Prevalence and correlates of elevated predicted atherosclerotic cardiovascular disease risk among people living with HIV in Zambia

People living with HIV (PLWH) are at increased risk of atherosclerotic cardiovascular disease (ASCVD) because of traditional cardiometabolic risk factors, chronic inflammation, and antiretroviral therapy-related metabolic effects. However, data from sub-Saharan Africa remain limited. We assessed the prevalence and correlates of elevated predicted ASCVD risk among PLWH receiving antiretroviral therapy in Zambia. We conducted a cross-sectional study among 130 adults living with HIV receiving antiretroviral therapy at Livingstone University Teaching Hospital between October 2023 and June 2024. Predicted 10-year ASCVD risk was estimated using the ACC/AHA pooled cohort equations and categorized as elevated (≥ 10%) or low (< 10%). Sociodemographic, clinical, metabolic, inflammatory, renal, and echocardiographic variables were compared between groups. Logistic regression was used to identify factors associated with elevated predicted ASCVD risk. The prevalence of elevated predicted ASCVD risk was (15/130) (11.5%, 95% CI: 6.6–18.5%). In multivariable analyses, age, hypertension, and sex showed expected associations with ASCVD risk but were not considered novel associations given their inclusion in standard risk algorithms. Among non-traditional factors, waist circumference was associated with increased ASCVD risk (AOR = 1.05, 95% CI: 1.00–1.10, p = 0.038). Additionally, Interventricular septal thickness showed a suggestive association with ASCVD risk in the primary analysis (AOR = 9.41, 95% CI: 1.15–76.9), but this finding was inconsistent in sensitivity analysis and should be considered exploratory. In contrast, metabolic (triglycerides, HOMA-IR), inflammatory (hs-CRP, IL-5), renal (eGFR), and HIV-related (duration on ART) variables were not independently associated with ASCVD after adjustment. Model diagnostics highlighted adequate fit and no evidence of multicollinearity across all models. Among adults living with HIV on antiretroviral therapy, a proportion were identified with elevated 10-year ASCVD risk. Central adiposity was the strongest associated factor, while IVSD showed cautious association. Traditional risk factors (older age, hypertensive status and female sex behaved as expected, while inflammatory biomarkers were not associated with ASCVD risk. These findings support routine cardiovascular risk screening and targeted management of modifiable cardiometabolic factors in HIV care, with further studies needed to validate risk prediction in African populations.