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

Abstract

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.

Introduction

The Centers for Disease Control and Prevention (CDC) estimated that around 1,173,900 people were living with HIV in the United States in 2018.¹ Among them, more than 50% were aged 50 years and older.² The life expectancy of people with HIV (PWH) has increased since the introduction of combination antiretroviral therapy (ART).³ Based on the most recent CDC study, the percentage of PWH who were virally suppressed on ART treatment rose from 28% in 2010 to 49% in 2014.⁴

However, there is a rise in the comorbidity burden across the older PWH partly due to the aging process and partly due to the long-term use of ART.^5–7 Despite an overall decrease in HIV-related mortality,^8,9 cardiovascular mortality rates doubled in the HIV population around the same time period. Moreover, cardiovascular disease (CVD) is the leading cause of death among PWH in high-resource countries.^10,11 For these reasons, it is of utmost significance to understand the impact of CVD risk factors among PWH.

Hypertension (HTN) is a well-known CVD risk factor affecting 22% of adults globally, contributing to 7.5 million deaths every year. Olaiya et al. demonstrated that among 8,631 PWH in the United States, 42.4% of patients had HTN¹² whereas Levy et al. noted a 49.8% prevalence of HTN among 7,018 PWH participants in the DC Cohort, a clinical cohort of people receiving HIV care in Washington DC.¹³ Hypertensive PWH adults have a higher risk of cardiovascular events and all-cause mortality compared with those with normal blood pressure (BP).^14–18

Armah et al. showed that the hypertensive HIV population had a twofold higher risk of incident acute myocardial infarction compared with the hypertensive uninfected HIV population in the Veterans Aging Cohort Study (VACS).¹⁷ It is critical that we recognize the prevalence of HTN and factors associated with poor HTN control in PWH.

With the release of recent HTN guidelines¹⁹ that redefined lower BP cutoffs for HTN, we examined the prevalence, control, and medication management of HTN among PWH in the DC Cohort. We hypothesized that the prevalence of HTN would increase after applying the updated 2017 HTN definition. We also hypothesized that there may be poorer HTN control among lower socioeconomic groups (using insurance type as a surrogate for socioeconomic group), African Americans, and older age.

Methods

Study population

The DC Cohort study was approved by George Washington University Institutional Review Board and the IRBs of the participating clinical sites. We analyzed data from the DC Cohort, an ongoing prospective, longitudinal, multi-center, observational study of outpatient PWH who are receiving medical care at 1 of the 15 HIV clinic sites (that includes 9 hospital-based clinics, 4 community-based clinics, and 1 non-public organization) in Washington DC.

The methodology of the DC Cohort has been described in detail elsewhere.²⁰ Briefly, children, adolescents, and adults diagnosed with HIV and who are currently receiving care at one of the participating HIV clinic sites provided informed written consent to participate in the research study. Enrollment began in 2011. All the participants consented to have their demographic and clinical data extracted from the electronic medical record systems across all the clinics, with the personal identifying information removed and stored in a secure centralized web-based database at George Washington University Biostatistics Center. Participants eligible for this analysis were enrolled in the DC Cohort study anytime between January 1, 2011, and December 31, 2018.

The study population comprised PWH enrolled in the DC Cohort with active follow-up during January 1, 2018, to June 30, 2019. The study participants included for defining the prevalence of HTN in the 18-month observation period were ≥18 years old by January 1, 2018, with at least 6 months active follow-up within the 18-month observation period. Active follow-up was defined as having an HIV care encounter, HIV RNA testing, and/or CD4 count testing.

Diagnosis of HTN was determined using International Classification of Diseases-Ninth Revision (ICD)-9 or International Classification of Diseases-Tenth Revision (ICD-10) diagnosis codes or ≥2 elevated BP readings taken at least a month apart in each 18-month observation period. However, study participants who had missing BP measurements, who had systolic blood pressure (SBP) <70 mm Hg or diastolic blood pressure (DBP) <40 mm Hg, did not have an encounter in the respective follow-up periods, or did not have HIV RNA testing and CD4 count were excluded.

