria [15·7 million; 5·2%], and Pakistan [12·6 million; 4·2%]) accounted for 55% of the combined global burden of HBV and HCV. There were more than 2·2 million (95% CI 1·8-2·7) new chronic HBV and HCV infections and more than 1·3 million (95% CI 1·1-1·6) deaths due to HBV and HCV in 2022, with the majority of deaths due to HBV (1·1 million [95% CI 0·98-1·24]); as a result, the point estimate for deaths due to hepatitis in 2022 exceeded that of deaths due to tuberculosis in 2023 (1·25 million [95% UI 1·13-1·37]). There were 1·2 million new chronic HBV infections worldwide in 2022; 62·7% (771 000) of these new infections occurred in the African Region. In 2022, 34·1 million (95% CI 30·2-38·5) individuals living with HBV were diagnosed; of these, 6·6 million (95% CI 5·9-7·5) received antiviral treatment. In 2022, 25·7 million (95% CI 19·5-28·8) individuals were diagnosed with HCV infection and 12·5 million (95% CI 9·5-14·0) were treated with direct-acting antiviral drugs in 2015-22. INTERPRETATION:Viral hepatitis represents a substantial burden of infectious disease globally, comparable with that caused by tuberculosis. Progress towards global hepatitis elimination is currently insufficient to meet the 2030 targets defined in the UN Sustainable Development Goals; efforts need to be rapidly and urgently scaled up across all regions. In particular, given the rising mortality due to hepatitis B globally, expansion of hepatitis B vaccination is a priority, particularly in the African Region, where the majority of new chronic HBV infections occur. Access to prevention, diagnosis, and treatment services needs to be scaled up substantially by the end of 2026 to meet the 2030 global hepatitis elimination targets. FUNDING:World Health Organization.

HIV programmes globally continue to face two persistent challenges: advanced HIV disease and high HIV incidence. These issues are often viewed separately, with advanced HIV disease viewed as a late-stage clinical failure and high HIV incidence as a failure of early prevention. However, these issues are closely linked at the individual and population level; both reflect the inability of current care models to engage and sustain viral suppression among a sizeable subgroup of people living with HIV who initiate antiretroviral therapy late or cycle in and out of care. In sub-Saharan Africa, where the HIV burden is highest, most individuals with advanced HIV disease are people who have previously initiated antiretroviral therapy and subsequently disengaged, often multiple times. This type of interruption in care has substantial implications for immune decline, viral rebound, and mortality. As donor funding decreases, there is a risk that global HIV responses will revert focus to maintaining aggregate antiretroviral therapy coverage, overlooking harder-to-reach populations with persistent viraemia.

Although viral suppression is attained for most adults living with diagnosed HIV in East, Central, Southern and West Africa (ECSWA), challenges remain with sustained adherence to daily oral pill taking for some in the population. Here, we evaluate the potential effectiveness and cost-effectiveness of introduction of a new combination of long-acting injectable drugs of lenacapavir + cabotegravir to increase levels of sustained viral suppression. We find there is potential for a significant impact on HIV deaths and disability adjusted life years, including due to a decrease in mother to child transmission. If lenacapavir + cabotegravir can be sourced at a cost of around $ 80 per year or less, our analysis suggests there is potential for a policy to introduce it to be cost-effective in settings in ECSWA. Recognising the limitations of a modelling study, we suggest that implementation studies be conducted to confirm the viability of these approaches.

