Racial disparities in the prevalence and control of hypertension among a cohort of HIV-infected patients in the southeastern United States

Awareness, treatment, and control of hypertension among women at risk or living with HIV in the US South

OBJECTIVES

Timely control of hypertension is vital to prevent comorbidities. We evaluated the association of race/ethnicity and HIV infection with incident hypertension outcomes, including awareness, treatment, and control.

DESIGN

We evaluated cisgender women living with HIV and sociodemographically matched women living without HIV recruited into four Southern sites of the Women's Interagency HIV Study (WIHS) (2013-2019).

METHODS

We calculated measurements of the time to four events or censoring: incident hypertension, hypertension awareness, hypertension treatment, and hypertension control. Hazard ratios for race/ethnicity and HIV status were calculated for each outcome using Cox proportional-hazards models adjusted for sociodemographic, behavioral, and clinical risk factors.

RESULTS

Among 712 women, 56% were hypertensive at baseline. Forty-five percentage of the remaining women who were normotensive at baseline developed incident hypertension during follow-up. Non-Hispanic white and Hispanic women had faster time to hypertension control compared with non-Hispanic black women ( P  = 0.01). In fully adjusted models, women living with HIV who were normotensive at baseline had faster time to treatment compared with normotensive women living without HIV ( P  = 0.04).

CONCLUSION

In our study of women in the US South, non-Hispanic black women became aware of their hypertension diagnosis more quickly than non-Hispanic white and Hispanic women but were slower to control their hypertension. Additionally, women living with HIV more quickly treated and controlled their hypertension compared with women living without HIV.

Evaluation of New Hypertension Guidelines on the Prevalence and Control of Hypertension in a Clinical HIV Cohort: A Community-Based Study

The prevalence and control of hypertension (HTN) among people with HIV (PWH) have not been widely studied since the release of newer 2017 ACC/AHA guidelines ("new guidelines"). To address this research gap, we evaluated and compared the prevalence and control of HTN using both 2003 JNC 7 ("old guidelines") and new guidelines. We identified 3,206 PWH with HTN from the DC Cohort study in Washington, DC, between January 2018 and June 2019. We defined HTN using International Classification of Diseases (ICD)-9/-10 diagnosis codes for HTN or ≥2 blood pressure (BP) measurements obtained at least 1 month apart (>139/89 mm Hg per old or >129/79 mm Hg per new guidelines). We defined HTN control based on recent BP (≤129/≤79 mm Hg per new guidelines). We identified socio-demographics, cardiovascular risk factors, and co-morbidities associated with HTN control using multivariable logistic regression [adjusted odds ratio (aOR); 95% confidence interval (CI)]. The prevalence of HTN was 50.9% per old versus 62.2% per new guidelines. Of the 3,206 PWH with HTN, 887 (27.7%) had a recent BP ≤129/≤79 mm Hg, 1,196 (37.3%) had a BP 130-139/80-89 mm Hg, and 1,123 (35.0%) had a BP ≥140/≥90 mm Hg. After adjusting for socio-demographics, cardiovascular risk factors, and co-morbidities, factors associated with HTN control included age 60-69 (vs. <40) years (aOR: 1.42; 95% CI: 1.03-1.98), Hispanic (vs. non-Hispanic Black) race/ethnicity (aOR 1.49; 95% CI: 1.04-2.15), receipt of HIV care at a hospital-based (vs. community-based) clinic (aOR 1.21; 95% CI: 1.00-1.47), being unemployed (aOR 1.42; 95% CI: 1.11-1.83), and diabetes (aOR 1.35; 95% CI: 1.13-1.63). In a large urban cohort of PWH, nearly two-thirds had HTN and less than one-third of those met new guideline criteria. Our data suggest that more aggressive HTN control is warranted among PWH, with additional attention to younger patients and non-Hispanic Black patients.

