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Abstract

Objectives

To estimate the prevalence and patterns of cardiac abnormalities among adults with HIV attending antiretroviral therapy clinics in Ethiopia and to identify clinical predictors of dilated cardiomyopathy (DCM).

Methods

A multicenter cross-sectional study enrolled 312 adults with HIV from three tertiary hospitals in Addis Ababa. All participants underwent transthoracic echocardiography and standardized clinical assessment; multivariable logistic regression identified independent predictors of DCM.

Results

Echocardiographic abnormalities were detected in 42.1% of participants, including diastolic dysfunction (8.9%), left ventricular hypertrophy (8.9%), systolic dysfunction (6.1%), DCM (5.4%), coronary artery disease (3.9%), pericardial effusion (2.5%), and pulmonary hypertension (1.4%). DCM was independently associated with CD4 < 200 cells/mm³, antiretroviral therapy–naïve status, and BMI <18.5 kg/m².

Conclusions

Ethiopian adults with HIV had a high burden of largely asymptomatic cardiac disease. Integrating targeted echocardiographic screening into routine HIV care, prioritizing patients with advanced immunosuppression, lack of ART, or malnutrition, may improve early detection and management.

Plain Language Summary

Hidden Heart Problems in Adults Living with HIV in Addis Ababa

People living with HIV are now surviving longer, so heart disease is becoming a growing problem, especially in countries like Ethiopia. In this study, adults with HIV who were attending three large treatment clinics in Addis Ababa had heart ultrasound scans and basic health checks. Almost half had some form of heart abnormality, even though many did not have symptoms. The most serious problem was a weak and enlarged heart (dilated cardiomyopathy), which was more common in people with very low CD4 counts, those who had not yet started HIV treatment, and those who were underweight. These findings show that many heart problems in people with HIV are hidden and would be missed without active screening. Adding simple heart ultrasound screening for high-risk patients in HIV clinics could help doctors detect problems earlier and start treatment sooner, potentially preventing serious complications.

Keywords

HIV/AIDS cardiac disorders echocardiography antiretroviral therapy Ethiopia

Introduction

Human immunodeficiency virus (HIV) infection remains a major public health challenge in sub-Saharan Africa, where Ethiopia ranks among countries with substantial disease burden.^1,2 The introduction of antiretroviral therapy (ART) has dramatically improved survival and transformed HIV into a chronic manageable condition, yet this therapeutic success has unveiled new challenges related to long-term complications, particularly cardiovascular diseases.^3,4 Cardiovascular manifestations have emerged as significant contributors to morbidity and mortality among people living with HIV, with infected individuals facing approximately two-fold increased risk of major adverse cardiovascular events compared to HIV-negative populations.^4,5

The spectrum of cardiac disorders in HIV-infected individuals is diverse, encompassing structural abnormalities such as dilated cardiomyopathy, left ventricular hypertrophy, and pericardial effusion, as well as functional impairments including diastolic and systolic dysfunction.^6,7 These cardiac complications arise through multiple pathogenic mechanisms including direct viral myocardial injury, chronic systemic inflammation, immune activation, opportunistic infections (particularly tuberculosis in Africa), nutritional deficiencies, and metabolic effects of antiretroviral medications.^3,8

Diastolic dysfunction represents one of the earliest and most common cardiac manifestations in HIV infection, with studies demonstrating 2.4-fold greater odds compared to uninfected controls even after adjusting for traditional cardiovascular risk factors.⁷ Dilated cardiomyopathy, defined by left ventricular dilatation with reduced ejection fraction, represents a more severe manifestation strongly associated with advanced immunosuppression, with incidence substantially higher in patients with CD4 + counts below 400 cells/mm³.⁹ Left ventricular hypertrophy occurs through compensatory mechanisms triggered by chronic anemia, volume overload, and inflammatory cytokines, affecting 20%-40% of HIV-infected populations.¹⁰ Pericardial effusion, frequently attributed to tuberculous pericarditis in African settings, affects 7%-17% of HIV-infected patients and serves as a marker of severe immunosuppression.^8–10

Nutritional status, particularly body mass index, plays a critical role in cardiac health among people living with HIV, with malnutrition and low body mass index consistently associated with increased risk of dilated cardiomyopathy independent of HIV disease stage.¹¹ in Ethiopia, data regarding the burden of cardiac diseases among HIV-infected populations remain scarce despite the country's high HIV prevalence.^1,2,9 Most cardiac manifestations in HIV remain asymptomatic and are detected only through systematic screening with echocardiography, making routine cardiovascular assessment crucial.^1,3

This study aimed to determine the prevalence and patterns of cardiac disorders among adults attending antiretroviral clinics at three major referral hospitals in Ethiopia and to identify demographic, clinical, and immunological predictors of these abnormalities.

