Introduction
Dyslipidemia is an imbalance of blood lipids associated with elevated concentrations of low-density lipoprotein cholesterol (LDL-c), total cholesterol (TC), triglycerides (TG), and low concentrations of high-density lipoprotein cholesterol (HDL-c) [
1‐
3]. It is responsible for more than half of global ischemic heart disease (IHD) and more than 4 million deaths annually [
4]. Mechanisms for the development of dyslipidemia are still unclear and are proposed to be multifactorial in HIV patients [
5]. Even after controlling for conventional cardiovascular disease (CVD) risk factors, human immunodeficiency virus (HIV)-infected people still have a higher risk of developing CVD, including acute myocardial infarction (MI). The majority of HIV-positive patients' fatalities result from cardiovascular problems, liver disease, and renal failure, all of which have links to the virus, the host, and antiretroviral therapy (ART) variables [
6].
Cardiovascular diseases (CVDs) are two times more likely to occur in people with dyslipidemia than in people with normal lipid levels [
7]. Africa is witnessing significant shifts in population health, characterised by an increasing prevalence of CVDs, which are expected to surpass infectious diseases as the primary cause of death by 2030 [
8]. The overall pooled prevalence of dyslipidemia in Africa's general population was 52.8% [
9]. The prevalence of dyslipidemia among HIV-infected patients in Africa, on the other hand, ranged from 13 to 70% [
10]. The prevalence of Dyslipidemia in the African population was 25.5% for high total cholesterol concentrations, 37.4% for low HDL cholesterol concentrations, 28.6% for elevated LDL cholesterol concentrations, and 17.0% for elevated triglyceride concentrations. Dyslipidemia is exacerbated by those living with HIV and other chronic conditions [
11].
ART that is started on time has been shown to significantly slow down the HIV virus from multiplying and destroying CD4 cells and then lengthen life in HIV-infected individuals [
12‐
14]. Despite the fact that HIV patients on ART have an increased life expectancy, degenerative diseases induced by HIV, ART, or inflammation are also taken into account [
15‐
19]. These diseases include Dyslipidemia, atherosclerosis, and insulin resistance. Moreover, increased exposure to ART might be associated with increased CVD diseases [
20,
21].
HIV patients should undergo lipid profile testing when initiating treatment or making changes to ART. Following that, if their previous lipid test results were normal, they should have their lipid profiles done annually, or every six months if they were abnormal [
22]. Determining the prevalence of dyslipidemia can be critical for predicting future disease development. In Ethiopia, even though there were few studies conducted to determine the prevalence of dyslipidemia among HIV-infected patients, the pooled prevalence is not yet known [
23]. Moreover, the studies were conducted in single-study settings with a small sample size. Therefore, providing the pooled prevalence of dyslipidemia among HIV-infected patients might be more informative and crucial for concerned bodies to make decisions on the management and monitoring of disease progress to prevent further cardiovascular complications.
Discussion
Dyslipidemia has emerged as a major risk factor for cardiovascular disease in African countries [
39]. It is associated with ART, HIV, or both and is known to increase the risk of cardiovascular disease [
40,
41]. This review study was the first to characterise the pooled prevalence of dyslipidemia among HIV-infected patients because no previous study has looked at the countrywide pooled prevalence of dyslipidemia among people with HIV. According to our findings, the pooled prevalence of dyslipidemia among HIV-infected individuals across the country in Ethiopia was 67.32% (95% CI = 61.68%–72.96%), which is comparable to a study in Brazil that found a prevalence of 66.7% [
42] and 73.3% in Nigeria [
43]. Not unexpectedly, we found that among HIV patients, dyslipidemia was highly prevalent. Due to changes in blood lipid levels, HIV and ART have been linked to an increased risk of CVD [
40,
41]. Therefore, ongoing dyslipidemia monitoring would be beneficial for HIV-positive individuals in order to take prompt preventive or remedial action.
The present pooled prevalence, however, is greater than previous studies in Zimbabwe (60%) [
44], the general population (ranging from 23 to 25% [
45], south-east Malawi (15.5% [
46], and Uganda (6.4%) [
47], the African pooled prevalence of 52.80% [
9], Thailand 51% [
48], India (50.7% [
49], and China (32.2%) [
50]. This increased prevalence of dyslipidemia among HIV-positive persons could be attributed to both ART and the virus itself. It can be caused by a variety of mechanisms, like viral particle competition on lipid metabolism receptors, such as cellular retinoic acid binding protein (CRABP-1) and LDL receptor-related protein (LRP), which reduces lipid clearance; suppression of lipoprotein lipase activity; increased liver beta-apolipoprotein levels; increased hepatic synthesis of very low-density lipoprotein (VLDL); increased cytokine levels (TNF and IL) [
51,
52]. On the other hand, the current pooled prevalence is lower than in previous studies in Kenya (79.6%) [
53] and South Africa (90.0%) [
54]. Differences in the study population, sample size, methodology, level of urbanisation, cut-off values, lifestyle, and socioeconomic status may account for this discrepancy.
