Detectable coronary artery score among people living with HIV with regional, study and population variations: a systematic review and meta-analysis

Background: People living with HIV (PLWH) have a higher risk of coronary artery disease, partly due to chronic inflammation and antiretroviral therapy-related effects. Coronary artery calcium (CAC) scoring is a non-invasive marker of subclinical atherosclerosis and cardiovascular risk. Previous reviews reported high CAC prevalence in PLWH but lacked data on severity and regional or population-specific differences. Methods: Systematic review and meta-analysis of records published before April 15, 2025, reporting the pooled percentage of PLWH with detectable CAC (CAC > 0), mild CAC (CAC 1-99), moderate CAC (CAC 100-400) and severe CAC (CAC >400). Subgroup analyses explored variation by region, study design, and population characteristics. Results: Fifty-three records were included; 31 contributed to the meta-analysis. The pooled prevalence of detectable CAC was 43.6% (95% CI: 39.1-48.1), with high heterogeneity (I 2 = 91%). Percentage of detectable CAC among PLWH was highest in North America (46.6%) and lowest in Africa (14.1%) and among general adult PLWH (55.8%) and less among those on ART (34.5%). The percentage of PLWH with detectable CAC was higher among cross sectional studies (44.2%) and prospective cohorts (43.3%) in comparison to clinical trials (35.5%). Regarding severity of CAC among PLWH, 27.6% had mild CAC, 10.8% moderate, and 5.1% severe CAC. No significant publication bias was detected. Conclusions: Nearly half of PLWH have detectable CAC, with substantial regional and population-level differences. These findings highlight the need for targeted cardiovascular screening strategies in PLWH and support further research into the clinical utility of CAC scoring to guide preventive therapy.