Methods

Study Design and Setting

This cross-sectional hospital-based study was conducted at the ART clinics of Tikur Anbessa Specialized Hospital (TASH), Saint Paul Millennium Medical College Hospital, and Saint Peter Specialized Hospital in Addis Ababa, Ethiopia. The study period spanned from October 1, 2024 to August 31, 2025. Data analysis and manuscript preparation were completed in November 2025. These tertiary hospitals serve as referral centers for large populations in the region and provide ART and chronic HIV care services to thousands of people living with HIV. The three study sites are large public tertiary referral hospitals with adult ART clinic populations of approximately 1800 patients at TASH, 1200 at Saint Paul Millennium Medical College Hospital, and 1000 at Saint Peter Specialized Hospital. While all three facilities are located in Addis Ababa and predominantly serve urban residents, they also receive referrals from surrounding rural regions, particularly for advanced or complicated HIV cases.

Study Population

The source population included all adult (≥18 years) HIV-infected patients attending ART follow-up clinics at the three hospitals during the study period. The study population comprised patients who met the inclusion criteria and consented to participate. Inclusion criteria were HIV infection confirmed by serological testing, attendance at the ART clinic during the study period, and willingness to provide informed consent. Patients with known cardiovascular diseases, hypertension, diabetes mellitus, renal failure, active tuberculosis, or on cardiotoxic drugs were excluded to reduce confounding. Clinically unstable patients were also excluded. These exclusions enhanced internal validity by minimizing confounding but likely underestimate the true cardiac disease burden in the general HIV population where comorbidities are prevalent.

Sample Size and Sampling

The sample size was calculated using a single population proportion formula, assuming a 50% prevalence of cardiac diseases among HIV-infected patients (due to lack of prior local data), 5% margin of error, and 95% confidence interval, yielding an initial sample size of 384. Applying a finite population correction due to the known clinic population (∼4000 patients) adjusted the final sample size to 350. Due to recruitment constraints, data were collected from 312 participants, ensuring at least 80% power. Convenience sampling was employed; all eligible patients who attended the clinics and consented during the study period were enrolled consecutively until the sample size was met. Participant enrollment from each site was broadly proportional to clinic size, with 112 participants recruited from Tikur Anbessa (35.9%), 106 from Saint Paul's (34.0%), and 94 from Saint Peter's (30.1%), minimizing the risk of over-representation from any single facility. No systematic differences in eligibility criteria or recruitment procedures existed across sites. Although facility-level variation was not the primary focus of analysis, the proportional sampling strategy and similar tertiary-care roles of the hospitals reduce the likelihood that site-specific factors materially influenced the observed associations.

Data were collected from 312 participants (89% of planned sample size of 350), which provided adequate statistical power to detect clinically meaningful associations with alpha = 0.05 and power >80%.

Data Collection

Data collection involved structured patient interviews, review of medical records, clinical examinations, and echocardiographic assessments. A pretested structured questionnaire was used to collect sociodemographic information (age, sex, marital status, occupation, and residence), cardiac symptoms (dyspnea, palpitations, chest pain, and edema), and selected clinical information obtained directly from participants. Additional HIV-related clinical data, including duration since diagnosis, antiretroviral therapy status, WHO clinical stage, and CD4 + cell count, were extracted from medical records using a standardized data extraction format. Anthropometric measurements, including weight and height, were obtained at the time of assessment to calculate body mass index (BMI).

