Cardiometabolic Disease in Aging HIV-Positive Populations in Sub-Saharan Africa: A Scoping Review of Long-Term Antiretroviral Therapy Effects

1.1 Background Sub-Saharan Africa (SSA) hosts approximately two-thirds of the global population of people living with HIV (PLHIV). The scale-up of antiretroviral therapy (ART) has transformed HIV into a chronic condition, yet prolonged survival has unveiled an escalating burden of cardiometabolic diseases (CMDs). This scoping review examines the prevalence, determinants, and mechanisms of CMD in aging, ART-experienced PLHIV in SSA, framed through a syndemic lens that integrates biological and social determinants. 1.2 Objective To map the evidence on CMD prevalence and incidence; characterize associations between ART duration, drug class, and cardiometabolic risk; identify vulnerable subgroups; synthesize pathophysiological mechanisms; and evaluate implementation strategies for integrated HIV-CMD care in SSA. 1.3 Methods We conducted a scoping review following the Joanna Briggs Institute methodology and PRISMA-ScR reporting guidelines. A comprehensive search of Scopus (2012–2026) was performed using PECO-structured search strings. Two independent screening, data charting, and quality appraisal using the Newcastle-Ottawa Scale (NOS) were undertaken. Narrative synthesis was organized by outcome, ART exposure, effect modifiers, and mechanisms, anchored by structured evidence tables. 1.4 Results Of 73 records screened, 31 met eligibility criteria for full review. Of these, 18 were original primary studies from sub-Saharan Africa examining cardiometabolic outcomes; the remainder were systematic reviews or non-regional studies. Most studies were cross-sectional clinic-based surveys (n = 18 original SSA primary studies) with moderate-to-high risk of bias. Reported CMD prevalence varied widely across studies: metabolic syndrome (range 20.6–38.8%), hypertension (range 15.2–58.0%), dyslipidemia (range 29.1–69.4%), diabetes/prediabetes (range 5.1–17.0%), and obesity (range 8.3–32.2%). Longer ART duration, and in two Zambian studies, integrase inhibitor-based regimens (particularly dolutegravir) were associated with increased MetS risk in some studies, though causal inference is limited by cross-sectional designs and potential confounding. Older age, female sex, elevated BMI, and traditional risk factors emerged as consistent predictors. Immune activation, adipose tissue dysfunction, gut permeability, and endothelial injury are implicated based primarily on evidence from high-income country cohorts; SSA-specific mechanistic data are scarce. CMD risk was present even in ART-naïve populations, suggesting HIV infection itself contributes to cardiometabolic dysregulation independent of treatment effects. Effect modification by sex, urbanicity, and HIV disease severity was evident but inconsistently reported. 1.5 Conclusion As SSA confronts a syndemic of HIV and non-communicable diseases, integrated HIV-CMD care models, routine metabolic screening with drug class-specific monitoring, and context-appropriate lifestyle interventions are urgently needed. Future research must prioritize longitudinal African cohorts, mechanistic studies of integrase inhibitor-associated metabolic dysfunction, and implementation science evaluating scalable integrated service delivery.