Prevalence of left ventricular systolic dysfunction in HIV-infected children from sub-saharan Africa: a systematic review and meta-analysis

BACKGROUND: Left ventricular systolic dysfunction (LVSD) is an emerging non-communicable complication among children living with Human Immunodeficiency Virus (HIV), particularly in Sub-Saharan Africa, where paediatric HIV burden remains high. However, reported prevalence varies widely across studies and treatment eras, reflecting differences in antiretroviral therapy (ART) exposure, disease severity, and diagnostic criteria. AIM: To estimate the prevalence of LVSD among children living with HIV in Sub-Saharan Africa and evaluate study-level factors associated with variability. METHODS: A systematic review was conducted according to PRISMA 2020 guidelines. Databases including PubMed, MEDLINE, Scopus, AJOL, and ScienceDirect were searched. Studies reporting echocardiographically defined LVSD (EF < 55% or FS < 28%) in individuals aged 0-19 years were included. Random-effects meta-analysis was performed using RevMan 5.4. Subgroup analyses were conducted by ART era, ART coverage, echocardiographic method, ART duration, and study quality. Sub-group and meta-regression analyses were performed using R (metafor package). Publication bias was assessed using Egger's test. RESULTS: Twenty studies (n = 3,994) were included. The pooled prevalence of LVSD was 6.0% (95% CI: 3.0-12.0%) with high heterogeneity (I² = 95%). Prevalence was substantially higher in pre-ART/early ART studies (27.8%) compared with ART-era studies (3.6%). Studies with ≥ 80% ART coverage reported lower prevalence (2.6%) compared with < 80% coverage (12.8%). There was, however, persistent high heterogeneity in subgroup analyses. Meta-regression showed that increasing ART coverage was associated with lower LVSD prevalence (OR 0.75 per 10% increase; p = 0.01). Echocardiographic method significantly influenced estimates, with FS-based studies reporting higher prevalence than EF-based studies. Egger's test showed no evidence of publication bias (p = 0.86). CONCLUSION: LVSD remains present in a persistent proportion of children living with HIV in Sub-Saharan Africa, although prevalence varies substantially across settings and treatment eras. Higher ART coverage and sustained treatment are associated with lower prevalence. Findings should be interpreted cautiously due to high heterogeneity. Longitudinal studies using standardised definitions are needed.