Echocardiographic Assessment

Echocardiography was performed using portable M-Turbo Sonosite machines operated by trained cardiographers. Participants were positioned in the left lateral decubitus position. Standard transthoracic echocardiographic views (parasternal long and short axis, apical views) were obtained following American Society of Echocardiography guidelines, with minor modifications for local setting. Measurements included left ventricular (LV) dimensions, wall thickness, ejection fraction (using biplane disk summation), and Doppler evaluation of diastolic function with mitral inflow patterns, pulmonary venous inflow, and tissue Doppler imaging. Pericardial effusion was assessed by fluid thickness >5 mm in the pericardial space. Pulmonary hypertension was suggested by tricuspid regurgitant jet velocity >2.5 m/s. All echocardiograms were interpreted by cardiologists blinded to patient clinical data for consistency. Coronary Artery Disease (CAD) was diagnosed based on regional wall-motion abnormalities observed on transthoracic echocardiography; pulmonary hypertension by tricuspid regurgitant jet velocity ≥2.5 m/s. These echocardiography-based criteria have known limitations without confirmatory angiography or right heart catheterization.

Data Management

Completed questionnaires and clinical data extraction forms were checked daily for completeness and consistency. Data were coded, entered, cleaned, and stored securely before analysis. Data quality was maintained through routine review, correction of incomplete entries, and verification of extracted clinical information against source documents where applicable.

Statistical Analysis

Data were entered, cleaned, coded, and analyzed using SPSS version 29 (IBM Corp, Armonk, New York, NY, USA). Continuous variables were summarized using means and standard deviations, whereas categorical variables were summarized using frequencies and percentages. Bivariate analyses were performed using the chi-square test or Fisher exact test, as appropriate. Variables with P values <.25 in bivariate analysis were considered for inclusion in the multivariable logistic regression model to identify independent predictors of dilated cardiomyopathy. Adjusted odds ratios with 95% confidence intervals were reported. A two-sided P value <.05 was considered statistically significant. Model fit was assessed using the Hosmer-Lemeshow goodness-of-fit test, and explanatory power was evaluated using Nagelkerke R².

Quality Control

To ensure data quality, the questionnaire was pretested on 10 patients in a similar setting to validate content and clarity. Data collectors—including one medical resident, one trained echocardiographer, and one nurse—underwent training regarding the study objectives and data collection procedures. Daily supervision was provided by the principal investigator to monitor completeness and accuracy of data. Echocardiography devices were calibrated and standardized protocols strictly followed.

Ethical Considerations

This multicenter cross-sectional study was approved by the Institutional Review Boards of Tikur Anbessa Specialized Hospital (TASH IRB, Approval Reference No. AAU/IMIF036/2024), Saint Paul Millennium Medical College Hospital (Approval Reference No. SPMMCH-CIF03/25), and Saint Peter Specialized Hospital (Approval Reference No. AAHBR123/24). The study was conducted in accordance with the World Medical Association Declaration of Helsinki. Written informed consent was obtained from all 312 participants prior to enrollment. Consent covered voluntary study participation, structured clinical interviews, physical examinations, transthoracic echocardiography, data collection/analysis, and publication of de-identified aggregate results.

Participants’ confidentiality was protected by immediate de-identification of data using unique study IDs, secure encrypted storage with principal investigator access only, and exclusion of personal identifiers from the analysis dataset. Abnormal echocardiographic findings were promptly communicated to attending clinicians for appropriate patient management. Participation was entirely voluntary; refusal or withdrawal did not affect access to routine HIV care services.

The reporting of this multicenter cross-sectional study conforms to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement for cross-sectional studies,¹² and the completed checklist is provided as Supplementary File 1.

Results

Sociodemographic and Clinical Characteristics

A total of 312 adult HIV-infected patients attending ART clinics at TASH, Saint Paul Millennium Medical College Hospital, and Saint Peter Specialized Hospital were enrolled between October 2024 and August 2025. Of these participants, 206 (66.0%) were female and 106 (34.0%) were male. The mean age was 33.6 ± 8.3 years, with the majority of participants aged between 18 and 40 years (84.3%). Most participants were married (52.1%), employed (41.8%), and resided in urban areas (83.2%) (Table 1). The mean body mass index (BMI) was 20.8 ± 3.4 kg/m². Nearly one-fifth (19.2%) of participants were underweight (BMI <18.5 kg/m²), while 70.5% had normal BMI (18.5-24.9 kg/m²), and 10.3% were overweight or obese (BMI ≥25 kg/m²).

