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Hypertension Among HIV-infected Patients in Clinical Care, 1996-2013
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Nwora Lance Okeke,1,2 Thibaut Davy,1,3 Joseph J. Eron,1,3 and Sonia Napravnik1,3
In conclusion, our data suggest that though risk determinants for hypertension in uninfected persons also predict risk in persons living with HIV, a history of severe HIV related immunosuppression and ongoing viremia may be independently associated with hypertension as well. Though the differential risk of immune vs conventional risk factors is still not well defined, it is clear that further consideration must be given to the long-term deleterious impact of immunosuppression, immune recovery and persistent immune activation on vascular physiology. Our data also indicate a continued increase in the incidence rate of hypertension in HIV-infected persons, a concerning trend in light the novel recognition of people living with HIV as a high-CVD risk group. Finally, our study suggests no clear association between protease inhibitors, duration of exposure to ART, and the risk of incident hypertension. Taken together, our findings present more evidence in support of early ART for all persons with HIV and further emphasizes the importance of high quality CVD primary preventive care in this high-risk population.
Abstract
Background. Persons infected with human immunodeficiency virus (HIV) are at higher risk for major cardiovascular disease (CVD) events than uninfected persons. Understanding the epidemiology of major traditional CVD risk determinants, particularly hypertension, in this population is needed.
Methods. The study population included HIV-infected patients participating in the UNC CFAR HIV Clinical Cohort from 1996 to 2013. Annual incidence rates of hypertension were calculated. Multivariable Poisson models were fit to identify factors associated with incident hypertension.
Results. 3141 patients contributed 21 956 person-years (PY) of follow-up. Overall, 57% patients were black, 28% were women, and the median age was 35 years. Hypertension age-standardized incidence rates increased from 1.68 cases per 100 PYs in 1996 to 5.35 cases per 100 PYs in 2013 (P < .001). In adjusted analyses, hypertension rates were higher among obese patients (incidence rate ratio [IRR] 1.70, 95% confidence interval [CI], 1.43-2.02), and those with diabetes mellitus (IRR 1.44, 95% CI, 1.14-1.83) and renal insufficiency (IRR 1.36, 95% CI, 1.16-1.61), but lower among patients with a CD4 nadir of ≥500 cells/mm3 (IRR 0.73, 95% CI, .53-1.01).
Conclusions. The incidence of hypertension increased from 1996 to 2013, alongside increases in traditional hypertension risk determinants. Notably, HIV-related immunosuppression and ongoing viral replication may contribute to an increased hypertension risk. Aggressive CVD risk factor management, early HIV diagnosis, linkage to care, antiretroviral therapy initiation, and durable viral suppression, will be important components of a comprehensive primary CVD prevention strategy in HIV-infected persons.
"Immunosenscence is a well-established consequence of chronic immune activation known to occur at a much higher level in persons with low CD4 nadirs compared to higher CD4 nadirs [14, 25, 26]."
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