HTN definitions

HTN was defined by either billing codes (ICD-9 or ICD-10) or BP measurement values. ICD-9 and ICD-10 billing codes for HTN were 401.x and I10.X, respectively. According to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High BP (JNC-7) guidelines released in 2003,²¹ ≥2 consecutive BP readings of SBP >139 mm Hg or DBP >89 mm Hg taken at least 1 month apart defined HTN within the 18-month observation period (Old Guidelines).

According to ACC/AHA Guidelines for the Prevention, Detection, Evaluation, and Management of High BP in Adults released in 2017,¹⁹ ≥2 consecutive BP readings of SBP >129 mm Hg or DBP >79 mm Hg taken at least 1 month apart defined HTN within the 18-month observation period (New Guidelines).

BP control

Study participants diagnosed with HTN were further assessed to define control of HTN in the 18-month observation period. PWH diagnosed with HTN were categorized as having adequate BP control if the most recently recorded BP reading, obtained within the 18-month observation period, was ≤129 mm Hg SBP and ≤79 mm Hg DBP (controlled HTN), consistent with the newer guidelines. Any readings above the stated values were categorized as having Stage I HTN (most recent BP 130–139/80–89 mm Hg) and Stage II HTN (most recent BP ≥140/≥90 mm Hg).

Clinical characteristics

Co-morbidities such as substance use disorder (including alcohol, cannabis, opioids, and stimulant use), psychiatric disorder (including anxiety, mood, stress related and psychotic disorders), smoking status, diabetes mellitus (DM), hyperlipidemia (HLD), chronic kidney disease (CKD) (I–IV), and end stage renal disease (ESRD) who are dialysis dependent (CKD V) were ascertained through electronic data abstraction system for the diagnosis. CD4 was classified into three stages based on the current CDC guidelines for defining HIV disease severity.

Stage 1 HIV disease is defined by CD4 count and ≥500 cells/μL, Stage 2 HIV disease was defined by CD4 count between 201 and 499 cells/μL, and Stage 3 HIV disease was defined by CD4 count ≤200 cells/μL.²² Viral load suppression was defined by viral load <200 copies/mL. Time varying co-variates were defined as of the date of the most recently recorded BP reading obtained within the 18-month observation period.

In the DC Cohort, prescription data are abstracted from provider orders in the electronic health record for each participant. The prescription data at the time of the most recently recorded BP reading within the 18-month period were taken. Appendix 1 and 2 lists the anti-hypertensive classes and drugs in each class that clinical PWH diagnosed with HTN were taking during the 18-month observation period.

Appendix 1.

