HIV-Associated Hypertension: Risks, Mechanisms, and Knowledge Gaps

HIV type 1 (HIV-1) is the causative agent of AIDS. Since the start of the epidemic, HIV/AIDS has been responsible for ≈40 million deaths. Additionally, an estimated 39 million people are currently infected with the virus. HIV-1 primarily infects immune cells, such as CD4+ (cluster of differentiation 4+) T lymphocytes (T cells), and as a consequence, the number of CD4+ T cells progressively declines in people living with HIV. Within a span of ≈10 years, HIV-1 infection leads to the systemic failure of the immune system and progression to AIDS. Fortunately, potent antiviral therapy effectively controls HIV-1 infection and prevents AIDS-related deaths. The efficacy of the current antiviral therapy regimens has transformed the outcome of HIV/AIDS from a death sentence to a chronic disease with a prolonged lifespan of people living with HIV. However, antiviral therapy is not curative, is challenged by virus resistance, can be toxic, and, most importantly, requires lifelong adherence. Furthermore, the improved lifespan has resulted in an increased incidence of non-AIDS-related morbidities in people living with HIV including cardiovascular diseases, renal disease, liver disease, bone disease, cancer, and neurological conditions. In this review, we summarize the current state of knowledge of the cardiovascular comorbidities associated with HIV-1 infection, with a particular focus on hypertension. We also discuss the potential mechanisms known to drive HIV-1-associated hypertension and the knowledge gaps in our understanding of this comorbid condition. Finally, we suggest several directions of future research to better understand the factors, pathways, and mechanisms underlying HIV-1-associated hypertension in the post-antiviral therapy era.

Characterizing blood pressure trajectories in people living with HIV following antiretroviral therapy: A systematic review

OBJECTIVES

The advent of antiretroviral therapy (ART) has reduced AIDS-related morbidity and mortality among people living with HIV (PLWH). Due to increased survival, PLWH have now been found to be at risk of chronic conditions related to ageing, such as cardiovascular disease (CVD). Hypertension is common in PLWH and is a major risk factor for the development of CVD. We conducted a systematic literature review to evaluate the research evidence on longitudinal blood pressure (BP) trajectories following ART initiation in PLWH.

METHODS

We searched the following databases: PubMed, CINHAL, Scopus, and Web of Science (up to 15 March 2021) for peer-reviewed published studies that reported BP trajectories following ART initiation in PLWH. Three reviewers independently screened all studies by title and abstract. We included articles in English, published up to March 2021, that report office BP trajectories in PLWH initiating ART. A total of 10 publications met our inclusion criteria. Eight studies were prospective cohorts and two were retrospective.

RESULTS

Nine out of 10 studies in the literature reported an increase in systolic BP (4.7-10.0 mmHg in studies with a follow-up range of 6 months to 8 years, and 3.0-4.7 mmHg/year in time-averaged studies). In addition, four out of 10 studies reported increases in diastolic BP (2.3-8.0 mmHg for a 6 month to 6.8-year follow-up range and 2.3 mmHg/year).

CONCLUSION

Systolic BP consistently increases while diastolic BP changes are more heterogeneous following ART initiation in PLWH. However, the studies were highly variable with respect to population demographics, ART regimen and duration, and follow-up time. Nevertheless, given the risks of CVD complications, such as stroke, heart failure and myocardial infarction, associated with elevated BP, results highlight the importance of future research in this area. It will be important to better characterize BP trajectories over time, identify the most critical times for interventions to reduce BP, determine the long-term CVD consequences in PLWH with elevated BP, and understand how different ART regimens may or may not influence BP and CVD disease.

Evidence of increased blood pressure and hypertension risk among people living with HIV on antiretroviral therapy: a systematic review with meta-analysis

Owing to antiretroviral drug-induced endothelial dysfunction, HIV-infected patients on antiretroviral therapy (ART) may have elevated blood pressure. We conducted a systematic review and meta-analysis to estimate the effects of ART on blood pressure levels and hypertension risk among HIV-infected populations worldwide. We sought articles that compared the mean blood pressure measurements and hypertension prevalence between HIV-infected adults naive and exposed to ART. Thirty-nine studies comprising 44 903 participants met the inclusion criteria. Overall, systolic (mean difference (MD) 4.52 mm Hg, 95% confidence interval (CI) 2.65-6.39, I(2)=68.1%, 19 studies) and diastolic blood pressure levels (MD 3.17 mm Hg, 95% CI 1.71-4.64, I(2)=72.5%, 16 studies) were significantly higher among ART-exposed patients compared with treatment-naive patients. Similarly, the risk of hypertension was significantly higher among ART-exposed patients, such that among 28 908 ART-exposed patients, 4195 (14.5%) had hypertension compared with 950 of 9086 (10.5%) in those who were treatment-naive (odds ratio 1.68, 95% CI 1.35-2.10, I(2)=81.5%, 32 studies). In summary, exposure to ART is significantly associated with increased systolic and diastolic blood pressure levels, and increased risk of hypertension, regardless of study-level sociodemographic differences. This meta-analysis supports the need for population-based strategies to reduce the risk of high blood pressure among people living with HIV on ART.

