https://orcid.org/0000-0003-4704-2649
Figures
Abstract
Background
Human Immunodeficiency Virus (HIV)/ Acquired Immunodeficiency Syndrome (AIDS) remains a significant burden in Ethiopia. People living with HIV/AIDS (PLWHA) are at increased risk of cardiovascular diseases due to both the virus and the side effects of antiretroviral therapy. Despite a growing body of research on cardiovascular diseases in PLWHA in Ethiopia, no review has synthesised the available evidence. This scoping review aims to summarise the existing literature on cardiovascular diseases among PLWHA in Ethiopia.
Methods
This scoping review followed the Arksey and O’Malley (2005) framework, with enhancements from Levac et al. (2010). A systematic search was conducted across six electronic databases (PubMed, EMBASE, ProQuest, Global Index Medicus, and Web of Science) in November 2023 and updated in March 2026. Studies on cardiovascular diseases among PLWHA in Ethiopia were included. Two reviewers independently screened titles, abstracts, and full texts. A data extraction template was used, and findings were synthesised narratively. The selection process was documented using a PRISMA flow diagram.
Results
Twenty-six studies were included, with nearly two-thirds (61.5%, n = 16) focused on hypertension. The prevalence of hypertension among PLWHA in Ethiopia ranged from 11.0 to 41.3%. Factors associated with hypertension included male gender, old age, rural residence, alcohol consumption, smoking, family history, low physical activity, obesity, and HAART duration/type. Other cardiovascular conditions studied included ischemic stroke, dilated cardiomyopathy, ECG abnormalities, atherosclerotic cardiovascular disease, and pericardial effusion. Most studies were cross-sectional and institution-based.
Conclusion
This review highlights the limited yet growing evidence on cardiovascular diseases among PLWHA in Ethiopia, with a predominant focus on hypertension. Future research should use more robust study designs, such as longitudinal and interventional studies, encompass a broader range of cardiovascular diseases, and include community-based studies to better understand the prevalence and burden of cardiovascular diseases among PLWHA in Ethiopia.
Citation: Errega D, Kantaris M, Deresse A, Berhanu K, Gebreegziabhere Y, Alemu SM (2026) Cardiovascular diseases among people living with HIV/AIDS in Ethiopia: A scoping review. PLoS One 21(5): e0348283. https://doi.org/10.1371/journal.pone.0348283
Editor: Adetayo Olorunlana, Caleb University, NIGERIA
Received: June 7, 2024; Accepted: April 14, 2026; Published: May 5, 2026
Copyright: © 2026 Errega et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) continue to pose significant public health challenges in Ethiopia. Although national HIV prevalence has declined over recent years due to the expansion of Highly Active Antiretroviral Therapy (HAART) and public health interventions, approximately 1% of the population (around 1.4 million people) is still affected, with regional variation, making the country one of the most affected countries in sub-Saharan Africa [1–3]. The epidemic’s impact is not limited to health; it has profound socioeconomic consequences, including increased healthcare costs, reduced labour productivity, and rising numbers of orphans and vulnerable children [4,5].
As the life expectancy of people living with HIV/AIDS (PLWHA) increases due to improved HAART coverage, the pattern of disease burden is shifting. Non-communicable diseases (NCDs), particularly cardiovascular diseases, have emerged as critical comorbidities among PLWHA globally, including in Low- and Middle-Income Countries (LMICs) like Ethiopia. PLWHA are at increased risk of cardiovascular complications due to a complex interplay of traditional risk factors, HIV-induced chronic inflammation, and side effects of long-term Antiretroviral Therapy (ART) use [6–8]. Studies have documented increased rates of atherosclerosis [9], coronary artery disease [10], myocardial infarction [7,8], ischemic stroke [11], heart failure [12], and pulmonary hypertension [13] in this population.
In Ethiopia, where the dual burden of infectious and non-communicable diseases strains the healthcare system, there is growing interest in understanding the intersection of HIV and cardiovascular health. Several primary studies have examined this relationship in the Ethiopian context. However, the existing literature remains fragmented, with wide variation in design, scope, population characteristics, and outcome measures. To our knowledge, there is no comprehensive synthesis of existing evidence that maps the extent, range, and nature of studies conducted on this topic in Ethiopia.
