Abstract
Despite seeing few cases during the 2022-2023 mpox global outbreak, reports in May-July 2024 of 22 cases among men-who-have-sex-with-men (MSM) in South Africa, including three deaths, have raised concerns about under-reported community transmission. We used a Monte Carlo simulation model to estimate the true epidemic size, considering the increased severity of mpox among MSM living with advanced HIV, documented over-representation of people living with HIV among mpox cases and HIV prevalence in South Africa. We estimate that there have been between 220 and 450 cases among MSM LHIV in South Africa, with a total of 290-560 cases among all MSM. We provide an upper bound of 750-1600 cases as a sensitivity analysis where the prevalence of HIV among mpox patients is the same as population prevalence among MSM in South Africa. Estimates in both scenarios suggest a substantial number of undetected cases, with case ascertainment rates estimated between 1% and 8%. Our findings underscore the need for enhanced surveillance, targeted public health interventions and awareness campaigns to mitigate the outbreak's impact at a population level.