Weight Gain After Antiretroviral Therapy Initiation and Subsequent Risk of Metabolic and Cardiovascular Disease

BACKGROUND

Weight gain following initiation of antiretroviral therapy (ART) is common. We assessed the impact of changes in weight in the year following ART initiation with subsequent cardiometabolic disease among AIDS Clinical Trials Group (ACTG) participants.

METHODS

Linear regression models were fit to examine the association between change in weight/waist circumference (WC) in weeks 0-48 and change in metabolic parameters in weeks 0-48 and 48-96. Cox proportional hazard models were fit to examine the association between changes in weight/WC in weeks 0-48 and diabetes mellitus (DM), metabolic syndrome, or cardiometabolic and cardiovascular events after week 48.

RESULTS

Participants (N = 2624) were primarily male (81%) and non-White (60%). Mean weight gain from 0-48 weeks was 3.6 kg (SD 7.3); 130 participants developed DM; 360 metabolic syndrome; 424 any cardiometabolic event; 28 any cardiovascular event, over 480 weeks of follow-up. In adjusted models, total cholesterol increased by 0.63 mg/dL (95% confidence interval [CI] [.38, .089]) and LDL by 0.39 mg/dL (0.19, 0.59) per 1 kg increase in weight from weeks 0 to48. Participants who experienced >10% weight gain (vs -5% to 5%) had an increased risk of DM (hazard ratio [HR] 2.01, 95% CI [1.30, 3.08]), metabolic syndrome (HR 2.24, 95% CI [1.55, 2.62]), and cardiometabolic outcomes (HR 1.54, 95% CI [1.22, 1.95]). Participants who lost more than 5% of their baseline weight had a lower risk of incident metabolic syndrome (HR 0.67, 95% CI [0.42, 1.07]). Trends for WC were similar.

CONCLUSIONS

Weight and body composition changes in the first year following ART initiation are associated with contemporaneous changes in metabolic parameters and subsequent cardiometabolic disease.

Hypertension burden, treatment, and control among people with HIV at a clinical care center in the Southeastern US, 2014-2019

Hypertension management outcomes in people with HIV (PWH) are not well characterized, despite high hypertension burden. We assessed hypertension prevalence, incidence, treatment, and outcomes among patients with HIV at a clinical center in the southeastern US, from 2014 to 2019. To identify characteristics associated with treatment and outcomes, we estimated adjusted risk ratios (aRR) and 95% confidence intervals (CI). Among 2274 patients, 72% were cisgender men, 56% non-Hispanic Black, median age 47 years, 48% MSM, 12% had CD4 cell count <200 cells/μl, 72% HIV RNA level <400 copies/mL and 39% prevalent hypertension. Hypertension incidence rate was 6.3/100 person-years (95% CI, 5.6-7.0). Among incident hypertension cases (n = 275), 16% (95% CI, 11-20) initiated an antihypertensive within one year. Compared to non-Hispanic white patients, Hispanic (aRR, 6.68; 95% CI, 1.50-29.74) and non-Hispanic Black patients (aRR, 2.18; 95% CI, 0.91-5.24) were more likely to initiate an antihypertensive. Among patients initiating an antihypertensive (n = 178), 63% (95% CI 56-70) experienced blood pressure control within one year. Patients with HIV experienced a high burden of hypertension with notable delays in antihypertensive initiation, as well as gaps in achieving blood pressure control, highlighting opportunities for interventions designed to minimize delays in controlling hypertension in this vulnerable population.

Cardiovascular Risk Assessment Among Adolescents and Youths Living With HIV: Evaluation of Electronic Health Record Findings and Implications

BACKGROUND

The HIV epidemic remains a major public health concern, particularly among youths living with HIV. While the availability of antiretroviral therapy has significantly improved the health outcomes of people living with HIV, there is growing evidence that youths living with HIV may be at increased risk of cardiovascular disease. However, the underlying mechanisms linking HIV and cardiovascular disease among youths living with HIV remain poorly understood. One potential explanation is that HIV-related biomarkers, including detectable viral load (VL) and low cluster of differentiation 4 (CD4) lymphocyte counts, may contribute to increased cardiovascular risk. Despite the potential importance of these biomarkers, the relationship between HIV-related biomarkers and cardiovascular risk among youths living with HIV has been understudied.