Table 1.

Sociodemographic Characteristics of Study Participants (N = 312).

Sociodemographic Variable	Number (%)
Study Site
TASH	112 (35.9%)
Saint Paul Millennium Medical College Hospital	106 (34.0%)
Saint Peter Specialized Hospital	94 (30.1%)
Sex
Male	106 (34.0%)
Female	206 (66.0%)
Age Group (years)
18-30	138 (44.2%)
31-40	125 (40.1%)
41-50	38 (12.2%)
51-60	11 (3.5%)
Marital Status
Married	162 (52.1%)
Single	49 (15.7%)
Divorced	62 (20.0%)
Widowed	39 (12.2%)
Occupation
Farmer	4 (1.4%)
Merchant	28 (8.9%)
Housewife	65 (20.7%)
Employee	130 (41.8%)
Other	85 (26.8%)
Annual Income (Birr/year)
<3000	94 (30.0%)
3000-6000	131 (42.0%)
>6000	87 (28.0%)
Literacy Status
Illiterate	64 (20.4%)
Semi-literate	165 (52.9%)
Literate	83 (26.8%)
Residence
Urban	259 (83.2%)
Rural	53 (16.8%)

HIV Disease Status and ART History

The mean duration since HIV diagnosis was 3.3 ± 2.5 years. The majority of participants (42.5%) had been diagnosed more than 3 years prior to enrollment, while 12.9% had been diagnosed within the past 6 months. A total of 192 participants (61.5%) were receiving ART at the time of the study, while 120 (38.5%) were ART-naïve. Among those on ART, 64.7% were female. The mean CD4 + cell count for all participants was 385.6 ± 237.4 cells/mm³. More than half of the participants (52.9%) had CD4 + counts between 200 and 499 cells/mm³, while 22.5% had counts below 200 cells/mm³, and 24.6% had counts above 500 cells/mm³. WHO clinical staging revealed that 43.2% were in stage I, 33.2% in stage II, 18.6% in stage III, and 5.0% in stage IV (Table 2 and Figure 1).

Figure 1.

Distribution of CD4+ cell count categories among study participants.

Table 2.

HIV Disease Status and Clinical Characteristics of Study Participants (N = 312).

HIV/AIDS Status	Number (%)
Duration Since HIV Diagnosis
<6 months	40 (12.9%)
6 months to 2 years	108 (34.6%)
2-3 years	31 (10.0%)
>3 years	133 (42.5%)
ART Status
ART-naïve	120 (38.5%)
Female (among ART-naïve)	82 (68.2%)
On ART	192 (61.5%)
Female (among on ART)	124 (64.6%)
Total Female	206 (66.0%)
CD4+ Count Category (cells/mm³)
<200	70 (22.5%)
200-499	165 (52.9%)
≥500	77 (24.6%)
WHO Clinical Stage
Stage I	135 (43.2%)
Stage II	104 (33.2%)
Stage III	58 (18.6%)
Stage IV	15 (5.0%)
Cardiac Symptoms*
Shortness of breath	118 (37.9%)
Palpitation	66 (21.1%)
Body/leg swelling	41 (13.2%)
Chest pain	72 (23.2%)
No symptoms	127 (40.7%)
One symptom	107 (34.3%)
Two or more symptoms	78 (24.9%)

*Percentages do not add up to 100% as some participants reported more than one symptom.

Cardiac Symptoms

Nearly half of the participants (49.7%, n = 155) reported at least one cardiac symptom. The most commonly reported symptom was shortness of breath (37.9%, n = 106), followed by chest pain (23.2%, n = 65), palpitations (21.1%, n = 59), and body or leg swelling (13.2%, n = 37). However, 40.7% (n = 127) of participants reported no cardiac symptoms. Among symptomatic patients, 34.3% (n = 96) reported one symptom, while 24.9% (n = 70) reported two or more symptoms.

