Impact of HIV infection on clinical presentation and diagnostic delay of skin neglected tropical diseases: a systematic review and meta-analysis

Introduction

Neglected Tropical Diseases (NTDs) comprise a diverse group of chronic and disabling infections that predominantly affect populations living in impoverished tropical and subtropical regions, with over one billion individuals impacted globally (1, 2). Among these, skin neglected tropical diseases (skin NTDs) represent a subset notable for their prominent cutaneous manifestations, including ulcers, nodules, and plaques, which often progress insidiously and result in long-term morbidity, stigma, and disability (3, 4). Classic examples of skin NTDs include Buruli ulcer caused by Mycobacterium ulcerans, cutaneous leishmaniasis, yaws, and lymphatic filariasis, which collectively contribute a substantial yet under-recognized burden due to delayed case detection and limited access to effective diagnostics in resource-poor settings (4, 5). The clinical spectrum of these diseases is heterogeneous and often overlaps with more common dermatological conditions, making early recognition challenging even for frontline health workers (6). This challenge is exacerbated by insufficient surveillance systems and scarce epidemiological data, underscoring why NTDs remain neglected in research, policy prioritization, and funding landscapes despite their high prevalence (1, 2).

Human Immunodeficiency Virus (HIV) infection remains a leading cause of global morbidity, with an estimated 39 million people living with HIV/AIDS worldwide as of 2025 (7). HIV profoundly disrupts immune function, particularly through depletion of CD4+ T-lymphocytes, predisposing affected individuals to opportunistic infections and atypical clinical presentations of co-morbid diseases (4, 8). Dermatologic manifestations, including seborrheic dermatitis, eosinophilic folliculitis, Kaposi’s sarcoma, and other opportunistic skin infections, occur in a large majority of HIV-infected patients and correlate with immunosuppression severity (4, 8). Evidence suggests that HIV co-infection may modify disease expression, severity, and natural history of several NTDs; for instance, co-infection with HIV has been linked to more extensive Buruli ulcer lesions and altered healing timelines, though findings remain inconsistent and context-specific (9, 10). Similarly, visceral leishmaniasis with skin involvement demonstrates distinct clinical and epidemiological features in HIV-infected persons, including higher relapse rates and dissemination beyond classical lesion patterns (11). Importantly, the co-occurrence of immunosuppression and NTDs is not merely additive but can exacerbate disease progression, complicate diagnosis, and heighten morbidity, especially where healthcare resource constraints delay definitive diagnosis and treatment initiation (2, 11). Yet, despite the plausible synergistic impact of HIV on skin NTDs, current literature lacks comprehensive synthesis on how HIV influences clinical presentation and diagnostic delays across these diseases.

Diagnostic delay remains a critical barrier to achieving timely treatment and improved outcomes for both HIV and skin NTDs. Delayed HIV diagnosis significantly increases mortality risk and reduces survival time, with studies reporting hazard ratios up to 3.01 for late diagnosis compared with early detection (12). By analogy, diagnostic delay in skin NTDs often due to non-specific presentation, limited point-of-care testing, and low clinical suspicion can lead to extensive tissue damage, secondary infections, and irreversible disability (3, 6). Integrated evidence elucidating the interplay between HIV status and diagnostic timelines for co-morbid skin NTDs remains fragmented. Therefore, a systematic review and meta-analysis synthesizing available evidence on the impact of HIV infection on both the clinical manifestations and diagnostic delay of skin NTDs is urgently needed to inform clinical practice, public health strategies, and policy efforts aimed at improving early detection and management in co-endemic settings. To systematically evaluate and quantify the impact of HIV infection on the clinical presentation and diagnostic delay of skin NTDs across diverse epidemiological contexts.

Methods

Study design and reporting standard

This review was registered on PROSPERO at https://www.crd.york.ac.uk/PROSPERO/view/CRD420261280839. Also, the methodology followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to ensure transparency, reproducibility, and methodological rigor (13). The review protocol was developed a priori and adhered to established guidance for systematic reviews of observational and clinical studies in global health research (14).

Search strategy

A comprehensive and systematic literature search was undertaken to identify relevant peer-reviewed studies examining HIV infection in relation to skin NTD clinical presentation and diagnostic delay. Five electronic databases were searched from inception to the most recent update: PubMed/MEDLINE, Embase, Web of Science, Scopus, and the Cochrane Library. These databases were selected to ensure broad coverage of biomedical, epidemiological, and global health literature.

