Cardiometabolic risk following dolutegravir-based antiretroviral therapy in Sub-Saharan Africa: a systematic review and meta-analysis of diabetes mellitus and hypertension

Background Dolutegravir (DTG)-based antiretroviral therapy (ART) is the preferred regimen across Sub-Saharan Africa (SSA), but concerns have emerged about its cardiometabolic effects. We evaluated the burden of diabetes mellitus (DM) and hypertension (HTN) among adults receiving DTG-based ART in SSA and the comparative risk of incident HTN versus non-DTG regimens. Methods Following PRISMA 2020, we searched eight bibliographic databases, Google Scholar and grey literature from 1 January 2018 to 30 May 2026. DerSimonian–Laird random-effects models pooled prevalence and comparative estimates; risk ratios (RRs) and hazard ratios (HRs) were combined as a pragmatic approximation. Sensitivity analyses explored diagnostic thresholds and study characteristics, and certainty of evidence was assessed with GRADE. Results Twenty-nine studies were included. The pooled prevalence of DM/hyperglycaemia (including prediabetes; five studies, N = 1,841) was 23.9% (95% CI 10.7–40.2%; I 2 = 98.3%), with reported estimates ranging from 7.7% (diabetes by strict American Diabetes Association criteria) to 55.9% (random blood sugar-based hyperglycaemia); excluding the random blood sugar-based study gave 17.1% (95% CI 11.4–23.7%), suggesting that diagnostic-threshold heterogeneity contributes substantially to this variation. HTN prevalence (three studies; N = 1,289) was 19.7% (95% CI 13.1–27.2%). In four studies with poolable published estimates, DTG was associated with a higher risk of incident HTN than non-DTG regimens (pooled RR/HR 1.23, 95% CI 1.13–1.34; I 2 = 0.0%), including after exclusion of the largest study (1.34, 95% CI 1.13–1.59). A large multi-country cohort (AFRICOS; approximately 3,250 participants) that reported no positive association could not be pooled because its adjusted estimate was available only in conference material. Incident DM (0.29–9.8 per 100 person-years) was synthesised narratively. Conclusion The burden of hyperglycaemia/DM and HTN among adults receiving DTG-based ART in SSA is substantial, although DM/hyperglycaemia estimates vary widely with diagnostic definitions, and single-arm estimates do not show that DTG caused this disease. The pooled RR/HR of 1.23 reflects only the published, quantitatively poolable studies and may overestimate the true association, because the AFRICOS cohort could not be included. Certainty of evidence ranged from very low to moderate. These findings support risk-based cardiometabolic monitoring within HIV care and standardised diagnostic definitions in future studies. Clinical trial number Not applicable.