Anti-Hypertensive Medications

Generic name	Brand name(s)
Bumetanide	Bumex
Chlorthalidone	Thalitone Hygroton
Chlorothiazide	Diuril Sodium Diuril
Ethacrynic acid	Edecrin
Furosemide	Lasix
Hydrochlorothiazide	HydroDIURIL Microzide Oretic Esidrix
Indapamide	Lozol
Methyclothiazide	Enduron
Metolazone	Mykroz Zaroxolyn
Torsemide	Demadex
Amiloride	Midamor
Amiloride/hydrochlorothiazide	Moduretic
Spironolactone/hydrochlorothiazide	Aldactazide
Spironolactone	Aldactone
Triamterene	Dyrenium
Triamterene/hydrochlorothiazide	Maxzide Dyazide
Bendroflumethiazide	Aprinox
Acebutolol	Sectral
Atenolol	Tenormin
Atenolol/chlorthalidone	Tenoretic
Bisoprolol fumarate	Zebeta
Carvedilol	Coreg CR Coreg
Esmolol	Brevibloc
Labetalol hydrochloride	Trandate Normodyne
Metoprolol	Lopressor Metoprolol Succinate ER Metoprolol Tartrate Toprol-XL
Metoprolol/hydrochlorothiazide	Lopressor HCT Dutoprol
Nadolol	Corgard
Nadolol/bendroflumethiazide	Corzide
Nebivolol	Bystolic
Pentbutolol sulfate	Levatol
Propranolol	Inderal
Propranolol/hydrochlorothiazide	Inderide
Sotalol	Betapace
Bisoprolol fumarate/hydrochlorothiazide	Ziac
Pindolol	Visken
Benazepril hydrochloride	Lotensin
Benazepril/hydrochlorothiazide	Lotensin HCT
Captopril	Capoten
Captopril/hydrochlorothiazide	Capozide
Enalapril maleate	Vasotec
Enalapril maleate/hydrochlorothiazide	Vaseretic
Fosinopril	Monopril
Fosinopril/hydrochlorothiazide	Monopril HCT
Lisinopril	Zestril Prinivil
Lisinopril/hydrochlorothiazide	Zestoretic Prinzide
Moexipril	Univasc
Moexipril hydrochloride/hydrochlorothiazide	Uniretic
Perindopril erbumine	Aceon
Quinapril hydrochloride	Accupril
Quinapril/hydrochlorothiazide	Accuretic
Ramipril	Altace
Trandolapril	Mavik
Trandolapril/verapamil hydrochloride	Tarka
Azilsartan	Edarbi
Candesartan	Atacand
Candesartan/hydrochlorothiazide	Atacand HCT
Eprosartan mesylate	Teveten
Eprosartan mesylate/hydrochlorothiazide	Teveten HCT
Irbesartan	Avapro
Irbesartan/hydrochlorothiazide	Avalide
Losartan Potassium	Cozaar
Losartan/hydrochlorothiazide	Hyzaar
Olmesartan	Benicar
Olmesartan/hydrochlorothiazide	Benicar HCT
Telmisartan	Micardis
Telmisartan/hydrochlorothiazide	Micardis HCT
Valsartan	Diovan
Valsartan/hydrochlorothiazide	Diovan HCT
Amlodipine besylate	Lotrel Norvasc
Amlodipine/hydrochlorothiazide/olmesartan	Tribenzor
Amlodipine/hydrochlorothiazide/valsartan	Exforge HCT
Aliskiren/amlodipine/hydrochlorothiazide	Amturnide
Clevidipine	Cleviprex
Diltiazem hydrochloride	Cardizem Cartia XT Dilacor XR Diltia XT Dilt XR Taztia XT Tiazac
Felodipine	Plendil
Isradipine	DynaCirc CR DynaCirc
Nicardipine hydrochloride	Cardene SR Cardene
Nifedipine	Adalat CC Afeditab CR Nifediac CC Nifedical XL Procardia Procardia XL Adalat
Nimodipine	Nimotop Nymalize
Nisoldipine	Sular
Verapamil hydrochloride	Calan Calan SR Isoptin SR Verelan Verelan PM Isoptin Isoptin I.V. Covera HS
Doxazosin mesylate	Cardura Cardura XL
Prazosin hydrochloride	Minipress
Terazosin hydrochloride	Hytrin
Phentolamine mesylate	Regitine Oraverse
Methyldopa	Aldomet
Clonidine	Kapvay Catapres
Chlorthalidone/clonidine	Clorpres
Guanfacine hydrochloride	Tenex
Guanadrel	Hylorel
Guanethidine monosulfate	Ismelin
Reserpine	Serpasil
Reserpine/hydrochlorothiazide	Hydropres-25 Hydropres-50 Hydroserpine Hydroserpine #1 Hydro-Reserp Hydroserp
Minoxidil	Loniten
Hydralazine	Apresoline
Hydralazine/hydrochlorothiazide	Hydra-Zide
Aliskiren	Tekturna

Appendix 2.

