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HIV-related renal dysfunction is associated with high mortality. Data on the prevalence of renal dysfunction among HIV-infected outpatients starting antiretroviral therapy (ART) in sub-Saharan Africa are limited. Recent recommendations to include the nephrotoxic drug tenofovir in first-line ART regimens make clarification of this issue urgent.We screened for renal dysfunction by measuring serum creatinine, proteinuria, and microalbuminuria in HIV-positive outpatients initiating ART in Mwanza, Tanzania. We excluded patients with pre-existing renal disease, hypertension, diabetes, or hepatitis C virus co-infection. Estimated glomerular filtration rates (eGFRs) were calculated by Cockroft–Gault and Modification of Diet in Renal Disease equations.Only 129 (36%) of 355 enrolled patients had normal eGFRs (grade 0 or 1) above 90 ml/min per 1.73 m2. Grade 2 renal dysfunction (eGFR between 60 and 89 ml/min per 1.73 m2) was present in 137 patients (38.6%), and 87 patients (25%) had grade 3 dysfunction (eGFR between 30 and 59 ml/min per 1.73 m2). Microalbuminuria and proteinuria were detected in 72 and 36% of patients, respectively. Factors predictive of renal dysfunction in multivariate analysis included female sex [odds ratio (OR) 3.0, 95% confidence interval (1.8–5.1), P < 0.0001], BMI less than 18.5 [OR 2.3 (1.3–4.1), P = 0.004], CD4+ T-cell count below 200 cells/μl [OR 2.3 (1.1–4.8), P = 0.04], and WHO clinical stage II or above [OR 1.6 (1.2–2.3), P = 0.001].Renal dysfunction was highly prevalent in this population of HIV-positive outpatients initiating first ART in Tanzania. This highlights the critical and underappreciated need to monitor renal function in HIV-positive patients in sub-Saharan Africa, particularly given the increasing use of tenofovir in first-line ART.