A scoping review is particularly well-suited to address this gap. Unlike systematic reviews that answer narrowly focused questions, scoping reviews are designed to provide an overview of the existing literature, clarify key concepts, identify research gaps, and inform future investigations or policy directions. Given the emerging and diverse nature of research on HIV-associated cardiovascular diseases in Ethiopia, a scoping review can help stakeholders, including clinicians, researchers, and policymakers, better understand the landscape and prioritise areas for intervention or further study.
Therefore, this scoping review aimed to summarise and map the available evidence on cardiovascular diseases among PLWHA in Ethiopia. Specifically, it sought to: (1) describe the type and content of existing studies on cardiovascular diseases among PLWHA in Ethiopia, (2) report the magnitude and distribution of cardiovascular diseases within this population, and (3) identify factors associated with cardiovascular comorbidities among PLWHA in Ethiopia.
Materials and methods
This scoping review was conducted using the methodological framework proposed by Arksey and O’Malley [14], which was later refined by Levac et al. [15] and aligned with the Joanna Briggs Institute (JBI) guidelines for scoping reviews [16]. To ensure clarity and transparency in reporting, we adhered to the PRISMA extension for Scoping Reviews (PRISMA-ScR) checklist [17].
Identification of the research questions
The review was guided by the following research questions: (1) What are the types of studies conducted on PLWHA concerning cardiovascular diseases in Ethiopia? (2) What is the prevalence/incidence of cardiovascular diseases in PLWHA in Ethiopia? And (3) What are the key factors associated with cardiovascular diseases among this population?
Studies were included if they investigated cardiovascular disease among PLWHA, were conducted in Ethiopia, and were published in English. There were no restrictions on the study design, participant age, or year of publication. We excluded studies that focused only on risk factors (such as obesity, dyslipidaemia, or metabolic syndrome) without measuring cardiovascular disease outcomes, studies only on the health service delivery process, studies involving Ethiopian migrants living outside of Ethiopia, multi-country studies where Ethiopia-specific data could not be extracted, and commentaries, protocols, editorials, letters, conference abstracts, and anonymous reports. Studies without accessible full texts were also excluded after attempts to contact the authors.
Identification of relevant studies
We systematically searched five electronic databases, i.e., PubMed, Embase, ProQuest, Global Index Medicus, and Web of Science, from inception to 13th November 2023, and later updated on 13th March 2026. A comprehensive search strategy was initially developed for PubMed using a combination of Medical Subject Headings (MeSH) and free text for four big terms, i.e., ‘cardiovascular disease,’ ‘HIV,’ AIDS,’ and ‘Ethiopia’. This strategy was then adapted for the remaining databases. In addition to electronic databases, we hand-searched the bibliographies of included studies and relevant grey literature sources, including the Addis Ababa University digital thesis repository. Full details of the search strategy are provided in S1 File.
Study selection and appraisal
All identified records were imported into EndNote citation manager for de-duplication, and the screening process was managed using Covidence, a web-based platform for systematic reviews [18]. Title and abstracts of each study were screened independently by two reviewers (DE and YG/SMA), and any discrepancies were resolved through discussion with a third reviewer (AD). After removing irrelevant studies, full texts were systematically reviewed for further eligibility analysis. Full texts of potentially relevant articles were then retrieved and assessed for eligibility by one reviewer (DE/SMA), with input from a second reviewer as needed. The screening and selection process is presented in a PRISMA flow diagram (Fig 1).
Data charting process
For all included studies, we developed a standardized data extraction form to collect relevant information, including title, year of publication, aim or research questions, sampling technique, country, outcome variables, study design, study period, study participants/population, sample size, data collection method, main data analysis technique, the cardiovascular disease of interest, and main findings and conclusions. Data extraction was performed by one reviewer (DE/SMA) and checked for accuracy and completeness by another reviewer (YG/AD/KB).
