Mercury (Hg) pollution remains an environmental global concern due to its non-degradable and toxic nature. Natural and anthropogenic sources of Hg adversely affect the functioning of aquatic ecosystems and biological processes. In sub-Saharan Africa (SSA), unregulated artisanal and small-scale gold mining (ASGM) contributes up to 20% of global gold production and uses 205–496 tonnes/yr of Hg. Despite being a vital economic driver for 20–30 million people, ASGM threatens the health of aquatic systems from Hg pollution, presenting a complex challenge that demands urgent interventions. This review seeks to (1) establish the current status of aquatic Hg pollution, (2) explore the environmental impacts of aquatic Hg, and (3) highlight the proposed interventions for aquatic Hg pollution in SSA. We examined publications and institutional reports between 2000 and 2023 addressing aquatic Hg pollution, impacts, and interventions in the ASGM of SSA. Results indicate a rise in aquatic Hg pollution due to the expansion and intensification of ASGM. West Africa remained the highest contributor (50.2%), followed by Central Africa (39.6%), Southern Africa (9.6%), and Eastern Africa (<1%). Contamination of freshwater ecosystems, toxicity to aquatic biota, and environmental health risks to humans were evident. Alternative Hg-free ASGM technologies, including physical, metallurgical, and pyrometallurgical, were investigated from case studies and recommended for adoption.