Search terms were developed iteratively using key concepts related to HIV infection, skin neglected tropical diseases, clinical manifestations, and diagnostic delay (Table 1). Controlled vocabulary terms (Medical Subject Headings [MeSH]) and free-text keywords were combined using Boolean operators (“AND”, “OR”) to maximize sensitivity while maintaining specificity. Truncation and phrase searching were applied where appropriate. In addition, the reference lists of all included articles and relevant reviews were manually screened to identify additional eligible studies not captured through database searching, in line with best practice recommendations (15).

Table 1. Search strategy table.

Eligibility criteria

The eligibility criteria were formulated using the PECO framework (Population, Exposure, Comparator, Outcome), which is appropriate for observational and clinical epidemiological reviews (16).

Inclusion criteria:

• Population: Individuals of any age diagnosed with skin neglected tropical diseases
• Exposure: Confirmed HIV infection
• Comparator: HIV-negative individuals or standard clinical presentation benchmarks
• Outcomes: Clinical presentation (severity, lesion characteristics, atypical manifestations) and/or diagnostic delay
• Study design: Study designs: observational studies, epidemiological studies, case series, and case reports reporting relevant outcomes.
• Publication characteristics: Peer-reviewed articles published in English

Exclusion criteria:

• Studies without stratification by HIV status
• Editorials, commentaries, conference abstracts, and reviews
• Studies focusing exclusively on non-cutaneous NTDs
• Non-peer-reviewed literature and non-English publications

Study selection

All retrieved citations were imported into Zotero reference manager, where duplicates were identified and removed. The de-duplicated records were then exported into a Microsoft Excel spreadsheet for screening. Title and abstract screening were independently conducted by multiple authors to assess eligibility against predefined criteria. Full-text articles were subsequently reviewed for inclusion. Disagreements were resolved through discussion and consensus. The PRISMA flow diagram was used to document the selection process and to record reasons for exclusion at the full-text stage (13).

Data extraction

Data extraction was performed using a standardized Microsoft Excel extraction form after transfer from Zotero. Extracted variables included: author(s), year of publication, country or region, study design, sample size, type of skin NTD, HIV status, clinical presentation characteristics, measures of diagnostic delay, diagnostic methods, and key outcomes. Data extraction was cross-checked by the authors to ensure accuracy and completeness.

Risk of bias and quality assessment

Methodological quality and risk of bias were assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Tools, which provide design-specific checklists for evaluating observational studies, case series, and case reports (17). Appropriate JBI appraisal instruments were applied according to study design, including the JBI Cohort Checklist, JBI Case-Control Checklist, JBI Analytical Cross-Sectional Checklist, JBI Case Series Checklist, and JBI Case Report Checklist.

Each item within the relevant checklist was scored as “Yes”, “No”, “Unclear”, or “Not Applicable”. For consistency across study designs, the proportion of criteria fulfilled was calculated and converted into an overall quality rating. Studies meeting ≥70% of applicable criteria were classified as low risk of bias (high methodological quality), studies meeting 50–69% were classified as moderate risk of bias, and studies meeting <50% were classified as high risk of bias. Quality assessments were conducted independently by the review authors, and disagreements were resolved through discussion and consensus. No studies were excluded on the basis of quality assessment because all contributed relevant evidence to the review objectives.

Data synthesis and meta-analysis

A quantitative synthesis was conducted using a random-effects meta-analysis to account for anticipated clinical and methodological heterogeneity across studies. Effect estimates, including odds ratios and mean differences with 95% confidence intervals, were calculated where appropriate. Statistical heterogeneity was assessed using the I² statistic. Meta-analyses were performed using Review Manager (RevMan) version 5.4.1. Narrative synthesis complemented the quantitative analysis where meta-analysis was not feasible (14). Although 10 studies were included in the systematic review, only studies reporting comparable quantitative outcomes were eligible for meta-analysis. Six studies contributed quantitative data, while the remaining studies were synthesized narratively.

