Stroke burden in HIV-infected individuals in Sub-Saharan Africa: an updated systematic review

Abstract

Abstract Background Stroke is an emerging public health challenge in sub-Saharan Africa (SSA), where HIV prevalence is the highest globally. Advances in antiretroviral therapy (ART) have transformed HIV into a chronic condition, but its impact on stroke burden in this region remains poorly understood. Objectives This systematic review aimed to synthesize current evidence on the burden of stroke among HIV-infected adults in SSA, focusing on prevalence, risk factors, stroke subtypes, neuroimaging characteristics, and clinical outcomes in the ART era. Methods We conducted a systematic literature search of PubMed, Scopus, Web of Science, Google Scholar, and AJOL for studies published between 2000 and 2023. Observational and interventional studies reporting stroke incidence, prevalence, risk factors, outcomes, or management among HIV-infected adults in SSA were included. Two independent reviewers screened studies, extracted data, and assessed methodological quality using the Newcastle-Ottawa Scale. A narrative synthesis was conducted to summarize findings. Results Twenty-one studies from nine SSA countries, including 5,693 stroke patients, met the inclusion criteria. Among general stroke cohorts in which HIV status was systematically assessed, HIV prevalence ranged from 4.8% to 34%, with higher prevalence in younger adults. Ischemic stroke predominated, associated with HIV-specific risk factors such as low CD4 counts, vasculopathy, coagulopathy, and early ART initiation, alongside a lower prevalence of traditional risk factors. Neuroimaging frequently revealed basal ganglia and small vessel involvement. Outcomes varied, with higher short-term mortality in some cohorts but potential for functional recovery. Most of the evidence originated in Southern Africa, highlighting regional disparities. Conclusion HIV significantly modifies stroke risk in SSA, contributing to premature ischemic events through distinct mechanisms in the ART era. Integrated HIV and stroke care, along with expanded, regionally diverse research, are critical to address this evolving public health challenge.