OBJECTIVE

To address this gap, we examined whether detectable VL and low CD4 lymphocyte counts, both of which are indications of unsuppressed HIV, were associated with cardiovascular risk among youths living with HIV.

METHODS

We analyzed electronic health record data from 7 adolescent HIV clinics in the United States (813 youths living with HIV). We used multivariable linear regression to examine the relationship between detectable VL and CD4 lymphocyte counts of ≤200 and cardiovascular risk scores, which were adapted from the gender-specific Framingham algorithm.

RESULTS

In our study, nearly half of the participants (366/766, 47.8%) had detectable VL, indicating unsuppressed HIV, while 8.6% (51/593) of them had CD4 lymphocyte counts of ≤200, suggesting weakened immune function. We found that those with CD4 lymphocyte counts of ≤200 had significantly higher cardiovascular risk, as assessed by Cardiac Risk Score2, than those with CD4 lymphocyte counts of >200 (P=.002). After adjusting for demographic and clinical factors, we found that for every 1000-point increase in VL copies/mL, the probability of having cardiovascular risk (Cardiac Risk Score2) increased by 38%. When measuring the strength of this connection, we observed a minor effect of VL on increased cardiovascular risk (β=.134, SE 0.014; P=.006). We obtained similar results with Cardiac Risk Score1, but the effect of CD4 lymphocyte counts of ≤200 was no longer significant. Overall, our findings suggest that detectable VL is associated with increased cardiovascular risk among youths living with HIV, and that CD4 lymphocyte counts may play a role in this relationship as well.

CONCLUSIONS

Our study highlights a significant association between unsuppressed HIV, indicated by detectable VL, and increased cardiovascular risk in youths living with HIV. These findings emphasize the importance of implementing interventions that address both VL suppression and cardiovascular risk reduction in this population. By tailoring interventions to meet the unique needs of youths, we can promote overall well-being throughout the HIV care continuum and across the life span. Ultimately, these efforts have the potential to improve the health outcomes and quality of life of youths living with HIV.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/11185.

Hypertension and one-year risk of all-cause mortality among women with treated HIV in the United States

OBJECTIVE

Hypertension is a critical cause of cardiovascular disease, and women with HIV have a higher prevalence of hypertension than women without HIV. The relationship between hypertension and mortality has not been well characterized in women with treated HIV. Here, we estimate the effect of hypertension on 1-year risk of all-cause mortality among women with HIV on antiretroviral therapy (ART) in the United States.

DESIGN

An analysis of multicenter, observational cohort data from the Women's Interagency HIV Study (WIHS) collected between 1995 and 2019.

METHODS

We included women with HIV who reported ever using ART. We used parametric g-computation to estimate the effect of hypertension (SBP ≥140  mmHg, DBP ≥90 mmHg, or use of hypertensive medication) on all-cause mortality within 1 year of a WIHS visit.

RESULTS

Among 2929 unique women, we included 57 034 visits with a median age of 45 (interquartile range: 39, 52) years. Women had hypertension at 34.5% of visits, and 641 deaths occurred within 1 year of a study visit. Comparing women at visits with hypertension to women at visits without hypertension, the standardized 1-year risk ratio for mortality was 1.16 [95% confidence interval (95% CI): 1.01-1.33]. The risk ratios were higher in Hispanic (risk ratio: 1.23, 95% CI: 0.86-1.77) and non-Hispanic black women (risk ratio: 1.19, 95% CI: 1.04-1.37) and lower in non-Hispanic white women (risk ratio: 0.93, 95% CI: 0.58-1.48).

CONCLUSION

Among women with treated HIV, those with hypertension, compared with those without, had an increased 1-year risk of all-cause mortality.

