Cognitive behavioral therapy (CBT) is a promising intervention for HIV prevention among high-risk individuals. However, its efficacy compared to standard counseling remains unclear. This meta-analysis aimed to evaluate the effectiveness of CBT in reducing HIV risk behaviors. A systematic review and meta-analysis were conducted to identify randomized controlled trials comparing CBT to standard counseling for HIV prevention from inception to November 30, 2024. Primary outcomes included sexual transmission risk behavior and the number of unprotected anal intercourse (UAI). Secondary outcomes included alcohol use, substance use, and suicidality. Nine studies with a total of 3189 participants were included in the meta-analysis. CBT did not significantly reduce sexual transmission risk behavior compared to standard counseling. However, CBT was associated with a significant reduction in UAI at the six- and 12-month post-intervention. Regarding secondary outcomes, CBT led to a significant reduction in substance use, while standard counseling was more effective in reducing alcohol use. CBT appears to be effective in reducing specific high-risk behaviors, particularly UAI, among high-risk individuals. However, the mechanisms of action of CBT and its long-term effects require further investigation.