Background and Objectives:Antiretroviral treatment (ART) era HIV-associated stroke data from Sub-Saharan Africa is limited. We determined the prevalence of HIV in patients presenting with acute symptomatic stroke, and compared risk factors, clinical characteristics, and brain imaging with age-matched stroke patients without HIV.Methods:We conducted a retrospective study of adults presenting with any type of stroke to Tygerberg Hospital in a 12-month period. Patients living with HIV (PLWH) and HIV-uninfected patients (HIV-) were matched on age group (1:2 ratio). Patients were identified by keyword search, while HIV status was ascertained from laboratory data. Clinical and imaging data were extracted from medical records.Results:Among 884 patients presenting with acute strokes, the minimum prevalence of HIV infection was 9.3% (95% CI: 7.4-11.2%), with 496 patients (56.1%) with negative HIV status and 306 patients with unknown HIV status (34.6%). Mean age at presentation in PLWH was 46 (± 11) years compared to 55 (± 14) years in HIV- (p<0.001). Smoking was less prevalent in PLWH with an adjusted relative risk of RR=0.58 (95% CI: 0.39–0.86). Concurrent infection was more prevalent in PLWH (25.6% vs 4.9%, p=<0.001) with an adjusted relative risk ratio of 2.07 (95% CI: 1.49–2.84), largely in patients with CD4 count <200 cells/mcL. PLWH with higher CD4 counts (≥200 cells/mcL, 51.3%) had more traditional risk factors and less concurrent infection. Among PLWH, 68.3% were on ART, and 39.3% of these had been started or restarted on ART within the past 6-months. Basal ganglia infarcts (35.6% vs 18.3%, p=0.014) and multiple vascular territory involvement (25.4% vs 7.7%, p=0.002) was more common in PLWH. Clinical presentation, ischaemic stroke type, and in-hospital outcomes did not differ between groups.Conclusion:Stroke patients with HIV were younger, had less traditional cardiovascular risk factors, and more concurrent infections than patients without HIV, especially those with a lower CD4 count. Recent ART initiation or reinitiation rates were high. Significant differences in CT brain imaging findings were seen. Understanding the multifactorial mechanisms underlying increased stroke risk, including associated infections and potential ART-associated immune reconstitution, is crucial and needs further study.

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