Risk Factors for Stroke in HIV-Positive and-Negative Patients in Pretoria, South Africa

Stroke, HIV and the Immune Reconstitution Inflammatory Syndrome in the absence of opportunistic infections

INTRODUCTION

Stroke in people living with HIV (PLWH) has been described to occur soon after the initiation of antiretroviral therapy (ART) possibly related to the Immune Reconstitution Inflammatory Syndrome (IRIS). We sought to investigate whether there was a temporal association between stroke and recent ART initiation in the absence of opportunistic infections (OIs), and to identify risk factors for this.

METHODS

This cross-sectional study recruited PLWH with new-onset stroke at a hospital in Johannesburg, South Africa, from 2014 to 2017, excluding all patients with OIs. Patients were assessed for ART duration, CD4 count, HIV viral load, inflammatory markers and cardiovascular risk factors.

RESULTS

77 PLWH were recruited, of which 35 were on ART at the time of stroke. Of the patients with confirmed ART duration (n = 28), 9 (32.1%) had a stroke within the first 6 months of starting ART (crude incidence rate of 0.73 cases per patient year). In the period beyond 6 months, 19 strokes occurred (crude incidence rate of 0.21 cases per patient year), translating to a 3.5 times greater risk in the first 6 months (p = 0.0002). There were no clearly identified risk factors when comparing those who had strokes in the first 6 months to those after 6 months and ART-naïve patients.

CONCLUSION

Almost a third of strokes in PLWH may be related to IRIS, with a crude incidence rate 3.5 times higher in the first 6 months following ART-initiation compared to beyond 6 months. This appears to be independent of OIs. Risk factors are unclear.

Stroke as the index presentation of traditional cardiovascular risk factors and Human Immunodeficiency Virus in a South African population

OBJECTIVES

We sought to identify what proportion of each cardiovascular risk factor and Human Immunodeficiency Virus (HIV) was first diagnosed at the time of stroke, compared to those that were diagnosed prior to the event, and to explore if this had any impact on the severity of stroke.

METHODS

Adult patients presenting with a new stroke to a quaternary hospital in Johannesburg between 2014 and 2017 were prospectively recruited. Patients were investigated for undiagnosed traditional cardiovascular risk factors (hypertension, diabetes mellitus, dyslipidaemia, atrial fibrillation, obesity and smoking), as well as HIV infection. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS).

RESULTS

346 patients were included. Stroke was the index presentation for at least one risk factor in 199 (57.5 %) patients. Dyslipidaemia was newly diagnosed in 76.0 % of all dyslipidaemics (95 out of 125). Newly-diagnosed dyslipidaemia was associated with a more severe neurological deficit (Median NIHSS of 12 (8-16) vs 7 (4-12), p=0.0007) and younger age on presentation (53 (44-63) years vs 62 (51-71) years, p=0.02) as compared to previously-diagnosed dyslipidaemia.

CONCLUSIONS

More than half of patients had previously undiagnosed modifiable risk factors at the time of their stroke. Dyslipidaemia was undiagnosed in a very high proportion, and this was associated with a higher stroke severity and younger age of presentation.

HIV Infection and 90-Day Stroke Outcomes in Uganda: A Prospective Observational Cohort Study

Background and Objectives

Little is known about the impact of HIV infection on the clinical presentation and outcomes after stroke in the modern antiretroviral therapy (ART) era. We aimed to compare stroke characteristics and outcomes between persons with HIV (PWH) and without HIV (PWOH) presenting with stroke in Uganda.

Methods

We conducted a matched cohort study at Mulago National Referral Hospital and Mbarara Regional Referral Hospital between January 2018 and November 2020. We enrolled consecutive PWH presenting with CT-confirmed acute or subacute stroke (symptom onset ≤14 days) and matched them by sex and stroke type to 2 consecutive available PWOH admitted to the same hospital. We obtained baseline clinical data and followed participants for 90 days from the day of clinical presentation. We compared stroke severity (defined by the NIH stroke scale [NIHSS]) and 90-day all-cause mortality and morbidity (using the modified Rankin Scale [mRS]) by HIV serostatus with and without adjustment for confounders.