Collating, summarising, and reporting of the results
A narrative synthesis approach was used to summarise the findings due to substantial heterogeneity in study designs (e.g., cohort, cross-sectional, case report), population (e.g., patients on HAART versus not on HAART), outcomes (e.g., hypertension, ischemic stroke, atherosclerotic, and ECG abnormalities), and measurement and analysis methods. As such, meta-analysis was not feasible. The findings are presented in both narrative form and summary tables. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline for scoping reviews [19] was strictly followed in reporting the review results (S2 File).
Results
Characteristics of included studies
A total of 678 studies were returned by the search, and 19 studies that met the inclusion criteria were included in the narrative synthesis; an additional 7 studies were included after the updated search (Fig 1). The list of excluded articles with the reason for exclusion is in S3 File. The total sample size represented in this review comprises 9,106 participants. Although not all studies reported participants’ age, gender, and residential characteristics, available data indicate that approximately 62% were female and 74.5% resided in urban areas. Nearly all studies focused on adult populations, except for two: one was a case report involving an infant [20], and the other included only foetuses [21].
Over three-quarters (76.9%, n = 20) of the studies were conducted in only three of the nine regions of Ethiopia (i.e., Addis Ababa [20,22 27], Amhara [28–33], and Southern Nations Nationalities and Peoples (SNNP) regions) [34–41]. The average sample size across the included studies was 350 participants; 21 (80.8%) were cross-sectional, 4 (15.4%) were cohort studies, and only one study was a case report. In addition, all the included studies were institution-based and were conducted after 2011. Nearly two-thirds (61.5%, n = 16) of the included studies were about hypertension [24,28–34,36–38,40,42,43]. Four (15.4%) studies were about more than one cardiovascular disease [21,23,35,44], while the remaining studies were about atherosclerotic cardiovascular disease [22,26], EEG abnormalities [39,41], pulmonary hypertension [25], and ischemic stroke [20] (Table 1).
Prevalence of cardiovascular disease among PLWHA
Sixteen studies of the included studies were about hypertension [24,28–34,36–38,40,42,43], of which two reported the incidence [32,36], while the rest reported the prevalence of hypertension among PLWHA. The definition of hypertension varied across the included studies. Five studies defined hypertension as blood pressure ≥140/90 mmHg; six studies used the same threshold or included individuals taking antihypertensive medication; and three studies applied a lower threshold, defining hypertension as ≥130/80 mmHg.
The prevalence of hypertension in these studies ranges from 11.0% [37] to 41.3% [28], while the two studies reported nearly similar incidence rates, 12.0% and 13.2% [32,36]. A comparative study found a one-year incidence of uncontrolled blood pressure in 60.2% of PLWHA with hypertension compared with 53% of people who are HIV-negative and have hypertension [45]. On the other hand, pulmonary hypertension was reported in 14% of PLWHA [25] and atherosclerotic cardiovascular disease among 11.5% to 28.7% of PLWHA [22,26].
Some studies also reported the prevalence of multiple cardiovascular disorders. For example, one study reported the prevalence of multiple echocardiographic abnormalities, such as diastolic dysfunction (30%), ischemic heart disease (19.3%), left ventricular hypertrophy (10.2%), enlarged left atrium (8.1%), pulmonary hypertension (3.6%), and pericardial effusion (2.1%) [23]. Another study found different cardiac abnormalities among 42.1% of PLWHA, the most common forms being diastolic dysfunction and left ventricular hypertrophy (LVH), each accounting for 8.9%, followed by systolic dysfunction (6.1%), dilated cardiomyopathy (5.4%), coronary artery disease (3.9%), pericardial effusion (2.5%), and pulmonary hypertension (1.4%) [44]. Another study on multiple cardiovascular disorders found 4.5% of PLWHA to have either hypertension, congestive heart failure, or rheumatic heart disease [35] (Table 2).
Factors associated with cardiovascular disease among PLWHA
Most studies reported similar factors associated with hypertension. The most frequently reported factors were sociodemographic factors such as male gender, old age, and rural residency; behavioural factors such as high levels of alcohol consumption, cigarette smoking, and insufficient physical activity; metabolic risk factors such as higher waist circumference, waist-to-hip ratio, body mass index (BMI), blood glucose and total cholesterol; disease-related factors such as current CD4 count and higher WHO stage; treatment-related factors such as the longer duration on HAART, type of HAART and taking concomitant other drug therapy; and family history of hypertension [28–34,37,38,40,42,43]. One study also reported that elementary educational status, compared to no education, and moderate monthly income, compared to low monthly income, were significantly associated with hypertension in PLWHA [30].
