Cytomegalovirus Retinitis: Prevalence and Risk Factors Among People Living with HIV in Sub-Saharan Africa in the Antiretroviral Therapy Era- A Systematic Review and Meta-Analysis

Background: Cytomegalovirus retinitis (CMVR) has remained an alarming and potentially vision-threatening opportunistic disease in the population living with HIV (PLHIV), especially in cases of extreme immunosuppression. Although the introduction of antiretroviral therapy (ART) has led to a drastic decline in the number of CMVR cases reported in most parts of the world, the current epidemiology of CMVR in sub-Saharan Africa (SSA) has seemed unusual in early reports, unexpectedly portraying low disease prevalence rates despite the high number of HIV cases in the concerned region. Methods: This systematic review and meta-analysis of observational studies published between 2000 and 2025 was undertaken to evaluate CMVR in HIV-infected patients in SSA. The search of databases included Medline using the search engine PubMed, Google Scholar, and the African Journals Online database named AJOL. For inclusion, studies must have included an eye examination to verify the presence of CMVR. The data was combined using the logit transformation model. Heterogeneity was tested using the I-squared test and the Cochran Q test. Results: A total of ten studies involving 1,931 participants from nine SSA countries were found eligible. The proportion of CMVR varied from 0.34% to 15.8%. Pooled Prevalence was found to be 3% (95% CI: 1.6–5.4%) with low to moderate inter-study variation (I² = 17.8%). Substantial variation in the proportion was found in different SSA regions; it was found to be less than 1% in West Africa, 3-4% in Southern Africa, 7% in East and 6% Central Africa. Across all studies, the strongest and most consistent risk factors for CMVR was profound immunosuppression, particularly CD4 <50 cells/ µL . ART-naïve status, poor adherence and presence of advanced AIDS- defining illnesses were additional contextual risk marker. Conclusion: CMVR is an under-recognized but important source of preventable blindness in SSA. Prevalence in SSA differed from that in Asian early-ART cohorts but is relevant in settings where late HIV presentation occurs. Systematic retinal screening in PLHIV with low CD4 counts < 50 cells/µL and expanded HIV care and treatment services are important to prevent blindness due to CMVR.