BACKGROUND:Women living with HIV have an elevated risk for cervical cancer, present earlier, and have more recurrent human papillomavirus (HPV) infections compared with women without HIV. To update WHO recommendations on screening and treatment to prevent cervical cancer, we aimed to identify whether women living with HIV should be screened for cervical cancer at a specific age, the optimal screening interval following a negative cervical screen, and the screening interval following treatment. METHODS:We conducted a systematic literature review on cervical cancer and HIV by searching MEDLINE, Embase, CENTRAL, the Cochrane Library, and clinical trial registries covering Jan 1, 2012, through to Oct 13, 2019, updating a previous systematic review covering database inception to July, 2012. Included articles reported original data and assessed one or more outcomes related to cervical precancer and cancer in women living with HIV; no restrictions on study design or setting were made. Articles were excluded if they did not include any women living with HIV, or if they reported only HPV genotype prevalence without any other relevant data. Two authors extracted data from any study reporting cervical cancer screening tests and histopathologically confirmed disease outcomes, by age. We analysed summary data on optimal age and screening intervals, providing pooled estimates when possible; we then conducted an individual patient data meta-analysis (IPDMA) to analyse age-specific data on cervical cancer and precancer. Authors of studies with 40 or more women living with HIV and cervical intraepithelial neoplasia (CIN) grade 2+ were invited to submit individual patient data for meta-analysis. Random-effects models were used to calculate predicted probabilities for cervical cancer screening results by age, HIV status, and antiretroviral therapy (ART) status. FINDINGS:Of the 304 full-text articles screened, 34 studies from 12 countries, with 128 732 women, including 63 790 women living with HIV, were included in the systematic review. Of 55 studies potentially eligible for the IPDMA, eight studies provided data for 72 350 women, 12 527 of whom were living with HIV, from seven countries (Burkina Faso, Cameroon, India, Kenya, South Africa, Thailand, and the USA). In the IPDMA, the pooled predicted probability of CIN2 or CIN3 among women living with HIV increased from 6·0% (95% CI 0·74-64·1) for ages 15-19 years to 32·4% (8·3-72·7) for ages 20-24 years, 42·1% (16·4-80·2) for ages 25-29 years, 50·3% (16·3-80·0) for ages 30-34 years, 47·0% (16·3-80·0) for ages 35-39 years, 49·0% (16·3-80·2) for ages 40-44 years, 58·1% (17·0-81·5) for ages 45-49 years, and 55·3% (21·0-86·6) for age 50 years and older; invasive cervical cancer was uncommon before 30 years of age. In the systematic review, women living with HIV who had a negative baseline cytology result and negative HPV test had a cumulative incidence of developing CIN2+ that ranged from 0·8% to 5% within 4·2-6·4 years and a cumulative incidence of developing of CIN of any grade up to 10% within 12 years. Also in the systematic review, women living with HIV had high recurrence of CIN2+ following treatment (11-27% by 1 year follow-up, 3-64% by 3 years, and 57% by 10 years). No significant evidence of publication bias was found in the data included in the IPDMA (Egger's test p=0·83). INTERPRETATION:Our data show a clear, age-related increase in CIN2 and CIN3 among women living with HIV, with the highest risk occurring in the 45-49-year age group. Our findings informed WHO recommendations to initiate cervical cancer screening for women living with HIV at age 25 years, with regular screening every 3-5 years. Expanding screening and treatment is necessary to reduce cervical cancer incidence towards its elimination. FUNDING:US Agency for International Development and US President's Emergency Plan for AIDS Relief.

BACKGROUND:Most cervical cancers can be prevented by population-wide vaccination of pre-adolescent girls with highly efficacious HPV vaccines. In South Africa, first-dose coverage of bivalent HPV vaccination among girls aged 10 is ∼80 %. We investigated the additional impact and cost-effectiveness of different bivalent and nonavalent vaccination strategies among the general population and women with HIV (WHIV). METHODS:We used an individual-based, population-level model for HPV and HIV transmission in South Africa to estimate the epidemiological impact of HPV vaccination. The costs of interventions in the cervical cancer care cascade are estimated in 2024 USD based on resource use and prices obtained from research studies. To estimate cost-effectiveness of different bivalent strategies, we calculated the median cost per disability adjusted life-year averted (DALY) between 2024 and 2120 and compared it to an opportunity cost (OC) threshold of USD 3015. We calculated a threshold price at which nonavalent vaccination will be cost-effective in South Africa. RESULTS:Current interventions are projected to reduce age-standardised cervical cancer incidence from 54 to 12 per 100,000 women by 2120. Increasing girl-only bivalent coverage to 90 % would prevent an additional 5 % of cases and be cost-saving. Gender-neutral vaccination at 80 % coverage would yield similar impact, with a USD/DALY averted of USD 2782 compared to girls-only vaccination. Vaccinating WHIV up to age 45 could prevent 10 % of cervical cancer cases in this group and remains cost-effective. The nonavalent vaccine would be cost-effective if priced below USD 40 per dose. CONCLUSION:Enhanced HPV vaccination strategies-including higher coverage, gender-neutral programs, and targeted vaccination of WHIV-are cost-effective in South Africa. However, no vaccination strategy alone will reach elimination, which will require integrated approaches combining vaccination with cervical cancer screening and treatment.

