Background: Men who have sex with men (MSM) in sub-Saharan Africa face disproportionate HIV risk amid stigma, criminalisation, and uneven access to key population–competent services. As long-acting PrEP (including injectable cabotegravir; CAB-LA) enters policy adoption, implementation planning requires accurate, context-specific estimates of HIV burden and clearer documentation of the evidence base. This review aimed to synthesise evidence on HIV burden among MSM (and mixed MSM/transgender women samples where reported) in South Africa and interpret implications for equity-centred prevention delivery, including long-acting PrEP. Methods: We searched PubMed/MEDLINE, Embase, Web of Science, Scopus, CENTRAL, CINAHL, PsycINFO, and Africa Index Medicus, plus registers and supplementary sources, from 1 January 1994 to 21 January 2026. We followed PRISMA 2020 and PRISMA-S. Two reviewers independently screened, extracted data, and appraised risk of bias using design-appropriate tools. We pooled HIV prevalence estimates using a random-effects meta-analysis (logit-transformed; DerSimonian–Laird) and quantified heterogeneity using I². Publication bias/small-study effects were explored using funnel plot inspection and Egger’s test. PROSPERO: CRD42026129016. Results: Fifteen eligible study-estimates were included; all were from South Africa (13/15 reported sample size; total N = 4911; two estimates did not report N). The pooled HIV prevalence was 29.2% (95% CI 23.1–36.1; I² = 94.4%). In subgroup analyses, pooled prevalence was 27.5% among MSM-only samples (95% CI 21.0–35.1; I² = 94.4%) and 41.2% among mixed MSM/transgender women samples (95% CI 37.3–45.2; I² = 0%; two estimates). Leave-one-out sensitivity analyses yielded pooled prevalence ranging from 27.8% to 30.6%. Egger’s test did not indicate strong evidence of small-study effects (p = 0.422). Conclusions: Evidence for MSM within this review is concentrated in South Africa and indicates a high, heterogeneous HIV burden. No included study reported CAB-LA effectiveness, safety, persistence, or resistance outcomes, highlighting a key evidence gap. Equity-centred scale-up of oral and long-acting PrEP should prioritise stigma-free, community-linked delivery models and strengthen HIV testing and surveillance systems to mitigate delayed diagnosis and potential resistance.

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