High Blood Pressure Increases Mortality Among HIV Seropositive Individuals

Without AIDS in Western KenyaGerald S. Bloomfield1, Joseph W. Hogan2, Alfred Keter3, Thomas L. Holland1,

James Osanya3, Edwin Sang3, Sylvester Kimaiyo3, Eric J. Velazquez1

 1Duke University, Durham, NC, USA; 2Brown University, Providence, RI, USA;

3Moi University School of Medicine, Eldoret, Kenya

AHA Scientific Sessions 2012

Abstract # 10909

Financial Disclosures

• None

Background

• HIV is associated with cardiovascular (CV) disease

• Most (>60%) HIV+ patients reside in Africa but CV risk in this population is not well-studied

• Call for integration of communicable / non-communicable disease care in low- and middle-income countries

-United Nations High Level Meeting 2011

Rationale

• Despite importance of CV disease globally and large HIV burden in Africa, no studies examining CV disease and mortality in HIV in the region

• Among Kenyan HIV+ patients without AIDS:– High blood pressure is associated with higher risk

of death– The blood pressure-mortality relationship varies

with World Health Organization HIV clinical stage

Hypotheses

Methodology

• Retrospective analysis of clinically-obtained patient medical records

• Large HIV treatment program in Kenya– Academic Model Providing Access to

Healthcare (AMPATH) – >115,000 adults enrolled from >20 clinics– Blood pressure from electronic medical

record

Study Site

Methodology

• Included data for 2005-10, ≥16 years old• Excluded those with AIDS, missing blood

pressure,CD4 count or pregnant• Categorized age, CD4, and blood pressure

– Systolic BP: <100, 100-119, 120-139, ≥140

• Calculated:– Unadjusted mortality incidence rate– Risk of death with proportional hazards

regression models

Results

• 30,231 patients • Median age 33.5 years (28-41), 75% female,

CD4 396 (287-556), 60% on HIV therapy• Incidence rate (IR) of death higher if SBP ≥140

SBPin mmHg

Person years(pyrs)

Deaths IR per 100 pyrs (95% CI)

<100 6190 207 3.3 (2.9-3.8)

100-119 39342 698 1.8 (1.6-1.9)

120-139 20323 285 1.4 (1.2-1.6)

≥140 2866 62 2.2 (1.7-2.8)

Overall 68721 1252 1.8 (1.7-1.9)

Proportional Hazard of Death

Other covariates: age, diastolic BP, creatinine, body mass index, hemoglobin, anti-retroviral therapy, residence, marital status, sex in combined analysis

Variable Women (n=16489)

Men (n=5507)

Combined (n=22356)

Systolic BP in mmHg

<100 1.2 (1.0 - 1.6) 1.3 (0.9 - 1.9) 1.3 (1.0 - 1.5)

100-119 ref ref ref

120-139 0.9 (0.7 - 1.1) 0.8 (0.6 - 1.1) 0.9 (0.7 - 1.0)

≥140 1.5 (1.0 - 2.3) 2.0 (1. 3- 3.1) 1.8 (1.3 - 2.4)

WHO HIV Stage

1 ref ref ref

2 1.5 (1.2 – 1.8) 1.4 (1.1 – 1.8) 1.4 (1.2 – 1.7)

3 2.3 (1.9 – 2.9) 2.0 (1.5 – 2.7) 2.2 (1.8 – 2.6)

CD4 <350 2.1 (1.8 – 2.6) 1.6 (1.3 – 2.1) 1.9 (1.7 – 2.3)

Mortality Rate Stratified by SBP & WHO Stage

Mortality0.24

0.12

0.0

Systolic BP --- <100 --- 100-119 --- 120-139 --- ≥140Time in Years

0.08

0.18

0.10

0.04

SBP, Stage 1 SBP, Stage 2 SBP, Stage 3

0 4 8

Conclusions

• High blood pressure is associated with high death rate in HIV+ Kenyans without AIDS

• The effect of high blood pressure on mortality is comparable to that of HIV immune status

• Greater effect of SBP on mortality with worse clinical stage of HIV

• Limitations: Observational study, clinically-obtained data

Implications

• Blood pressure control is a missed opportunity to modify health in HIV+

• There is need for expansion of HIV programs to address CV diseases (IOM report 2010)