Drug induced hypertension--An unappreciated cause of secondary hypertension

Most patients with hypertension have essential hypertension or well-known forms of secondary hypertension, such as renal disease, renal artery stenosis, or common endocrine diseases (hyperaldosteronism or pheochromocytoma). Physicians are less aware of drug induced hypertension. A variety of therapeutic agents or chemical substances may increase blood pressure. When a patient with well controlled hypertension is presented with acute blood pressure elevation, use of drug or chemical substance which increases blood pressure should be suspected. Drug-induced blood pressure increases are usually minor and short-lived, although rare hypertensive emergencies associated with use of certain drugs have been reported. Careful evaluation of prescription and non-prescription medications is crucial in the evaluation of the hypertensive individual and may obviate the need for expensive and unnecessary evaluations. Discontinuation of the offending agent will usually achieve adequate blood pressure control. When use of a chemical agent which increases blood pressure is mandatory, anti-hypertensive therapy may facilitate continued use of this agent. We summarize the therapeutic agents or chemical substances that elevate blood pressure and their mechanisms of action.

Arterial hypertension and cardiovascular risk in HIV-infected patients

The dramatic change of the natural history of HIV-infected patients by highly active antiretroviral therapy (HAART) has exposed these patients to cardiovascular risk, including cardiovascular disease and hypertension. In HIV-infected patients, the development of arterial hypertension, at least in the medium-long term is an established feature, although recognized predictors of its development have not been clearly identified. In addition, conflicting data regarding the influence of antiretroviral therapy (ART) are reported. The presence of a proinflammatory state and oxidative stress-mediated endothelial dysfunction seem, however, to play a pathophysiologic role. In this review, we examine and provide a comprehensive, literature based, consideration of the pathophysiologic aspects of hypertension in these patients. HIV-infected patients, independently of the presence of hypertension, remain at very high cardiovascular risk due to the presence of the same cardiovascular risk factors recognized for the general population with, in addition, the indirect influence of the ART, essentially via its effect on lipid metabolism. This review based on the evidence from the literature, concludes that the management of HIV-infected patients in terms of cardiovascular prevention emerges as a priority. The consideration of cardiovascular risk in these patients should receive the same emphasis given for the general population at high cardiovascular risk, including adequate blood pressure control according to international guidelines.

Diabetes and Hypertension among Patients Receiving Antiretroviral Treatment Since 1998 in Senegal: Prevalence and Associated Factors

Cardiovascular risk factors in people on antiretroviral treatment (ART) are poorly documented in resource-constrained settings. A cross-sectional study was conducted in 2009 to assess prevalence of diabetes and hypertension in a sample of 242 HIV-infected patients who had initiated ART between 1998 and 2002 in Dakar, Senegal (ANRS 1215 observational cohort). World Health Organization (WHO) criteria were applied to diagnose diabetes and hypertension. Multiple logistic regressions were used to identify factors associated with diabetes and hypertension. Patients had a median age of 46 years and had received ART for a median duration of about 9 years. 14.5% had diabetes and 28.1% had hypertension. Long duration of ART (≥119 months), older age, higher body mass index (BMI), and higher levels of total cholesterol were associated with higher risks of diabetes. Older age, higher BMI at ART initiation, and higher levels of triglycerides were associated with higher risk of hypertension. This study shows that diabetes and hypertension were frequent in these Senegalese HIV patients on ART. It confirms the association between duration of ART and diabetes and highlights the need to implement programs for prevention of cardiovascular risk factors in HIV patients from resource-constrained settings.

