BACKGROUND: Kidney disease is a growing non-AIDS-related comorbidity among people living with HIV (PLWH). Tenofovir disoproxil fumarate (TDF) can result in proximal tubulopathy and acute tubular injury, whereas atazanavir/ritonavir (ATV/r) can cause interstitial nephritis and renal stones, both of which can lead to chronic kidney disease. OBJECTIVES: To examine the relationship between second-line combination antiretroviral therapy (ART) and the risk of kidney disease and morphological changes among PLWH in Dar es Salaam, Tanzania. METHOD: A cross-sectional study of adult PLWH receiving TDF-based second-line ART. Socio-demographic and clinical data were gathered, and laboratory tests were conducted to determine the estimated glomerular filtration rate (eGFR). Ultrasonography was performed to visualise the kidneys. RESULTS: A total of 323 patients were enrolled (67.8% women), with a median age of 44 (interquartile range [IQR]: 39-51) years. Patients were on second-line ART for a median of 49 [IQR: 25-73] months, and 60% received ATV/r. Low eGFR (<
90 mL/min per 1.73 m CONCLUSION: Adults on second-line ART containing TDF were found to have a high prevalence of renal kidney disease in the Tanzanian context. Predictors of kidney disease were older age, proteinuria, and ATV/r-based regimen as compared to LPV/r.