Results

Overview of the search process

Following a comprehensive search across multiple electronic databases, a total of 1,573 records were initially identified, comprising 1,568 records retrieved from databases and 5 additional records identified through reference list screening. After removal of 318 duplicate records, 1,255 unique records remained and were subjected to title and abstract screening. Of these, 923 records were excluded for lack of relevance, leaving 332 full-text articles assessed for eligibility. Subsequently, 322 articles were excluded for reasons including failure to address skin NTDs, lack of HIV focus, non-quantitative design, review articles, or non-English publication. Ultimately, Ten studies met the predefined inclusion criteria and were included in the systematic review, of which six contributed data to the meta-analysis (9, 11, 18–25). Figure 1 presents the PRISMA flow diagram detailing the study selection process.

Characteristics of included studies

The ten included studies were published between 2008 and 2025 and represented a diverse range of study designs, including retrospective cohort studies, observational studies, epidemiological analyses, cross-sectional studies, case series, and case reports. The studies were conducted across sub-Saharan Africa (Ghana, Togo, and Nigeria), South America (Brazil), and South Asia (India), regions characterized by overlapping endemicity of HIV infection and skin neglected tropical diseases. Sample sizes ranged from single-patient clinical reports to large population-based datasets involving thousands of participants, providing both detailed clinical insights and broader epidemiological evidence. Across studies, HIV status was consistently ascertained using serological testing, while skin NTD diagnoses were based on clinical assessment supported by microbiological, histopathological, or molecular confirmation. Outcomes extracted included lesion severity, atypical or disseminated clinical presentation, immunological markers (e.g., CD4 count), and indicators of diagnostic delay or advanced disease stage at presentation, thereby enabling comparative synthesis across heterogeneous study designs (Table 2).

Table 2. Characteristics of included studies (n = 10).

Risk of bias

As shown in Table 3, the methodological quality of the included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Tools appropriate to each study design. Overall, the included studies demonstrated acceptable methodological quality, with most studies classified as having a low risk of bias. Cohort, case-control, and cross-sectional studies generally showed strong participant selection procedures, valid ascertainment of HIV status and skin NTD diagnoses, and appropriate outcome measurement. The large observational studies by Christinet et al., Cota et al., Moura de Souza et al., and Amoako et al. achieved the highest appraisal scores owing to their robust methodology and comprehensive reporting.

Table 3. Risk of bias assessment using Joanna Briggs Institute (JBI) critical appraisal tools.

Case series and case reports provided important clinical evidence regarding atypical presentations and diagnostic delays in HIV-associated skin NTDs. Although these designs inherently lack comparator groups and are more susceptible to selection bias, most fulfilled the majority of relevant JBI criteria and were considered to provide valuable contextual evidence. Only one study was judged to have a moderate risk of bias due to limited reporting and incomplete methodological detail. No study was excluded based on quality assessment because all contributed relevant evidence addressing the review objectives.

Meta analysis of HIV infection and severe clinical presentation of skin neglected tropical diseases at diagnosis

The meta-analysis demonstrated a strong and statistically significant association between HIV infection and severe clinical presentation of skin neglected tropical diseases at the time of diagnosis (Figure 2). Pooled analysis of five eligible studies showed that individuals living with HIV had over four times higher odds of presenting with severe disease compared with HIV-negative individuals (pooled OR = 4.05, 95% CI 2.65–6.19; Z = 6.46, p < 0.00001). All contributing studies consistently favored an increased risk of severe presentation among HIV-positive patients, with individual odds ratios ranging from 3.28 to 6.55. There was no evidence of between-study heterogeneity, as indicated by an I² of 0%, a non-significant Chi-square test (χ² = 1.98, p = 0.58), and a Tau² of 0.00, supporting the robustness and consistency of the pooled estimate. These findings suggest that HIV-associated immunosuppression substantially exacerbates disease severity at presentation, likely contributing to advanced clinical stages and poorer outcomes among co-infected individuals.

Meta-analysis of association between HIV infection and late diagnosis of skin neglected tropical diseases

The meta-analysis demonstrated a statistically significant association between HIV infection and late diagnosis or advanced presentation of skin neglected tropical diseases (Figure 3). Pooled data from the eligible studies showed that individuals living with HIV had nearly fourfold higher odds of presenting with late-stage disease compared with HIV-negative individuals (pooled OR = 3.91, 95% CI 2.56–5.96; Z = 6.33, p < 0.00001). All included studies consistently favored an increased likelihood of delayed diagnosis among HIV-positive patients, with individual odds ratios ranging from 3.28 to 5.48. There was no evidence of statistical heterogeneity across studies, as indicated by a Tau² of 0.00, a non-significant Chi-square test (χ² = 1.02, p = 0.80), and an I² value of 0%, suggesting high consistency of effect estimates. These findings indicate that HIV infection is strongly associated with delayed recognition and advanced clinical presentation of skin NTDs, likely reflecting diagnostic challenges, atypical disease manifestations, and healthcare access barriers in co-endemic settings.