Cardiometabolic Diseases and Quality-of-Life Outcomes in Adults With HIV in the Deep South: A Cross-sectional Study

ABSTRACT

The role of cardiometabolic diseases (CMDs) on physical health-related quality of life (P-HRQoL) and quality of sleep was examined among 261 PLWH ≥40 years, recruited from a university-affiliated HIV clinic in the Deep U.S. South. Using a cross-sectional study design, participants completed the Medical Outcomes Study HIV Health Survey (MOS-HIV; P-HRQoL) and Pittsburgh Sleep Quality Index. The overall prevalence of self-reporting ≥1 CMD was 64.4%. P-HRQoL scores were lower in PLWH with ≥1 CMD compared with those with no CMDs (45.53 ± 11.54 vs. 49.67 ± 10.77, p <.01). Poor sleep quality was higher among participants with ≥1 CMD compared with those with no CMDs (9.28 ± 4.42 vs. 7.26 ± 4.17, p <.01). Each additional CMD resulted in a 1.83-point decrease in P-HRQoL and 0.74-point increase in poor sleep quality scores. Interventions that focus on targeting these quality-of-life domains in PLWH with CMDs are needed.

Cardiovascular disease and risk assessment in people living with HIV: Current practices and novel perspectives

Human immunodeficiency virus (HIV) infection represents a major cardiovascular risk factor, and the cumulative cardiovascular disease (CVD) burden among aging people living with HIV (PLWH) constitutes a leading cause of morbidity and mortality. To date, CVD risk assessment in PLWH remains challenging. Therefore, it is necessary to evaluate and stratify the cardiovascular risk in PLWH with appropriate screening and risk assessment tools and protocols to correctly identify which patients are at a higher risk for CVD and will benefit most from prevention measures and timely management. This review aims to accumulate the current evidence on the association between HIV infection and CVD, as well as the risk factors contributing to CVD in PLWH. Furthermore, considering the need for cardiovascular risk assessment in daily clinical practice, the purpose of this review is also to report the current practices and novel perspectives in cardiovascular risk assessment of PLWH and provide further insights into the development and implementation of appropriate CVD risk stratification and treatment strategies, particularly in countries with high HIV burden and limited resources.

Ethnic/Racial Disparities in Longitudinal Neurocognitive Decline in People With HIV

BACKGROUND

To examine longitudinal neurocognitive decline among Latino, non-Latino Black, and non-Latino White people with HIV (PWH) and factors that may explain ethnic/racial disparities in neurocognitive decline.

METHODS

Four hundred ninety nine PWH (13.8% Latino, 42.7% Black, 43.5% White; baseline age: M = 43.5) from the CNS HIV Anti-Retroviral Therapy Effects Research (CHARTER) study completed neurocognitive, neuromedical, and laboratory assessments every 6-12 months with up to 5 years of follow-up. Longitudinal neurocognitive change was determined via published regression-based norms. Survival analyses investigated the relationship between ethnicity/race and neurocognitive change, and baseline and time-dependent variables that may explain ethnic/racial disparities in neurocognitive decline, including socio-demographic, HIV-disease, medical, psychiatric, and substance use characteristics.

RESULTS

In Cox proportional hazard models, hazard ratios for neurocognitive decline were increased for Latino compared with White PWH (HR = 2.25, 95% CI = 1.35 to 3.73, P = 0.002), and Latino compared with Black PWH (HR = 1.86, 95% CI = 1.14 to 3.04, P = 0.013), with no significant differences between Black and White PWH (P = 0.40). Comorbidities, including cardiometabolic factors and more severe neurocognitive comorbidity classification, accounted for 33.6% of the excess hazard for Latino compared with White PWH, decreasing the hazard ratio associated with Latino ethnicity (HR = 1.83, 95% CI = 1.06 to 3.16, P = 0.03), but did not fully account for elevated risk of decline.

CONCLUSIONS

Latino PWH may be at higher risk of early neurocognitive decline compared with Black and White PWH. Comorbidities accounted for some, but not all, of this increased risk among Latino PWH. Future research examining institutional, sociocultural, and biomedical factors, including structural discrimination and age-related biomarkers, may further explain the observed disparities.