Echocardiographic Findings

Echocardiographic abnormalities were detected in 131 participants (42.1% of the total). The mean left ventricular ejection fraction (LVEF) was 63.0 ± 9.7%, with 83.2% of participants having normal LVEF values (≥55%). The most common echocardiographic abnormalities were diastolic dysfunction and left ventricular hypertrophy (LVH), each identified in 25 participants (8.9%). Systolic dysfunction (defined as LVEF <55%) was present in 17 participants (6.1%). Dilated cardiomyopathy (DCM) was diagnosed in 15 participants (5.4%), coronary artery disease (CAD) in 11 participants (3.9%), pericardial effusion in seven participants (2.5%), and pulmonary hypertension in four participants (1.4%). Other incidental findings included chronic rheumatic heart disease (2.5%, n = 7), hypertrophic cardiomyopathy (2.1%, n = 6), and ventricular septal defect (0.4%, n = 1) (Figure 2).

Figure 2.

Distribution of echocardiographic abnormalities among study participants.

The mean measurements of cardiac structural parameters were as follows: interventricular septum (IVS) thickness, 10.5 ± 2.1 mm; left ventricular posterior wall (LVPW) thickness, 9.9 ± 1.8 mm; and left atrial diameter, 32.4 ± 4.6 mm.

Predictors of Dilated Cardiomyopathy

Multivariable logistic regression analysis identified several independent predictors of DCM. Participants with CD4 + counts below 200 cells/mm³ had significantly higher odds of DCM compared to those with CD4 + counts ≥200 cells/mm³ (adjusted odds ratio [AOR] = 6.65, 95% CI: 2.02-21.85, P < .002). ART-naïve participants had higher odds of DCM compared to those on ART (AOR = 3.34, 95% CI: 1.02-11.01, P = .047). Participants with low BMI (<18.5 kg/m²) had increased odds of DCM compared to those with normal or high BMI (AOR = 3.23, 95% CI: 1.00-10.46, P = .050) (Table 3).

Table 3.

Multivariable Logistic Regression Analysis of Predictors of Dilated Cardiomyopathy (N = 312).

Variable	Adjusted Odds Ratio (AOR)	95% Confidence Interval	P-Value
Body Mass Index (BMI), kg/m²
Underweight (<18.5)	3.23	1.00-10.46	.050
Normal (18.5-24.9)	1.00 (reference)	–	–
Overweight/Obese (≥25.0)	0.72	0.15-3.41	0.67
CD4 + count (cells/mm³)
<200	6.65	2.02-21.85	.002
200–499	1.48	0.39-5.63	.56
≥500	1.00 (reference)	–	–
ART status
ART-naïve	3.34	1.02-11.01	.047
On ART	1.00 (reference)	–	–
Annual income (Birr/year)
<3000	1.00 (reference)	–	–
3000-6000	0.38	0.11-1.36	.138
>6000	0.44	0.12-1.61	.22

Note: BMI categories follow WHO definitions; overweight and obese categories were combined due to small cell counts. CD4 + count categories reflect clinically relevant immunologic strata. Odds ratios for nonsignificant strata are shown for completeness. Annual income categories are reported in Ethiopian Birr (ETB) and reflect self-reported income at the time of data collection (October 2024-August 2025). Based on average official exchange rates during the study period, these categories correspond approximately to <USD 55, USD 55-110, and >USD 110 per year. Bold values indicate statistically significant associations at p < .05 in the multivariable logistic regression model.

Model diagnostics confirmed adequate fit and explanatory power. The Hosmer-Lemeshow goodness-of-fit test yielded P = .45, indicating no significant departure from linearity in the logit (good fit). Nagelkerke R² was 28.4%, suggesting the model explained approximately 28% of the variance in DCM outcomes (Table 4).

Table 4.

Bivariate Associations with Dilated Cardiomyopathy (DCM).

Variable	Test Statistic	P Value
CD4 count <200 cells/mm³	χ² = 18.42	<.001
ART-naïve status	χ² = 7.65	.006
BMI <18.5 kg/m²	χ² = 5.21	.022
Age (>40 years)	Fisher's exact	.312
Female sex	χ² = 1.04	.307
Urban residence	χ² = 0.89	.346

Note: Variables shown had P ≤ .25 in bivariate screening for multivariable inclusion. χ² = Chi-square test; Fisher's exact test used for expected cell counts <5. All analyses performed in SPSS v29.

No significant associations were identified between other echocardiographic abnormalities (pericardial effusion, pulmonary hypertension, CAD, LVH, or diastolic dysfunction) and demographic or clinical variables in bivariate or multivariable analyses.