Narrative synthesis

In this review two themes were discussed narratively and they included (i) Atypical and Disseminated Clinical Manifestations of Skin NTDs in HIV-Infected Individuals and diagnostic pathways, health system barriers, and delayed recognition of skin NTDS in HIV co-infection.

Atypical and disseminated clinical manifestations of skin NTDs in HIV-infected individuals

Evidence from case series and small observational studies consistently indicates that HIV infection is associated with atypical, disseminated, and unusually severe cutaneous manifestations of skin NTDs, reflecting the profound impact of immunosuppression on disease expression. Several included studies not contributing to the meta-analysis provide critical clinical insights into these patterns. In a Ghanaian case series of Buruli ulcer (BU)–HIV co-infected patients (19),. reported rapidly progressive lesions with extensive ulceration, multifocal involvement, and poor wound healing, often occurring at relatively young ages and low CD4 counts. These findings align with observations from Nigeria, where (20) described severe BU with extensive tissue destruction in an HIV-positive patient, highlighting the tendency for delayed recognition and aggressive disease courses in co-infected individuals.

Similarly, studies on leishmaniasis demonstrate that HIV infection profoundly alters classical dermatological presentations (25). documented diffuse cutaneous leishmaniasis among HIV-infected patients in India, characterized by widespread, non-ulcerating nodules mimicking other dermatoses and leading to diagnostic confusion (11). further reported visceral leishmaniasis–HIV co-infection with post-kala-azar dermal leishmaniasis (PKDL)-like skin lesions, illustrating how HIV may facilitate dermal dissemination of parasites beyond typical clinical patterns. These atypical manifestations complicate differential diagnosis and often result in prolonged diagnostic pathways.

Importantly, findings from studies included in the quantitative synthesis reinforce this narrative. Cohort studies from Ghana and Brazil reported significantly higher proportions of advanced lesion categories, disseminated disease, and extensive skin involvement among HIV-positive individuals compared with HIV-negative counterparts (9, 18, 21). Benjamin and Otrofanowei (24) highlighted the diagnostic challenges posed by atypical lesion morphology in HIV-infected patients. With this body of evidence, it suggests that HIV-related immune dysfunction not only increases disease severity but also drives atypical and disseminated cutaneous phenotypes of skin NTDs, with important implications for clinical recognition, surveillance, and timely management.

Diagnostic pathways, health system barriers, and delayed recognition of skin NTDs in HIV co-infection

Narrative evidence across the included studies indicates that delayed recognition of skin NTDs among people living with HIV is driven by intersecting diagnostic, clinical, and health-system barriers. Case series and small observational studies illustrate how atypical lesion morphology in HIV co-infection frequently leads to misclassification as common dermatoses or opportunistic infections, prolonging diagnostic pathways. For example, diffuse cutaneous leishmaniasis and PKDL-like presentations reported among HIV-infected patients often mimicked eczema, psoriasis, or drug reactions, resulting in repeated empirical treatments before definitive diagnosis (11, 25). Similarly, Buruli ulcer (BU) case series from Ghana and Nigeria described prolonged symptom duration and multiple healthcare visits prior to diagnosis, reflecting low clinical suspicion and limited access to confirmatory testing in peripheral facilities (19, 20).

Findings from studies included in the meta-analysis reinforce these observations at population level. Retrospective cohorts from Ghana demonstrated that HIV-positive BU patients were more likely to present with advanced WHO category III lesions at first diagnosis, suggesting substantial delays in disease recognition rather than rapid disease progression alone (9, 18). In Brazil, observational studies of leishmaniasis similarly reported higher odds of late or advanced presentation among HIV-infected individuals, attributed to atypical clinical features and fragmented referral pathways between HIV and NTD services (21, 22). Large surveillance analyses further indicated that HIV co-infection was associated with delayed case detection at health-system level, reflecting gaps in integrated screening and follow-up (23).