Classes of Anti-Hypertensive Medications

Diuretics
Thiazide diuretic
Chlorthalidone	Thalitone Hygroton
Chlorothiazide	Diuril Sodium Diuril
Hydrochlorothiazide	HydroDIURIL Microzide Oretic Esidrix
Indapamide	Lozol
Methyclothiazide	Enduron
Metolazone	Mykroz Zaroxolyn
Bendroflumethiazide	Aprinox
Loop diuretic
Bumetanide	Bumex
Ethacrynic acid	Edecrin
Furosemide	Lasix
Torsemide	Demadex
Potassium sparing diuretic
Amiloride	Midamor
Spironolactone	Aldactone
Triamterene	Dyrenium
Eplerenone
Combination drugs
Amiloride/hydrochlorothiazide	Moduretic
Spironolactone/hydrochlorothiazide	Aldactazide
Triamterene/hydrochlorothiazide	Maxzide Dyazide
Beta-blockers
Beta1 selective beta-blockers
Acebutolol	Sectral
Atenolol	Tenormin
Bisoprolol fumarate	Zebeta
Esmolol	Brevibloc
Metoprolol	Lopressor Metoprolol Succinate ER Metoprolol Tartrate Toprol-XL
Nebivolol	Bystolic
Non-selective beta blockers
Carvedilol	Coreg CR Coreg
Labetalol hydrochloride	Trandate Normodyne
Nadolol	Corgard
Pindolol	Visken
Pentbutolol sulfate	Levatol
Propranolol	Inderal
Sotalol	Betapace
Combination drugs
Bisoprolol fumarate/hydrochlorothiazide	Ziac
Propranolol/hydrochlorothiazide	Inderide
Nadolol/bendroflumethiazide	Corzide
Atenolol/chlorthalidone	Tenoretic
Metoprolol/hydrochlorothiazide	Lopressor HCT Dutoprol
ACEI
Benazepril hydrochloride	Lotensin
Captopril	Capoten
Enalapril maleate	Vasotec
Fosinopril	Monopril
Lisinopril	Zestril Prinivil
Moexipril	Univasc
Perindopril erbumine	Aceon
Quinapril hydrochloride	Accupril
Ramipril	Altace
Trandolapril	Mavik
Combination drugs
Benazepril/hydrochlorothiazide	Lotensin HCT
Captopril/hydrochlorothiazide	Capozide
Enalapril maleate/hydrochlorothiazide	Vaseretic
Fosinopril/hydrochlorothiazide	Monopril HCT
Lisinopril/hydrochlorothiazide	Zestoretic Prinzide
Moexipril hydrochloride/hydrochlorothiazide	Uniretic
Quinapril/hydrochlorothiazide	Accuretic
Trandolapril/verapamil hydrochloride	Tarka
ARBs
Azilsartan	Edarbi
Candesartan	Atacand
Eprosartan mesylate	Teveten
Irbesartan	Avapro
Losartan potassium	Cozaar
Olmesartan	Benicar
Telmisartan	Micardis
Valsartan	Diovan
Combination drugs
Candesartan/hydrochlorothiazide	Atacand HCT
Eprosartan mesylate/hydrochlorothiazide	Teveten HCT
Irbesartan/hydrochlorothiazide	Avalide
Losartan/hydrochlorothiazide	Hyzaar
Olmesartan/hydrochlorothiazide	Benicar HCT
Telmisartan/hydrochlorothiazide	Micardis HCT
Valsartan/hydrochlorothiazide	Diovan HCT
Calcium channel blockers
Amlodipine besylate	Lotrel Norvasc
Clevidipine	Cleviprex
Diltiazem hydrochloride	Cardizem Cartia XT Dilacor XR Diltia XT Dilt XR Taztia XT Tiazac
Felodipine	Plendil
Isradipine	DynaCirc CR DynaCirc
Nicardipine hydrochloride	Cardene SR Cardene
Nifedipine	Adalat CC Afeditab CR Nifediac CC Nifedical XL Procardia Procardia XL Adalat
Nimodipine	Nimotop Nymalize
Nisoldipine	Sular
Verapamil hydrochloride	Calan Calan SR Isoptin SR Verelan Verelan PM Isoptin Isoptin I.V. Covera HS
Combination drugs
Amlodipine/hydrochlorothiazide/olmesartan	Tribenzor
Amlodipine/hydrochlorothiazide/valsartan	Exforge HCT
Aliskiren/amlodipine/hydrochlorothiazide	Amturnide
Alpha-blockers
Doxazosin mesylate	Cardura Cardura XL
Prazosin hydrochloride	Minipress
Terazosin hydrochloride	Hytrin
Phentolamine mesylate	Regitine Oraverse
Central alpha agonist
Methyldopa	Aldomet
Clonidine	Kapvay Catapres
Guanadrel	Hylorel
Guanethidine monosulfate	Ismelin
Combination drugs
Chlorthalidone/clonidine	Clorpres
Rauwolfia alkaloids
Reserpine	Serpasil
Combination drugs
Reserpine/hydrochlorothiazide	Hydropres-25 Hydropres-50 Hydroserpine Hydroserpine #1 Hydro-Reserp Hydroserp
Vasodilators
Minoxidil	Loniten
Hydralazine	Apresoline
Isosorbide mononitrate
Isosorbide dinitrate
Combination drugs
Hydralazine/hydrochlorothiazide	Hydra-Zide
Renin inhibitor
Aliskiren	Tekturna

ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker.