Exploring the psychological impact of HIV: health comparisons of older Australian HIV-positive and HIV-negative gay men

Little is known about the impact of HIV on the mental health of older gay men. In a nationwide online survey, 1,135 Australian gay men aged 40 years and older reported on their physical and mental health. Compared with HIV-negative men, those with HIV were more likely to report currently receiving treatment for a mental health condition (37 vs. 25 %, p = 0.001), but no more likely to report treatment for a major physical health condition other than HIV (39 % vs. 40 %). On a measure of psychological distress, more HIV-positive men were highly distressed (14 vs. 8 %, p = 0.01). There were no significant differences in mental health across age groups for either HIV-positive or HIV-negative men. Underlying factors for poorer mental health included lower income (p = 0.003), not working (p = 0.004), living alone (p = 0.03), treatment for a major physical health condition (p < 0.001), recent experiences of discrimination (p = 0.03), and regarding one's sexual orientation as an essential part of self-identity (p < 0.001). With disparities between older HIV-positive and HIV-negative gay men greater for mental than physical health, more attention may need to be given to the psychological well-being of those living with HIV, particularly by addressing underlying psychosocial factors.

Drug-induced hypertension: an unappreciated cause of secondary hypertension

A myriad variety of therapeutic agents or chemical substances can induce either a transient or persistent increase in blood pressure, or interfere with the blood pressure-lowering effects of antihypertensive drugs. Some agents cause either sodium retention or extracellular volume expansion, or activate directly or indirectly the sympathetic nervous system. Other substances act directly on arteriolar smooth muscle or do not have a defined mechanism of action. Some medications that usually lower blood pressure may paradoxically increase blood pressure, or an increase in pressure may be encountered after their discontinuation. In general, drug-induced pressure increases are small and transient: however, severe hypertension involving encephalopathy, stroke, and irreversible renal failure have been reported. The deleterious effect of therapeutic agents is more pronounced in patients with preexisting hypertension, in those with renal failure, and in the elderly. Careful evaluation of a patient's drug regimen may identify chemically induced hypertension and obviate unnecessary evaluation and facilitate antihypertensive therapy. Once chemical-induced hypertension has been identified, discontinuation of the causative agent is recommended, although hypertension can often be managed by specific therapy and dose adjustment if continued use of the offending agent is mandatory. The present review summarizes the therapeutic agents or chemical substances that elevate blood pressure and their mechanisms of action.

[Metabolic disorders in emerging and neglected infectious diseases]

The gradual and progressive replacement of infectious and parasitic by chronic diseases as causes of morbidity and mortality, characterizing the process of epidemiological transition hasn't been observed in various populations, especially in underdeveloped or developing countries characterizing a superposition of these profiles (incomplete transition). Besides the increased prevalence of metabolic disorders, various infectious diseases remain endemic in several regions, such as leprosy, tuberculosis, leishmaniasis, viral hepatitis, among others, as well as emerging diseases in recent decades, as HIV infection/Aids. In this context, more attention has been given to the occurrence of metabolic disturbances in the recent years, mainly from the observation of a high incidence of metabolic disorders associated with HIV infection/Aids, and its therapy with antiretroviral drugs. This review addresses clinical and epidemiological aspects of metabolic disturbances reported in some infectious and parasitic diseases with worldwide and local (Brazil) relevance, as well as possible mechanisms and factors involved in these associations.

The prevalence of metabolic syndrome in Danish patients with HIV infection: the effect of antiretroviral therapy

OBJECTIVES

The prevalence of metabolic syndrome (MS) in HIV-infected patients on highly active antiretroviral therapy (HAART) is a subject of debate. We investigated the prevalence of MS in a cohort of Danish HIV-infected patients and estimated the effect of the various classes of antiretroviral therapies on the prevalence of MS and its components.

METHODS

A cross-sectional study was performed in which data were obtained from fasting blood tests, anthropometry, an interview questionnaire and whole-body dual-energy X-ray absorptiometry (DEXA) scans. MS was defined using the National Cholesterol Education Programme (NCEP) Adult Treatment Panel (ATP) III diagnostic criteria.

RESULTS

Five hundred and sixty-six patients were included in the study, of whom 27% were diagnosed with MS. In univariate analysis, the duration of treatment with different drug classes was associated with the prevalence of MS. In multivariate analysis, no association was demonstrated between therapeutic duration or modality and the occurrence of MS. Current nonthymidine reverse transcriptase inhibitor (NRTI) and protease inhibitor (PI) therapies were both associated with increased plasma triglycerides (TG) [odds ratio (OR) 3.42, 95% confidence interval (CI) 1.73-6.74; and OR 1.96, 95% CI 1.19-3.22, respectively].

CONCLUSIONS

MS is prevalent in HIV-infected Danes. However, treatment with specific drug classes does not seem to confer an elevated risk for MS, other than the risk conferred by known acute effects on triglycerides.