| Summary: | Abstract Background Despite significant efforts to enhance access to antiretroviral therapy (ART), opportunistic infections among children on ART remain a major concern in low-income countries, including Ethiopia. Currently, there are no pooled estimates of opportunistic infections incidence among children on ART in Ethiopia. Consequently, this review aimed to determine the pooled incidence and identify the predictors of opportunistic infections among children under 15 years of age on ART, addressing the existing information gap. Methods This systematic review followed the PRISMA guidelines, and relevant studies were obtained from the PubMed, CINAHL, Scopus, EMBASE, and Google Scholar databases. Data analysis for pooled estimates of incidence and predictors of opportunistic infections was conducted via STATA 17 software with random-effects model. Heterogeneity was evaluated via Cochrane's Q-test and the I2 statistic, and publication bias was assessed through funnel plots and Egger's test. Results Of the 5,631 studies identified, 20 studies involving 9,196 participants were included in the meta-analysis. The pooled incidence of opportunistic infections among children under 15 years of age on antiretroviral therapy was 5.61 per 100 person-years (95% CI: 4.37–6.86), based on 36,716.4 person-years of observation. Predictors of opportunistic infections included advanced WHO clinical stage (HR 1.45, 95% CI: 1.35–1.55), poor ART adherence (HR 1.49, 95% CI: 1.35–1.63), lack of isoniazid (HR 1.56, 95% CI: 1.40–1.74) and cotrimoxazole preventive therapy (HR 1.56, 95% CI: 1.38–1.66), malnutrition (HR 1.50, 95% CI: 1.34–1.67), and severe immunosuppression (HR 1.39, 95% CI: 1.27–1.51). Conclusion The incidence of opportunistic infections in this review was high, highlighting the need for intensified efforts to achieve the 2030 target. Moreover, advanced WHO clinical stage, poor adherence, lack of isoniazid and cotrimoxazole preventive therapy, malnutrition, and severe immunosuppression were identified as predictors of opportunistic infections. This suggests that early initiation of ART, regular nutritional assessments, intensive follow-up and monitoring, and a multidisciplinary approach need be prioritized to address the identified predictors.
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