Prevalence of Cardiometabolic Risk Factors Among People Living with HIV in Southern Texas

The aim of this study is to estimate the prevalence of cardiometabolic risk factors among people living with HIV (PLWH) in the south Texas region between 2014 and 2018. A total of 2,808 PLWH from the southern Texas region were included using electronic medical records from a combination of health care system databases. The prevalence of cardiometabolic factors such as elevated blood pressure (BP), triglycerides, total cholesterol and blood glucose, low high-density lipoprotein cholesterol (HDL-C), and obesity was evaluated. The association between cardiometabolic risk factors and age, sex, race/ethnicity, and HIV-related variables was evaluated using logistic regression. Approximately 50.8% had elevated BP, followed by low HDL-C (41.7%), elevated glucose (40.3%), elevated triglycerides (35.5%), obesity (27.8%), and elevated total cholesterol (20%). Hispanics had a higher prevalence of low HDL-C (45.5% vs. 39.7%, p = .012), elevated glucose (48.9% vs. 36.3%, p < .001), elevated triglycerides (40.4% vs. 33.0%, p = .001), and obesity (31.3% vs. 26.0%, p = .004) than non-Hispanics. Females had a higher prevalence of low HDL-C (51.9% vs. 39.1%, p < .001), elevated total cholesterol (24.4% vs. 18.8%, p = .010), and obesity (49.5% vs. 21.8%, p < .001) than males. Variables such as age, sex, race/ethnicity, CD4⁺ T cell count, and viral load use were associated with multiple cardiometabolic risk factors. The prevalence of cardiometabolic risk factors remains high among PLWH in the southern Texas region, especially among Hispanics and females.

Prevalence of diabetes mellitus and hypertension amongst the HIV-positive population at a district hospital in eThekwini, South Africa

Background

Life expectancies of HIV-positive patients have been increasing with the rapid implementation of antiretroviral therapy (ART). This has led to an increase in comorbidities such as diabetes mellitus (DM) and hypertension (HT) amongst the HIV population. The burden of the non-communicable diseases (NCDs) such as DM and HT need to be quantified in order to ensure that patients receive optimal integrated care as patients often access care at different clinics compromising holistic care.

Aim

The aim of the study was to determine the prevalence of DM and HT amongst the HIV-positive population.

Setting

The study was conducted at Wentworth Hospital, a district facility in South Durban, KwaZulu-Natal.

Methods

This cross-sectional study was undertaken to determine the prevalence of two NCDs, namely DM and HT in HIV-positive patients attending the ART clinic at a district hospital in the eThekwini district. We compared the socio-demographic and clinical profiles of those with and without comorbidities. A sample of 301 HIV-positive patients were administered a structured questionnaire.

Results

Of the 301 patients, 230 (76.41%) had HIV only (95% confidence interval [CI]: 71.25–80.89) and 71 (23.59%) had HIV and at least one comorbidity, namely DM and/or HT (95% CI: 19.11-28.75). Hypertension was the most prevalent comorbidity. This study revealed that there was no association between the duration of ART and comorbidities. Older age and body mass index (BMI) were associated with comorbidities, whilst gender and ethnicity were not associated.

Conclusion

Non-communicable diseases such as DM and HT do pose a burden for HIV-positive patients attending the ARV clinic at this district facility. This study highlights the definite need to plan for the increased burden of NCDs as HIV-positive patients live longer and gain weight.

Proof of Concept for the FLEX Intervention: Feasibility of Home Based Coaching to Improve Physical Activity Outcomes and Viral Load Suppression among African American Youth Living with HIV

FLEX is a Motivational Interviewing, home-based coaching program that concurrently targets HIV-related and physical activity goals among African American youth living with HIV in the United States. To create and pilot test FLEX, we leveraged a 2-step exploratory sequential mixed methods design informed by the ORBIT model with initial qualitative work followed by pre-post analysis of quantitative outcomes, concluding with qualitative exit surveys. Data were evaluated pre- and 3-months post-intervention. Recruitment was 90%. Participants reported high program satisfaction and program adherence (76% completion rate). Preliminary findings indicate reductions in participants’ viral loads and improvements across 4 measures of physical activity.

