Prevalence and epidemiological patterns of <i>Neisseria gonorrhoeae</i> infection in sub-Saharan Africa, 1964–2025: Systematic review, meta-analyses, and meta-regressions
by Aisha Osman, Hina Akram, Bayan Alemrayat, Sumaya Al-Maraghi, Manale Harfouche, Laith J. Abu-Raddad Background Neisseria gonorrhoeae (NG) infection is a global health concern because of its morbidity and increasing antimicrobial resistance. Sub-Saharan Africa is believed to carry a disproportionately high burden of NG infection, but the epidemiology of NG infection in this region has not been comprehensively synthesized. This study systematically reviewed and analyzed NG prevalence in sub-Saharan Africa to characterize prevalence patterns and identify populations at risk. Methods and findings A systematic review was conducted and reported following PRISMA guidelines. Embase, PubMed, Scopus, and Web of Science were searched from inception to June 4, 2025. Eligible studies reported NG prevalence in sub-Saharan Africa. Random-effects meta-analyses generated pooled prevalence estimates, and random-effects meta-regression analyses identified associations and sources of heterogeneity.Nine hundred fifty publications contributed 1,604 prevalence measures spanning 1964–2025. In the general population, pooled urogenital prevalence was 3.2% (95% confidence interval (CI): 2.9–3.5), with substantial between-study heterogeneity and a wide prediction interval, indicating considerable variation in prevalence across settings. Prevalence was high in key populations: among female sex workers, 11.5% (95% CI: 9.9–13.2) for urogenital and 2.0% (95% CI: 0.4–4.5) for anorectal infection; and among men who have sex with men, 2.8% (95% CI: 2.4–3.3) for urogenital, 8.3% (95% CI: 5.8–11.0) for anorectal, and 5.7% (95% CI: 3.6–8.3) for oropharyngeal infection. Symptomatic men exhibited high urogenital prevalence (51.5%; 95% CI: 47.5–55.5), and symptomatic women showed 9.0% (95% CI: 7.7–10.4). Among women with adverse pregnancy or birth outcomes, urogenital prevalence was 8.6% (95% CI: 5.3–12.6). Meta-regression analyses explained over half of the variability in prevalence, showing a long-term decline of 1% per year, a clear population type gradient, subregional differences, and decreasing prevalence with increasing age, but no variation by sex. These findings may be affected by variability in data availability across countries, anatomical sites, and population groups, as well as heterogeneity across included studies. Conclusions NG prevalence remains markedly high in this region but has declined over time. These findings highlight the need for strengthened surveillance, expanded prevention and diagnostic strategies, and continued monitoring of gonococcal antimicrobial resistance to support effective control efforts in sub-Saharan Africa.