This Viewpoint discusses the need to develop products, such as long-acting antiretrovirals, for people with HIV in settings with minimal resource requirements.

BACKGROUND:We investigated in-hospital mortality trends across waves of different SARS-CoV-2 variants and assessed the effect of COVID-19 immunization among people with HIV (PWH). METHOD:We analyzed individual-level data from the WHO Global Clinic Platform comprising 823 845 hospitalized children and adults from 61 countries. Survival analyses were used to assess the association of HIV co-infection with in-hospital mortality across SARS-CoV-2 pre-Delta, Delta, and Omicron variant waves. FINDINGS:PWH experienced significantly higher in-hospital mortality compared to HIV-negative individuals across all variant waves. Adjusted hazard ratios (aHRs) for PWH mortality were 1.85 [95% confidence interval (CI) 1.76-1.93] during the pre-Delta wave, 1.58 (95% CI 1.42-1.74) during the Delta wave, and 3.07 (95% CI 2.75-3.42) during the Omicron wave. In-hospital mortality risk was notably higher in PWH with CD4 + cell count 200 cells/μl or less. While mortality declined modestly between pre-Delta and Delta waves in both HIV-negative (10% reduction) and HIV-positive populations (9% reduction), the decline was more substantial for HIV-negative individuals during the Omicron wave (from 18.9 to 8%) than for PWH (from 24.2 to 19.3%) relative to the Delta wave. INTERPRETATION:Although in-hospital mortality among HIV-negative individuals declined markedly during the Omicron wave, reduction in PWH was less pronounced, leading to a relatively higher mortality risk for this group. These findings highlight the need for adherence to WHO recommendations on booster vaccinations and therapeutics for populations at elevated risk of severe COVID-19 outcomes, including PWH.

Abstract Introduction Recent studies have indicated a high enduring burden of advanced HIV disease, but estimates across regions and settings are lacking. The aim of this study was to estimate the prevalence of advanced HIV disease since 2015 among those people with CD4 measured in healthcare settings, disaggregated by age group, level of healthcare and region. Methods We searched MedLine via Pubmed and Hinari for studies that reported the proportion of individuals with advanced HIV disease (defined as CD4 cell count <200 cells/mm3) in healthcare settings since 2015; this search was complemented by conference abstracts and data from the International epidemiology Databases to Evaluate AIDS Consortium (IeDEA). We estimated pooled prevalence of advanced HIV disease using random‐effects models and performed subgroup and sensitivity analyses to explore heterogeneity. Results We obtained data from 117 cohorts, representing 1,814,362 individuals from 52 countries across all six World Health Organization regions. The majority of studies (n = 83) were conducted among adults and recorded CD4 cell count among treatment naïve individuals at antiretroviral therapy start (n = 86). Studies included data reported up to 2023. The proportion of individuals with advanced HIV disease was higher in inpatient settings (44.3%, 95% CI 39.1−49.6%) compared to outpatient settings (33.5%, 95% CI 31.5−35.4%). Prevalence was similar across age groups, time since HIV diagnosis and treatment status, and highest in West and Central Africa, South‐East Asia and the Eastern Mediterranean region. Discussion This review finds that at least a third of people presenting to healthcare settings have advanced HIV disease, with no evidence that this has changed in recent years. Screening for advanced HIV remains important to be able to direct appropriate preventive, diagnostic and therapeutic interventions to prevent progression to severe illness and death. Conclusions This review summarizes recent evidence of the continued high proportion of individuals who (re)present to care with advanced HIV disease. These findings underscore the urgent need to reinforce programme capacity to diagnose, prevent and treat advanced HIV disease as an essential pillar of the global AIDS response.