Discussion

This cross-sectional study demonstrates a high prevalence (42.1%) of echocardiographic abnormalities among HIV-infected adults attending antiretroviral clinics in major Ethiopian hospitals, with diastolic dysfunction and left ventricular hypertrophy being the most common findings. These results align with prior studies from sub-Saharan Africa reporting cardiac abnormality prevalence ranging from 42% to -63% among HIV-infected populations.^6,13 The observed prevalence is notably higher than that reported in developed countries where widespread early ART initiation and comprehensive HIV care have reduced cardiac complications to approximately 20%-30%.¹⁴ This disparity likely reflects delayed HIV diagnosis, late ART initiation, higher rates of opportunistic infections, and nutritional challenges characteristic of resource-limited settings.¹⁵

Diastolic dysfunction, identified in 8.9% of our participants, represents an early marker of HIV-associated cardiac involvement. The pathophysiology involves chronic inflammation, elevated cytokine levels, myocardial fibrosis, and direct viral effects on cardiomyocytes.^7,16 Importantly, diastolic dysfunction often precedes systolic impairment and predicts future development of heart failure and increased all-cause mortality.^7,14 The relatively lower prevalence in our study compared to some studies may reflect younger patient age (mean 33.6 years) and shorter duration of HIV infection, as diastolic dysfunction accumulates with prolonged disease exposure.¹⁴ Differences may also stem from varying diagnostic thresholds across studies or echocardiography modalities, such as use of tissue Doppler imaging, which was employed here per American Society of Echocardiography guidelines.^7,8,16

Left ventricular hypertrophy, also present in 8.9% of participants, appears paradoxical given the wasting syndrome commonly associated with HIV infection but is explained by compensatory mechanisms including volume overload from anemia and chronic inflammatory cytokine release.¹⁰ HIV infection independently increases left ventricular mass by approximately 5-8 g/m², even after adjusting for blood pressure and metabolic factors.¹⁰ Systolic dysfunction (6.1%) and dilated cardiomyopathy (5.4%) were less prevalent than diastolic abnormalities, consistent with the natural history of HIV-associated cardiac disease where diastolic impairment typically precedes systolic failure.⁶ The observed prevalence of dilated cardiomyopathy aligns with ART-era estimates of 3%-8% but remains substantially lower than pre-ART era rates exceeding 15%.^9,17 This reduction reflects the cardioprotective effects of ART through viral suppression, immune reconstitution, and reduction of chronic inflammation.^17,18

The strong association between CD4 + count below 200 cells/mm³ and dilated cardiomyopathy (AOR = 6.65) corroborates extensive literature linking advanced immunosuppression to cardiac complications.⁹ Studies have consistently demonstrated that dilated cardiomyopathy occurs predominantly when CD4 + counts fall below 400 cells/mm³, with risk escalating as immune function deteriorates.⁹ Multivariable analysis confirmed that ART-naïve status independently predicted dilated cardiomyopathy (AOR = 3.34), reinforcing evidence that timely ART initiation reduces cardiac risk.¹⁸

Low body mass index (BMI <18.5 kg/m²) emerged as an independent predictor of dilated cardiomyopathy (AOR = 3.23), consistent with findings where BMI was identified as a risk factor for HIV-associated cardiomyopathy.¹¹ Malnutrition affects cardiac function through multiple pathways including micronutrient deficiencies, reduced myocardial protein synthesis, mitochondrial dysfunction, and cardiac cachexia.¹¹ Pericardial effusion, detected in 2.5% of participants, predominantly reflects tuberculous pericarditis in African contexts where tuberculosis remains the leading cause of HIV-associated pericardial disease.¹⁹ The association between pericardial effusion and CD4 + counts below 200 cells/mm³ aligns with its characterization as a late-stage HIV manifestation.^1,19

Pulmonary hypertension prevalence (1.4%) falls at the lower end of reported ranges for African HIV populations (5%-14%), potentially reflecting our use of stringent echocardiographic criteria.²⁰ Coronary artery disease, identified in 3.9% of participants, reflects the accelerated atherosclerosis observed in HIV infection through mechanisms including chronic inflammation, endothelial dysfunction, and metabolic effects of certain antiretroviral regimens.^21,22 While relatively uncommon in our young participants (mean age 33.6 years), coronary artery disease prevalence increases substantially with age and ART duration.²¹