Health-system constraints—including limited laboratory capacity, reliance on syndromic diagnosis, and weak integration between HIV programs and NTD control services emerged as recurring barriers. A prospective field study showed that standard diagnostic algorithms for skin NTDs performed less accurately in HIV-infected patients, increasing the risk of missed or delayed diagnoses (24). Collectively, these findings highlight that delayed recognition of skin NTDs in HIV co-infection is not solely a clinical issue but a systemic one, underscoring the need for integrated diagnostic pathways and targeted training in co-endemic settings.

Discussion of findings

The aim of this systematic review and meta-analysis was to synthesize and critically evaluate evidence on the impact of HIV infection on the clinical presentation and diagnostic delay of skin NTDs. By integrating quantitative pooled estimates with narrative synthesis, this review addresses an important gap in the literature, as previous evidence on HIV–NTD interactions has largely focused on visceral disease, immunological outcomes, or single-disease contexts, rather than cutaneous manifestations and diagnostic processes across skin NTDs.

Our findings are broadly consistent with earlier reviews that have highlighted the synergistic and bidirectional relationship between HIV and NTDs and a narrative review by (2) argued that NTDs and HIV often co-exist within the same socio-ecological contexts, with immunosuppression accelerating disease progression and complicating clinical recognition. However, that review primarily examined population-level interactions and disease burden, whereas the present review extends this understanding by quantitatively demonstrating how HIV modifies disease severity and delays diagnosis specifically for skin NTDs. This distinction is critical, as skin NTDs rely heavily on early visual recognition for effective management (5).

Previous systematic reviews on Buruli ulcer and leishmaniasis have separately reported more severe disease and poorer outcomes among HIV-infected individuals, but without pooled estimates or a diagnostic lens. The WHO report that advanced lesions at presentation are common in endemic regions, attributing this largely to health system delays and sociocultural barriers (26). Our review complements and refines this interpretation by demonstrating that HIV infection independently amplifies the likelihood of severe presentation, suggesting that immunological vulnerability interacts with structural delays to worsen disease trajectories. Similarly, reviews of leishmaniasis–HIV co-infection have emphasized relapse, treatment failure, and mortality (27, 28), but have paid comparatively little attention to how HIV alters cutaneous phenotypes and delays recognition at the primary care level.

Importantly, the consistency of our pooled estimates contrasts with the heterogeneity reported in earlier syntheses of HIV-associated opportunistic infections and for example, a global meta-analysis of HIV-related tuberculosis diagnostic delay reported substantial between-study heterogeneity, reflecting diverse diagnostic algorithms and healthcare systems (29). In contrast, the absence of heterogeneity in our meta-analyses suggests that the effect of HIV on severe presentation and late diagnosis of skin NTDs may be robust across geographical and disease contexts. This reinforces WHO observations that skin NTDs share common diagnostic challenges irrespective of setting, particularly when atypical manifestations occur (30).

The narrative synthesis further aligns with scoping reviews on skin NTDs that emphasize diagnostic complexity and misclassification (31). highlighted that skin NTDs frequently resemble common inflammatory or infectious dermatoses, leading to diagnostic uncertainty even among trained clinicians. Our findings suggest that HIV infection magnifies this challenge by producing atypical, disseminated, or PKDL-like lesions that fall outside classical teaching. This echoes observations from dermatological reviews of HIV-associated skin disease, which consistently report higher rates of unusual morphology and overlapping presentations (8, 32). However, unlike general HIV dermatology reviews, our synthesis situates these atypical features within NTD-endemic contexts, where diagnostic resources are limited and syndromic algorithms dominate.

From a health systems perspective, our findings resonate with broader critiques of vertical disease programs. Integrated HIV–NTD care has long been advocated in policy documents, yet remains poorly implemented in practice (33, 34). A scoping review by (6) on patient experiences of skin NTDs underscored fragmented care pathways and delayed referrals, particularly in rural settings. Our review adds an HIV-specific dimension to this critique, suggesting that parallel service delivery for HIV and NTDs may inadvertently exacerbate diagnostic delays among co-infected individuals. This aligns with health systems research demonstrating that patients with multimorbidity often experience longer diagnostic pathways due to poor service integration (35).

The implications of these findings extend beyond clinical management to surveillance and elimination efforts. WHO roadmaps for NTD elimination increasingly emphasize early detection and community-based screening (30). However, our synthesis suggests that without explicit consideration of HIV co-infection, such strategies may underperform. Previous modelling studies have shown that delayed diagnosis substantially increases disability-adjusted life years for skin NTDs (36), and HIV-related delays may therefore undermine progress toward elimination targets in co-endemic regions.