Background Advanced HIV disease (AHD) is a critical stage in the progression of HIV infection and is associated with heightened susceptibility to opportunistic infections, malignancies, and other life-threatening complications. Estimates of the burden of AHD in sub-Saharan Africa are scarce but are needed for programme planning which includes the allocation of resources and the monitoring of outcomes. The aim of the study was to assess the prevalence of and the number of people living with HIV with AHD. Methods In this nationally representative study, we analysed data from 13 Population-based HIV Impact Assessment (PHIA) household surveys conducted between 2016 and 2021 to determine the proportion of adults living with HIV who have AHD (defined as CD4 count <200 cells per mm(3)). We analysed the prevalence of AHD by various demographic and socioeconomic factors; we then estimated the number of individuals with AHD in sub-Saharan Africa by combining these proportions with the latest UNAIDS HIV estimates for the region by the treatment and care cascade. We also assessed policies related to the provision of the recommended package of care for the diagnosis and management of AHD. Findings A total of 28 040 people living with HIV were included in this study from 13 PHIA surveys. 19 364 were females (weighted percentage 64.5%) and 8676 (35.5%) were males, and the median age of participants was 38 years (IQR 30-47). Pooled across the 13 countries, 9.8% (95% CI 9.3-10.3) had a CD4 cell count of less than 200 cells per mm(3). AHD was more common among males than females (13.2% vs 8.0%) and differed across the treatment cascade: 15.4% among people living with HIV who did not know their HIV status, 20.9% among people who knew their status but were not on antiretroviral treatment (ART), 29.5% among people who were on ART but not virally suppressed, and 4.3% among people who were virally suppressed. Extrapolating these results to sub-Saharan Africa yielded an estimated 1.88 million people living with AHD (uncertainty interval [UI] 1.58-2.20); 920 000 (UI 770 000-1.07 million) females and 970 000 (UI 810 000-1.13 million) males. Interpretation Despite advances in ART that have transformed HIV into a manageable chronic condition, a substantial number of people continue to develop AHD. These figures highlight the need for urgent and innovative programmatic improvements in monitoring, prevention, testing, and diagnosis of AHD in the context of well-established and maturing ART programmes.

Chronic hepatitis B virus (HBV) infection is a major public health problem and cause of chronic liver disease and led to an estimated 1·1 million deaths in 2022, mainly due to cirrhosis and hepatocellular carcinoma. 1 WHOGlobal hepatitis report 2024: action for access in low- and middle-income countries. World Health Organization, Geneva2024https://www.who.int/publications/i/item/9789240091672Date accessed: April 9, 2024 Google Scholar In 2022, WHO estimated that 254 million people were living with chronic hepatitis B, of whom 65% were in the African and Western Pacific regions. 1 WHOGlobal hepatitis report 2024: action for access in low- and middle-income countries. World Health Organization, Geneva2024https://www.who.int/publications/i/item/9789240091672Date accessed: April 9, 2024 Google Scholar Most of this global burden can be attributed to mother-to-child transmission at the time of or shortly after birth and horizontal household transmission. Considerable progress has been made towards eliminating perinatal transmission of HBV through universal infant HBV immunisation, including timely hepatitis B birth-dose vaccination administered within 24 h of birth. This regimen is 90–95% effective in preventing infection and in reducing new infections among children. However, hepatitis B birth-dose coverage is only 45% globally, with particularly low coverage (18%) in the WHO African region. 2 WHOImmunization coverage. https://www.who.int/news-room/fact-sheets/detail/immunization-coverageDate accessed: March 14, 2024 Google Scholar For people with chronic hepatitis B, nucleoside analogue treatment with tenofovir or entecavir is highly effective, reducing progression of liver disease and incidence of hepatocellular carcinoma and improving long-term survival. However, a major testing and treatment gap remains. In 2022, only 13% of those living with chronic hepatitis B had been diagnosed and 3% treated. 1 WHOGlobal hepatitis report 2024: action for access in low- and middle-income countries. World Health Organization, Geneva2024https://www.who.int/publications/i/item/9789240091672Date accessed: April 9, 2024 Google Scholar Scaling up testing and treatment to reach the 90% testing and 80% treatment coverage targets and achieve the elimination goals will require radical simplification of treatment criteria, diagnostic approaches, and care pathways to overcome barriers in access to hepatitis B testing and treatment.