The predominantly asymptomatic nature of cardiac abnormalities in our study, with 40.7% reporting no cardiac symptoms despite 42.1% having echocardiographic abnormalities, highlights a critical diagnostic challenge and emphasizes the necessity of systematic cardiovascular screening in HIV care.^1,23 Studies have similarly documented high rates of asymptomatic cardiac disease detectable only through routine echocardiography.^20,23 Early detection enables timely intervention including heart failure medications, ART optimization, and cardiovascular risk factor modification, potentially preventing progression to symptomatic heart failure and reducing mortality.²⁴

Our findings have important implications for HIV care in resource-limited settings. First, integration of cardiovascular screening, including baseline and periodic echocardiography, into routine HIV care is warranted, particularly for patients with CD4 + counts below 200 cells/mm³, those who are ART-naïve, and individuals with low BMI.^1,23 Second, universal early ART initiation regardless of CD4 + count should be prioritized as a primary cardiovascular prevention strategy.¹⁸ Third, nutritional assessment and support must be incorporated into comprehensive HIV management to address malnutrition as a modifiable risk factor for dilated cardiomyopathy.²⁵ Fourth, heightened vigilance for tuberculosis screening and treatment is essential given its role in pericardial disease.¹⁹ Finally, cardiovascular risk factor management including hypertension control, lipid management, and lifestyle modification should be integrated into HIV care platforms.^26–29

Strengths of the Study

This study has several strengths. It was conducted across three tertiary hospitals, which improved site-level diversity relative to a single-center study. All participants underwent echocardiographic assessment using a standardized protocol, allowing objective identification of cardiac abnormalities, including subclinical disease. The study also provides clinically relevant data from Ethiopia, where evidence on cardiac manifestations among adults living with HIV remains limited.

Limitations

This study has several limitations that should be considered when interpreting the findings.

Study Design Limitations

The cross-sectional nature prevents establishing causality or temporal relationships between risk factors and cardiac abnormalities, raising risks of reverse causation such as low BMI resulting from dilated cardiomyopathy rather than causing it and precluding assessment of disease progression, which requires longitudinal follow-up. Convenience sampling from three urban tertiary hospitals may introduce selection bias by overrepresenting more engaged clinic attendees, potentially inflating prevalence estimates compared to less adherent or rural HIV populations.

Measurement Limitations

Echocardiography alone was used without confirmatory tests like right heart catheterization for pulmonary hypertension or coronary angiography for coronary artery disease, risking over- or under-diagnosis; CAD was specifically identified via wall-motion abnormalities. Interobserver reliability was not systematically captured, nutritional assessment relied solely on BMI without micronutrient levels (eg, selenium, carnitine, vitamin B12), and critical HIV variables; viral load suppression, specific ART regimens (eg, protease inhibitors vs non-PI), and ART duration were not uniformly collected, limiting causal insights and regimen-specific risk analysis.

Generalizability Limitations

The use of convenience sampling from three urban tertiary hospitals may limit the representativeness of the findings, as it likely over-represents engaged clinic attendees and under-represents less adherent patients or those from rural primary care settings. Excluding patients with hypertension, diabetes, known cardiac disease, and tuberculosis enhanced internal validity but underestimated real-world cardiac burden in comorbid HIV populations; the young age (mean age 33.6 years) with shorter HIV duration may further underrepresent long-term complications. Future longitudinal multicenter studies including these groups, comprehensive virological/ART data, tissue Doppler details for diastolic dysfunction differences, and statistical enhancements (eg, Hosmer-Lemeshow tests) across diverse Ethiopian settings are needed.

Conclusion

This multicenter study reveals that over two-fifths of Ethiopian adults with HIV harbor cardiac abnormalities detectable by echocardiography, yet most remain asymptomatic. Dilated cardiomyopathy, the most severe cardiac complication identified, disproportionately affects individuals with advanced immunosuppression (CD4 + count <200 cells/mm³), those not yet initiated on antiretroviral therapy, and patients with malnutrition. These findings have urgent implications for both clinical practice and public health policy in Ethiopia.