Antiretroviral therapy, on the other hand, is linked to an increase in the incidence of lipoatrophy, dyslipidemia, and irregularities of fat distribution in HIV patients. Studies found that HIV-infected patients receiving ART had a considerably greater incidence of dyslipidemia than the naive group and that this incidence rose sharply with cumulative ART exposure [
55]. We found that more than two-thirds of ART-taking HIV-infected patients had experienced dyslipidemia. According to the evidence from the current review study, the prevalence of dyslipidemia was slightly higher among ART-taking HIV-infected patients. Similar to the current finding, a study in China found that the pooled prevalence of dyslipidemia among ART-taking patients was slightly higher than that among those without ART [
56]. Additionally, a number of studies conducted in African nations found that individuals subjected to ART had a higher prevalence of dyslipidemia, ranging from 36.90 to 85% [
57‐
60]. Another study in Malaysia found that 82.30% of 1,583 antiretroviral medication-taking HIV-infected patients had experienced dyslipidemia [
61]. Furthermore, comprehensive evidence revealed that HIV-infected individuals receiving ART had greater levels of dyslipidemia than those who were not receiving treatment. The issue is complex and has been linked to both HIV infection itself and the use of antiretroviral medications [
62‐
66]. The ART itself increases biosynthesis and reduces hepatic clearance of serum cholesterol, thereby leading to dyslipidemia [
41,
42].
The pooled prevalence of elevated total cholesterol in the current review was 39.08%, comparable to studies in Iran at 41.6% [
67], Poland at 37% [
68], Ethiopian studies at 34.08% [
69], Turkish studies at 37.50% [
70], and Lebanon at 36.90% [
71], but higher than China at 33% [
72], Tanzania at 30.4% [
73], and Korean studies at 6.00% [
74]. However, studies in Saudi Arabia (54% [
75]) and South Africa (67.30% [
76]) found a greater prevalence of total cholesterol elevation. Furthermore, the pooled prevalence of increased LDL cholesterol concentrations in this review study was 28.40%, which is comparable to earlier studies in Iran at 35.5% [
67], Lebanon at 32.1% [
71], Poland at 31% [
68], Switzerland at 20.80% [
77], and China at 24.80% [
72]. On the other hand, the present result of 28.40% elevated LDL-c is lower than other studies in Ethiopia (41.13% [
69]) and Turkey (44.5%) [
70]. Environmental factors associated with persistent HIV infection include nutrition, genetics, ART-induced dyslipidemia, and adipose tissue dysfunction. All of these factors are likely to contribute to metabolic illness [
78,
79].
Regarding the low concentrations of HDL cholesterol, we found 39.42%, which is comparable to Lebanon's 32.10% [
71]. In contrast, this is higher than south-east Malawi's 15.90% [
46], Poland's 20.50% [
68], Turkey's (21.10%) [
70], Switzerland's 2.80% [
77], China's 24.80% [
72], Cameroon's 19.5% [
80], and Botswana's (6.3%) [
81]. Likewise, studies in Iraq (40.90% [
82], Turkey (44.50%) [
70], Uganda (85.60%) [
47], Tanzania (43.60%) [
83], Brazil (53.50%) [
42], and Nepal (56.70% [
84]) reported higher prevalence than our study. This disparity may be explained by the fact that the current study is a meta-analysis of nine studies, whereas the majority of the earlier studies were original studies conducted in single-study settings. Furthermore, the prevalence of aberrant TC/HDL ratios (> 5) ranged from 30.20% [
35] to 43.40% [
31], consistent with Eritrea's 33.20% [
85] but higher than Southeast Malawi's 3.80% [
46]. Because low HDL cholesterol is a component of HIV-induced dyslipidemia, the metabolism of HDL cholesterol in these people is also hindered. Although the exact causes of HIV infection and HAART-induced HDL cholesterol lowering are unknown, hypoalphalipoproteinemia is a common observation in HIV patients [
86].
For the pooled prevalence of elevated triglycerides, we found 38.73%, which is similar to other Ethiopian studies of 39.70% [
87], Ethiopian meta-analysis 48.15% [
69], Eastern India 37.70% [
88], and Iraq 41.60% [
82]. However, higher than African studies (17.0% [
73], Korean 32.10% [
74], south-east Malawi 28.70% [
46], Cameroon 7.8% [
80], Uganda 29.60% [
47], Switzerland 12.50% [
77], while lower than studies in Poland 52% [
68], India 93.80% [
89], and Nepal 48.30% [
84]. The wide variety of dyslipidemia seen in numerous studies, including the current review, may be explained by differences in study population, genetic factors, physical activity, dietary habits, consumption of alcohol, smoking, overweight or obesity, ART duration, and ART regimens among the studies. Notably, due to the complex and multidirectional relationships among diet, genetic factors, ART, viral replication, chronic inflammation, and lipid metabolism, careful monitoring and treatment of lipid levels are likely more informative in individuals with HIV infection than in those without the infection [
90].
With respect to the patterns of dyslipidemia prevalence over time, the pooled estimations of dyslipidemia in studies conducted between 2012 and 2017 were 71.69%, while in studies conducted between 2018 and 2023, they were found to be 65.93%. Assefa et al. [
23] in 2023 found the lowest prevalence of dyslipidemia (55.20%), whereas Tedewos et al. [
31] in 2012 reported the highest prevalence (79.60%) of the condition. Nonetheless, when we look at the general trends in the prevalence of dyslipidemia among HIV-infected patients, we can observe that there was some fluctuation over the year (Fig.
4). The extensive search of the literature across all relevant databases, the careful screening of relevant studies, and the comprehensive evaluation of quality to eliminate quality bias are among the strong points of this review. However, due to inconsistencies in the data from the included studies, associated risk factors were not assessed.
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