Background:Following reports of an outbreak of HIV infection among children in Larkana District, Pakistan, an international team investigated the extent and cause of the outbreak between April and June 2019. Aims:To investigate the incidence of HIV among children in Larkana District, Pakistan and describe the distribution of cases by time, place and person. Methods:Self-referred persons were tested for HIV using the national testing protocol. Local epidemiology of HIV was reviewed to generate hypotheses. An infection prevention and control (IPC) team conducted site visits and reviewed IPC practices. Results:Between 25 April and 27 June 2019, a total of 30 191 persons were tested for HIV in Larkana District, and 876 of them tested positive. Of those who tested positive, 719 (82%) were children aged <15 years. Traditional skin piercing procedures and transmission from high-risk populations to children were ruled out during the investigation. Informative interviews with parents or guardians of a convenience sample of 211 children aged <15 years showed that 99% of children had an injection or infusion for medical treatment within the past 12 months. Our investigation identified lack of HIV prevalence data for the general population including tuberculosis patients and those who attended antenatal care services. Conclusions:Investigations indicate that unsafe healthcare practices in formal and informal healthcare settings as the most likely cause of the 2019 outbreak of HIV infection in Larkana, Pakistan. Measures should be taken to improve IPC practices at the facility level, especially in pediatric and antenatal care clinics.

BACKGROUND:After rapid epidemic growth between May and August, 2022, new mpox diagnoses declined in Europe and the Americas, with low-level transmission continuing thereafter. Characterising the extent of behavioural adaptation, mpox vaccination, and mpox prevalence across these regions could improve our understanding of the transmission dynamics of the virus. We aimed to characterise the presence and duration of adaptations to sexual behaviour related to the emergence of mpox during the first year of the outbreak among affected communities in Europe and the Americas. METHODS:This retrospective, cross-sectional online survey was conducted in 23 countries in Europe and the Americas between May 19 and May 31, 2023. The survey was advertised via four geospatial dating apps used by affected communities. Eligible participants were aged 18 years or older and identified as a gay man, a bisexual man, a man who has sex with men, as transgender, or as non-binary. We described and regionally compared the mpox prevalence, mpox vaccination rates (one dose or two doses of modified vaccinia virus Bavarian Nordic), and the extent and duration of behavioural adaptation during the outbreak. For these behavioural outcomes, we used regression analyses to estimate crude prevalence ratios (PRs) and adjusted prevalence ratios (aPRs) with 95% CIs. FINDINGS:Of 17 428 individuals who completed the survey, 16 875 (96·8%) met the eligibility criteria and were included in the study. 1086 (6·4%) participants reported having mpox during the outbreak. Vaccination with at least one dose was reported by 4987 (29·6%) participants; 3502 (20·8%) reported two doses. Vaccination rates in Latin America and eastern Europe and the western Balkans were significantly lower than in western Europe and northern America (p<0·0001). Adaptations to sexual behaviour were reported by 8583 (50·9%) of 16 875 participants and across all regions; 3045 (35·5%) of these 8583 participants said they continued adapting their sexual behaviour until May, 2023. Participants who reported concerns about mpox (9884 [58·6%] of 16 875) were more likely to adapt their behaviour than those who did not report concerns (PR 2·43 [95% CI 2·34-2·53]). In adjusted regression models, participants who reported vaccination (aPR 0·25 [95% CI 0·21-0·28] for two doses and 0·43 [0·37-0·51] for one dose) or having had mpox (0·37 [0·30-0·44]) were less likely to continue adaptations than those who did not. Participants in Latin America or northern America were significantly more likely to adapt their sexual behaviour and to continue with adaptations than those in western Europe. INTERPRETATION:Adaptations to sexual behaviour due to mpox were widespread, dynamic, and responded to evolving individual risk perceptions. We propose that the decline in mpox transmission seen at the end of 2022 resulted primarily from a combination of behavioural adaptation and naturally acquired immunity. As mpox vaccination is an important preventive measure, stark vaccine inequity highlights the need to increase access to mpox vaccines. FUNDING:WHO Contingency Fund for Emergencies.