We recommend three immediate actions. First, the Ethiopian Federal Ministry of Health should integrate baseline and periodic echocardiographic screening into national HIV care guidelines, prioritizing high-risk patients with CD4 + counts below 200 cells/mm³, ART-naïve status, or malnutrition. Second, national HIV programs must accelerate universal test-and-treat strategies to ensure immediate ART initiation regardless of CD4 + count, as early treatment provides substantial cardiovascular protection. Third, HIV care packages should incorporate routine nutritional assessment and targeted nutritional support as a modifiable intervention to reduce cardiac disease risk.

Implementation of these evidence-based recommendations within Ethiopia's existing HIV infrastructure could prevent substantial cardiovascular morbidity, reduce hospitalizations, and improve long-term survival outcomes for the estimated 1.2 million Ethiopians living with HIV. The time to act is now. Future longitudinal studies should include patients with comorbidities (hypertension, diabetes, known cardiac disease, tuberculosis) to provide real-world prevalence estimates of cardiac abnormalities among broader HIV populations, enhancing generalizability beyond our study.

Supplemental Material

sj-doc-1-jia-10.1177_23259582261444796 - Supplemental material for High Burden of Cardiac Abnormalities in Adults with HIV in Ethiopia: A Multicenter Cross-Sectional Study

Supplemental material, sj-doc-1-jia-10.1177_23259582261444796 for High Burden of Cardiac Abnormalities in Adults with HIV in Ethiopia: A Multicenter Cross-Sectional Study by Biniyam Fiseha Abera, Mikiyas G. Teferi, Biruk T. Mengistie, Chernet T. Mengistie, Rebecca Haile Tesfay, Caleb M. Hailemariam, Temesgen H. Gebremeskel and Gadisa Megersa in Journal of the International Association of Providers of AIDS Care (JIAPAC)

Supplemental Material

sj-docx-2-jia-10.1177_23259582261444796 - Supplemental material for High Burden of Cardiac Abnormalities in Adults with HIV in Ethiopia: A Multicenter Cross-Sectional Study

Supplemental material, sj-docx-2-jia-10.1177_23259582261444796 for High Burden of Cardiac Abnormalities in Adults with HIV in Ethiopia: A Multicenter Cross-Sectional Study by Biniyam Fiseha Abera, Mikiyas G. Teferi, Biruk T. Mengistie, Chernet T. Mengistie, Rebecca Haile Tesfay, Caleb M. Hailemariam, Temesgen H. Gebremeskel and Gadisa Megersa in Journal of the International Association of Providers of AIDS Care (JIAPAC)

Footnotes

Acknowledgment

This work has not been submitted for publication in any other journal, and all the references are acknowledged.

Abbreviations

ORCID iDs

Biniyam Fiseha Abera

Chernet T. Mengistie

Mikiyas G. Teferi

Caleb M. Hailemariam

Temesgen H. Gebremeskel

Ethics Approval and Consent to Participate

Ethical approval was obtained from the Institutional Review Boards of Tikur Anbessa Specialized Hospital (Approval No. AAU/IMIF036/2024), Saint Paul Millennium Medical College Hospital (Approval No. SPMMCH-CIF03/25), and Saint Peter Specialized Hospital (Approval No. AAHBR123/24). Written informed consent was obtained from all participants prior to enrollment.

Consent for Publication

Not Applicable.

Author Contributions

Biniyam Fiseha Abera: conceptualization, methodology, investigation, project administration, data curation, formal analysis, writing—original draft, and writing—review and editing. Mikiyas G. Teferi: conceptualization, methodology, investigation, project administration, data curation, formal analysis, writing—original draft, and writing—review and editing. Biruk T. Mengistie: investigation, data curation, validation, and writing—review and editing. Chernet T. Mengistie: investigation, data curation, validation, and writing—review and editing. Rebecca Haile Tesfay: investigation, data curation, validation, and writing—review and editing. Caleb M. Hailemariam: investigation, data curation, validation, and writing—review and editing. Temesgen H. Gebremeskel: investigation, data curation, validation, and writing—review and editing. Gadisa Megersa: supervision, methodology, validation, and writing—review and editing.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Availability of Data and Material

The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Supplemental Material

Supplemental material for this article is available online.

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