Background Gay, bisexual, and other men who have sex with men (MSM) are disproportionately affected by HIV. In Africa, MSM face structural barriers to HIV prevention and treatment including socio-economic disadvantages, stigma, and criminalization that increase their vulnerability to HIV acquisition and transmission and undermine progress towards ending AIDS. This systematic review explores progress towards increases in HIV testing, improving engagement in the HIV treatment cascade, and HIV incidence reductions among MSM in Africa. Methods We searched Embase, Medline, Global Health, Scopus, and Web of Science from January 1980-March 2022 for cross-sectional and longitudinal studies reporting HIV testing, knowledge of status, care, antiretroviral therapy (ART) use, viral suppression, and/or HIV incidence among MSM in Africa. We pooled surveys using Bayesian generalized linear mixed-effects models, used meta-regression to assess time trends, and compared HIV incidence estimates among MSM with those of all men. Findings Of 8,992 articles identified, we included 148 unique studies published from 2005-2022. HIV testing increased over time in Central/Western and Eastern Africa and in 2020, we estimate that 88% (95% credible interval (CrI) 57-97%) of MSM had tested in the past 12 months, but 66% (19-94%) of MSM living with HIV knew their HIV status, although this is probably underestimated given non-disclosure. Current ART use increased over time in Central/Western (ORyear=1.4, 95%CrI 1.1-2.0, N=8) and Eastern/Southern Africa (ORyear=1.4, 1.0-1.8, N=17) and in 2020 we estimate that 75% (18-98%) of MSM living with HIV in Africa were currently on ART. Nevertheless, we did not find strong evidence viral suppression increased, and in 2020 we estimate that only 62% (12-95%) of MSM living with HIV were virally suppressed. HIV incidence among MSM did not decrease over time (IRRyear=1.0, 0.7-1.3, N=38) and remained high in 2020 (5.4 per 100 person-years, 0.9-33.9) and substantially higher (27-150 times higher) than among all men. Interpretation No decreases in HIV incidence have been observed among MSM in Africa over time, despite some increases in HIV testing and ART use. Achieving the UNAIDS 95-95-95 targets for diagnosis, treatment, and viral suppression equitably for all requires renewed focus on this key population. Combination interventions for MSM are urgently required to reduce disparities in HIV incidence and tackle the social, structural, and behavioural factors that make MSM vulnerable to HIV acquisition. Funding US National Institutes of Health, UK Medical Research Council, Canadian Institutes of Health Research, Fonds de Recherche du Quebec - Sante.

The authors have declared no competing interest.

We thank the HPTN Modelling Centre, which is funded by the US National Institutes of Health (NIH UM1 AI068617) through HPTN, and the GHP-MI4 Steinberg Seed Fund Grant for partial funding of this work. JS is supported by a doctoral award from the Fonds de recherche du Quebec-Sante (FRQ-S). MCB acknowledges funding from the MRC Centre for Global Infectious Disease Analysis (reference MR/R015600/1), jointly funded by the UK Medical Research Council (MRC) and the UK Foreign, Commonwealth & Development Office (FCDO), under the MRC/FCDO Concordat agreement and is also part of the EDCTP2 programme supported by the European Union. NK is supported by a career award from the Fonds de Recherche Quebec - Sante (FRQ-S; Junior 1). MM-G's research program is funded by a Canada Research Chair (Tier 2) in Population Health Modeling.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

Yes

I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.

Yes

All data produced in the present study are available upon reasonable request to the authors.