Nevertheless, the existing literature including this review remains limited by an overreliance on observational data and proxy measures of diagnostic delay and few studies directly quantify time to diagnosis, a gap also identified in previous reviews of NTD surveillance quality (37). Future research should prioritize longitudinal designs and integrated datasets linking HIV care records with NTD surveillance systems to better characterize diagnostic pathways and intervention points. Overall, this review strengthens existing evidence that HIV infection fundamentally alters the clinical and diagnostic landscape of skin NTDs.

Implications of the review

The findings of this review have important implications for clinical practice, public health policy, and health systems strengthening in HIV–NTD co-endemic settings. The strong and consistent associations observed between HIV infection and both severe clinical presentation and delayed diagnosis of skin neglected tropical diseases (NTDs) underscore the need for HIV-sensitive diagnostic algorithms for skin conditions in endemic regions. Existing syndromic approaches and visual inspection tools, which are central to skin NTD control programs, may be insufficient for people living with HIV due to atypical and disseminated disease manifestations. Integrating routine HIV status consideration into skin NTD screening and referral pathways could enhance early case detection and reduce progression to advanced disease. From a policy perspective, the findings support greater integration of HIV and NTD services, including joint training of frontline health workers, shared surveillance platforms, and coordinated referral systems. Such integration aligns with the WHO NTD Roadmap 2021–2030, which emphasizes people-centered and integrated approaches to disease control. Furthermore, the evidence highlights the need for targeted community awareness and case-finding strategies among HIV-affected populations, who may face compounded stigma and barriers to care. Collectively, these implications suggest that addressing HIV co-infection is not ancillary but central to achieving timely diagnosis, reducing morbidity, and advancing skin NTD elimination goals.

Limitations of the review

This review has certain limitations that should be considered when interpreting the findings. First, only studies published in English were included, which may have resulted in language bias and exclusion of relevant evidence from francophone or lusophone endemic regions. Second, most included studies were observational in design, limiting causal inference. Third, diagnostic delay was often assessed using proxy measures such as disease stage at presentation rather than direct time-to-diagnosis data. Additionally, heterogeneity in disease types and outcome definitions constrained the number of studies eligible for meta-analysis. Finally, publication bias could not be formally assessed due to the limited number of pooled studies.

Conclusion

This systematic review and meta-analysis provides robust evidence that HIV infection substantially influences both the clinical presentation and diagnostic trajectory of skin neglected tropical diseases. Quantitative synthesis demonstrated that individuals living with HIV had over fourfold higher odds of presenting with severe skin NTD disease (pooled OR = 4.05, 95% CI 2.65–6.19) and nearly fourfold higher odds of late or advanced presentation (pooled OR = 3.91, 95% CI 2.56–5.96) compared with HIV-negative individuals, with no observed between-study heterogeneity. Narrative synthesis further revealed that HIV co-infection is associated with atypical, disseminated, and diagnostically challenging cutaneous manifestations, contributing to misclassification and prolonged care-seeking pathways. Together, these findings indicate that HIV-related immunosuppression and health system fragmentation interact to exacerbate disease severity and delay diagnosis. Addressing these challenges will require integrated HIV–NTD diagnostic strategies, enhanced clinical training, and health system reforms that prioritize early recognition in high-risk populations. Without such targeted interventions, HIV co-infection is likely to remain a significant barrier to reducing morbidity and achieving elimination targets for skin NTDs in co-endemic settings.

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Footnotes

Edited by: Emmanuel Siddig, University of Khartoum, Sudan

Reviewed by: Sunny Doodu Mante, African Filariasis Morbidity Project, Ghana

Antonio Ferreira Mendes-Sousa, Federal University of Piauí, Brazil

Footnotes

AIDS, Acquired Immunodeficiency Syndrome; CDC, Center for Disease Control and Prevention; CI, Confidence Intervals; HIV, Human Immunodeficiency Virus; MESH, Medical Subject Headings; NTD, Neglected Tropical Diseases; PICO, Population Intervention Comparison Outcome; RCT, Randomized controlled Trials; RoB, Risk of Bias; RR, Risk Ratio; WHO, World Health Organization.