Other studies have found different factors associated with various cardiovascular disorders. A study on cardiac disorders found that lower CD4 counts, not starting on ART, and lower BMI were associated with dilated cardiomyopathy, and ART status was associated with pericardial effusion [44]. In studies assessing predictors of atherosclerotic cardiovascular disease, younger age, lower systolic blood pressure, second-line combined HAART, detectable viral load, alcohol use, and lower total cholesterol were associated with atherosclerotic cardiovascular disease [22,26].
In a study of echocardiographic abnormalities, various factors were reported to be associated with specific abnormalities. Hypertension, left ventricular hypertrophy, and older age predicted diastolic dysfunction abnormality; male gender, older age, and higher fasting blood glucose level predicted ischemic heart disease; elevated blood pressure and older age predicted left ventricular hypertrophy; and hypertension predicted the presence of an enlarged left atrium. On the contrary, the severity of HIV infection did not contribute significantly to echocardiography findings [23]. Another study on the general cardiovascular effects of HIV exposure found no statistically significant differences between the HIV-exposed and non-exposed children [21]. Similarly, a study on pulmonary hypertension found no significant differences in gender, cigarette smoking, previous history of pulmonary tuberculosis treatment, chronic obstructive pulmonary disease or bronchial asthma, duration of antiretroviral therapy, or antiretroviral regimen type between PLWHA with or without pulmonary hypertension [25].
One case report also presented the case of a 19-month-old HIV-positive boy from Addis Ababa who developed an ischemic stroke following disseminated extrapulmonary tuberculosis. The study suggests extrapulmonary tuberculosis to be considered a cause for sudden focal neurologic deficits in children and adolescents with HIV infection, especially in tuberculosis-endemic countries [20] (Table 2).
Discussion
To the best of our knowledge, this scoping review represents the first systematic synthesis of available evidence on cardiovascular diseases among PLWHA in Ethiopia. We included 26 institution-based studies, predominantly conducted in three of the nine regions, focusing largely on hypertension but also covering conditions such as atherosclerotic cardiovascular disease, ischemic stroke, diastolic dysfunction, left ventricular hypertrophy, and pericardial effusion. The majority of studies were cross-sectional, conducted after 2011, and had relatively small sample sizes. These findings underscore a growing but still limited and fragmented body of literature on cardiovascular disorders in the Ethiopian HIV population. The disproportionate focus on hypertension may reflect its relatively straightforward diagnosis using basic clinical tools such as blood pressure cuffs, compared with other cardiovascular disorders that require more advanced diagnostics like echocardiography or laboratory biomarkers.
The reported prevalence of hypertension among PLWHA in Ethiopia ranged widely from 11.0% to 41.3%, which could be attributed to variations in diagnostic thresholds, participant characteristics (e.g., HAART status), comorbidities, and institutional differences in clinical practice. This heterogeneity underscores the need for standardised diagnostic criteria and robust surveillance systems for hypertension and other cardiovascular comorbidities among PLWHA in Ethiopia. Our findings align with other regional and global studies. For instance, two recent meta-analyses reported the global hypertension prevalence rates of 25.2% and 23.6% among PLWHA [46,47]. In East Africa, a recent meta-analysis estimated the pooled prevalence in Ethiopia at 16.13% [48]. These results suggest that Ethiopia’s rates are within global estimates but also reflect underrepresentation due to the limited number and scope of existing studies. The lack of community-based studies in Ethiopia limits the generalizability of findings, as institution-based research might not reflect the true prevalence due to selection bias. Furthermore, according to the hypertension treatment guideline, in Ethiopia, hypertension is diagnosed if, on two visits on different days, systolic blood pressure is ≥ 140 mmHg and/or diastolic blood pressure is ≥ 90 mmHg on both days. However, the studies included in these reviews used various definitions of hypertension, which requires careful interpretation of the findings.