Results

We enrolled 105 PWH and 157 PWOH with stroke. PWH were younger (mean [SD] age 49 [14] vs 59 [16] years, p < 0.001), and nearly 80% (82/105) were on ART for a median of 5 years and a median CD4 count of 214 cells/uL (interquartile range 140, 337). Compared with PWOH, PWH presented with a 3-point lower median NIHSS (16 vs 19, p = 0.011), a 20% lower proportion of all-cause mortality at 90 days (p = 0.001), and had less disability at 90 days (median mRS 4 vs 5, p = 0.004). Age and NIHSS-adjusted odds ratio of 90-day all-cause mortality in PWH compared with PWOH was 0.45 (95% CI 0.22-0.96, p = 0.037).

Discussion

In the modern ART era, PWH with acute stroke in Uganda present with modest stroke and are significantly less likely to die within 90 days than PWOH. This potentially reflects the protective effects of ART, enhanced health care access, and their younger age at stroke presentation.

Prevalence and Characteristics of HIV-Associated Stroke in a Tertiary Hospital Setting in South Africa

BACKGROUND AND OBJECTIVES

Antiretroviral treatment (ART) era HIV-associated stroke data from sub-Saharan Africa are limited. We determined the prevalence of HIV in patients presenting with acute symptomatic stroke and compared risk factors, clinical characteristics, and brain imaging with age-matched stroke patients without HIV.

METHODS

We conducted a retrospective study of adults presenting with any type of stroke to Tygerberg Hospital in a 12-month period. Patients living with HIV (PLWH) and HIV-uninfected (HIV-) patients were matched based on age group (1:2 ratio). Patients were identified by keyword search, while HIV status was ascertained from laboratory data. Clinical and imaging data were extracted from medical records.

RESULTS

Among 884 patients presenting with acute strokes, the minimum prevalence of HIV infection was 9.3% (95% CI: 7.4%-11.2%), with 496 patients (56.1%) with negative HIV status and 306 patients with unknown HIV status (34.6%). The mean age at presentation in PLWH was 46 (±11) years compared with 55 (±14) years in HIV- patients (p < 0.001). Smoking was less prevalent in PLWH with an adjusted relative risk ratio of RR = 0.58 (95% CI: 0.39-0.86). Concurrent infection was more prevalent in PLWH (25.6% vs 4.9%, p ≤ 0.001) with an adjusted relative risk ratio of RR = 2.07 (95% CI: 1.49-2.84), largely in patients with a CD4 count <200 cells/μL. PLWH with higher CD4 counts (≥200 cells/μL, 51.3%) had more traditional risk factors and less concurrent infection. Among PLWH, 68.3% were on ART, and 39.3% of them had been started or restarted on ART within the past 6 months. Basal ganglia infarcts (35.6% vs 18.3%, p = 0.014) and multiple vascular territory involvement (25.4% vs 7.7%, p = 0.002) were more common in PLWH. Clinical presentation, ischemic stroke type, and in-hospital outcomes did not differ between the groups.

DISCUSSION

Stroke patients with HIV were younger, had less traditional cardiovascular risk factors, and more concurrent infections than patients without HIV, especially those with a lower CD4 count. Recent ART initiation or reinitiation rates were high. Significant differences in CT brain imaging findings were seen. Understanding the multifactorial mechanisms underlying increased stroke risk, including associated infections and potential ART-associated immune reconstitution, is crucial and needs further study.

Trends and Clinical Characteristics of HIV and Cerebrovascular Disease in Low- and Middle-Income Countries (LMICs) Between 1990 and 2021

PURPOSE OF THE REVIEW

To describe trends and clinical characteristics of HIV and cerebrovascular disease between 1990 and 2021 in LMICs and identify the gaps in our understanding.

RECENT FINDINGS

In the era of antiretroviral therapy (ART), people living with HIV (PLWH) live longer and risk excess cerebrovascular events due to ageing and HIV-driven factors. Despite the highest burden of HIV infection in low-to-middle income countries, there is underreporting in the literature of cerebrovascular events in this population. We systematically reviewed published literature for primary clinical studies in adult PLWH and cerebrovascular disease in LMICs. The clinical phenotype of cerebrovascular disease among PLWH over the last three decades in LMICs has evolved and transitioned to an older group with overlapping cerebrovascular risk factors. There is an important need to increase research in this population and standardise reporting to facilitate understanding, guide development of appropriate interventions, and evaluate their impact.