Prevention of cardiovascular disease for historically marginalized racial and ethnic groups living with HIV: A narrative review of the literature

Despite developments to improve health in the United States, racial and ethnic disparities persist. These disparities have profound impact on the wellbeing of historically marginalized racial and ethnic groups. This narrative review explores disparities by race in people living with cardiovascular disease (CVD) and the Human Immunodeficiency Virus (HIV). We discuss selected common social determinants of health for both of these conditions which include; regional historical policies, incarceration, and neighborhood effects. Data on racial disparities for persons living with comorbid HIV and CVD are lacking. We found few published articles (n = 7) describing racial disparities for persons living with both comorbid HIV and CVD. Efforts to reduce CVD morbidity in historically marginalized racial and ethnic groups with HIV must address participation in clinical research, social determinants of health and translation of research into clinical practice.

The Intersection of HIV, Diabetes, and Race: Exploring Disparities in Diabetes Care among People Living with HIV

In a setting of universal health care access, we compared diabetes control between Caucasians and African Americans (AA) living with HIV. This was a cross-sectional analysis of data from a cohort study among military members living with HIV and diabetes. Using adjusted logistic regression models, we compared proportions of Caucasians and AA meeting the following diabetes treatment goals: hemoglobin A1c <7.0%, blood pressure (BP) <140/90 mm Hg, low density lipoprotein cholesterol <100 mg/dL, and not smoking. We included 107 Caucasian (mean age 37 years) and 126 AA (mean age 33 years) participants. A similar proportion of Caucasians and AA were prescribed diabetes (∼60%) and BP (∼80%) medications. Yet, more Caucasians met the BP treatment goal (77% [54%, 90%]) than AA (61% [36%, 82%]). Thus, more Caucasians met the combined A1c, BP, and cholesterol goals for diabetes control (25% [10%, 49%]) than AA (13% [5%, 31%]). Despite having equal access to health care, AA in this study have poorer diabetes control than Caucasians.

Why Do People Living with HIV Adhere to Antiretroviral Therapy and Not Comorbid Cardiovascular Disease Medications? A Qualitative Inquiry

BACKGROUND

After achieving viral suppression, it is critical for persons living with HIV (PLWH) to focus on prevention of non-AIDS comorbidities such as cardiovascular disease (CVD) in order to enhance their quality of life and longevity of life. Despite PLWH elevated risk of developing CVD compared to individuals without HIV, PLWH do not often meet evidence-based treatment goals for CVD prevention; the reasons for PLWH not meeting guideline recommendations are poorly understood. The objective of this study was to identify the factors associated with adherence to CVD medications for PLWH who have achieved viral suppression.

METHODS

Qualitative data were obtained from formative research conducted to inform the adaptation of a nurse-led intervention trial to improve cardiovascular health at three large academic medical centers in the United States. Transcripts were analyzed using content analysis guided by principles drawn from grounded theory.

RESULTS

Fifty-one individuals who had achieved viral suppression (<200 copies/mL) participated: 37 in 6 focus groups and 14 in individual semi-structured interviews. Mean age was 57 years (SD: 7.8); most were African Americans (n=31) and majority were male (n=34). Three main themes were observed. First, participants reported discordance between their healthcare providers' recommendations and their own preferred strategies to reduce CVD risk. Second, participants intentionally modified frequency of CVD medication taking which appeared to be related to low CVD risk perception and perceived or experienced side effects with treatment. Finally, participants discussed the impact of long-term experience with HIV care on adherence to CVD medication and motivational factors that enhanced adherence to heart healthy behaviors.

CONCLUSION

Findings suggest that future research should focus on developing interventions to enhance patient-provider communication in order to elicit beliefs, concerns and preferences for CVD prevention strategies. Future research should seek to leverage and adapt established evidence-based practices in HIV care to support CVD medication adherence.