Introduction: Several studies performed before the introduction of highly active antiretroviral therapy (HAART) have shown that HIV-1 infection is an important cause of dilated cardiomyopathy. However, factors associated with the development of HIV-associated cardiomyopathy in developing countries are still debated. Objectives: To assess the prevalence of dilated cardiomyopathy, diagnosed by echocardiography, in HIV-infected Rwandese patients not receiving HAART and the risk factors associated with its development. Methods: A sample of 416 HIV-infected african patients, without a previous definite history of cardiovascular disease, attending University hospitals in Rwanda, from January to December 2005, were included in a multicenter, observational, prospective, cohort study, with the collaboration of two European Clinical Centers (in France and in Italy). Clinical and laboratory tests along with echocardiographic examination were performed in all patients included in the study. Results: Out of 416 patients included in the study, dilated cardiomyopathy was documented by echocardiography in 71 (17.7%). By both univariate and multivariate univariate analysis, low socio-economic status, estimated duration of HIV-1 infection, CD4 count, HIV-1 viral load, CDC stage B and C of HIV disease and low plasmatic level of selenium were factors significantly associated with the development of cardiomyopathy. Alcohol consumption and smoking were factors associated with the development of cardiomyopathy only by univariate analysis. Conclusions: HIV-associated cardiomyopathy is a significant clinical problem in HIV-infected patients not receiving HAART in Rwanda. Early tracking of cardiomyopathy in african HIV-infected patients is therefore recommended. Before administering HAART, clinicians should be aware of a possible existing cardiomyopathy to ensure appropriate, comprehensive, and rational patient care.