Several modifiable and non-modifiable risk factors were consistently associated with hypertension, including older age, male sex, alcohol consumption, physical inactivity, elevated body mass index (BMI), central obesity, and prolonged exposure to HAART regimens. Similar associations have been noted in studies from Burundi and other East African countries [48,49]. However, given the predominance of cross-sectional designs, causal inferences remain limited. Prospective cohort studies are urgently needed to better delineate the temporal associations between HIV-related risk factors and cardiovascular outcomes.
The high burden of hypertension and other cardiovascular complications among PLWHA calls for the integration of cardiovascular screening into routine HIV care in Ethiopia, especially for patients with modifiable risk factors. Evidence from high-income countries and emerging programs in sub-Saharan Africa suggests that integrated care models can improve outcomes and reduce costs [50,51]. Preventive strategies such as promoting physical activity, healthy diets, and blood pressure monitoring should be prioritised. In particular, patients on ART are at elevated risk of developing metabolic syndromes, including hypertension, due to both the effects of ART and ageing.
High rates of uncontrolled hypertension reported in some studies further highlight gaps in follow-up care and adherence monitoring. Strengthening chronic care delivery through regular follow-up, task-shifting, and community health worker involvement could mitigate these issues. Additionally, the Ethiopian Ministry of Health should consider updating national HIV treatment guidelines to incorporate cardiovascular screening and prevention strategies.
Despite the growing number of studies in recent years, significant research gaps remain. For instance, few studies explored conditions like ischemic stroke, cardiomyopathy, or pulmonary hypertension in depth, even though emerging evidence suggests these are increasingly relevant complications in long-term HIV care. Moreover, almost all studies were limited to urban health facilities, with an overrepresentation of regions such as Addis Ababa, Amhara, and SNNPR, leaving rural areas understudied. Future research should prioritise community-based epidemiological studies to determine the actual prevalence and burden of cardiovascular disease among PLWHA; longitudinal studies to better understand causal relationships and disease progression; and the evaluation of the effectiveness of integrated HIV-cardiovascular disease management models in Ethiopian healthcare settings.
This scoping review has strengths and limitations. The study is the first in Ethiopia to summarise evidence on cardiovascular diseases in PLWHA. We tried to look at the relationship between HIV/AIDS and any cardiovascular diseases without restriction. We extensively searched both grey and peer-reviewed literature from 6 different sources. Additionally, there were no restrictions on study design or on the time frame for article inclusion. However, our study also has limitations that should be considered while interpreting the results. Most of the included primary studies were cross-sectional and institution-based studies. Therefore, the prevalence reported in those studies might not represent the community’s prevalence. Additionally, the review was restricted to English-language studies, which may have excluded relevant studies in other languages, although we do not expect Ethiopian studies to be published in languages other than English. We recommend that future studies utilise a community-based approach and employ diverse study designs, including longitudinal and interventional designs that support causal inference.
Conclusion
This scoping review highlights a growing body of evidence on cardiovascular diseases among people living with HIV/AIDS in Ethiopia, with a predominant focus on hypertension. The findings reveal a wide range of hypertension prevalence and identify several common risk factors, including age, sex, lifestyle behaviours, metabolic indicators, and antiretroviral therapy-related variables. However, the evidence remains limited in scope, with most studies being institution-based, cross-sectional, and concentrated in a few regions of the country. Other significant cardiovascular conditions, such as atherosclerotic disease, cardiomyopathies, and stroke, have received minimal research attention.
The findings underscore the need for more comprehensive, community-based, and longitudinal studies to better understand the true burden and determinants of cardiovascular diseases among PLWHA in Ethiopia. There is also a clear call for integrating cardiovascular disease screening and preventive strategies into routine HIV care to mitigate the growing double burden of infectious and non-communicable diseases. Strengthening surveillance, diagnostic capacity, and awareness among healthcare providers will be critical for early detection and management of cardiovascular diseases in this vulnerable population.
Acknowledgments
We thank the School of Public Health, Liverpool John Moores University, for providing the opportunity to conduct this study as a partial fulfilment of the requirements for the Master of Public Health (General MPH) for the primary author (DE).
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