Anti-hypertensive classes were diuretics, beta-blockers, angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), alpha blocker, rauwolfia alkaloid, renin inhibitor, vasodilator, and central alpha agonist. Mineralocorticoids that have a mild diuretic effect were added to the anti-hypertensive class of diuretics. Fixed drug combination pills containing a chemical combination of different anti-hypertensive classes were also retrieved.

Statistical analysis

Prevalence of HTN was calculated using definitions of HTN defined by the old and the new guidelines. HTN control was calculated using the new guidelines. Demographic and clinical characteristics of individuals with and without HTN (per the new guidelines) were compared with chi-square and Wilcoxon sum-rank tests, as appropriate.

Multivariable logistic regression with sociodemographic and behavioral variables was used to calculate the adjusted odds of HTN control associated with the predictor variables (any factors with p value <.10 in the univariate models and any factors with associations with the outcome designated a priori). All statistical analysis was completed using SAS version 9.4.

Results

The primary objective of the study was to evaluate the prevalence of HTN with the re-defined HTN update and thus further assess the factors associated with HTN control and HTN management. There were 5,153 PWH among which 2,625 (50.9%) were diagnosed with HTN; this increased to 3,206 (62.2%) after applying new guideline definitions of HTN (Supplementary Table S1).

Study population characteristics

As shown in Table 1, socio-demographic and clinical characteristics of PWH with HTN according to the new guidelines were described by comparing the four groups: no HTN, controlled HTN, Stage I HTN, and Stage II HTN. About one-third (37.8%) did not have HTN; among those with HTN, 17.2% were controlled, 23.2% had Stage I HTN, and 21.8% had Stage II HTN.

Table 1.

Socio-Demographic and Clinical Characteristics Stratified by the Presence and Control of Hypertension Based on New Hypertension Guidelines, DC Cohort, January 2018 to June 2019 (n = 5,153)

	No HTN	Has HTN (n = 3,206)
		Recent BP in mm Hg:
		≤129/≤79	130–139/80–89	≥140/≥90
	n (%)	n (%)	n (%)	n (%)	p
Total sample	1,947 (37.8)	887 (17.2)	1,196 (23.2)	1,123 (21.8)	—
Age group					<.0001
<40 years old	636 (32.7)	76 (8.6)	164 (13.7)	109 (9.7)
40–49 years old	464 (23.8)	118 (13.3)	237 (19.8)	171 (15.2)
50–59 years old	552 (28.4)	303 (34.2)	424 (35.5)	438 (39.0)
60–69 years old	251 (12.9)	298 (33.6)	300 (25.1)	310 (27.6)
≥70 years	44 (2.3)	92 (10.4)	71 (5.9)	95 (8.5)
Race/ethnicity					<.0001
Non-Hispanic Black	1,401 (72.0)	730 (82.3)	990 (82.8)	948 (84.4)
Non-Hispanic White	276 (14.2)	83 (9.4)	99 (8.3)	93 (8.3)
Hispanic	181 (9.3)	51 (5.8)	65 (5.4)	45 (4.0)
Other/unknown	89 (4.6)	23 (2.6)	42 (3.5)	37 (3.3)
Gender					<.0001a
Cisgender male	1,387 (71.2)	601 (67.8)	789 (66.0)	746 (66.4)
Cisgender female	511 (26.3)	272 (30.7)	380 (31.8)	359 (32.0)
Transgender male	5 (0.3)	0 (0)	1 (0.1)	3 (0.3)
Transgender female	44 (2.3)	14 (1.6)	26 (2.2)	15 (1.3)
Clinic type					<.0001
Community-based	804 (41.3)	419 (47.2)	629 (52.6)	576 (51.3)
Hospital-based	1,143 (58.7)	468 (52.8)	567 (47.4)	547 (48.7)
Insurance statusb					<.0001
Public	1,054 (54.1)	622 (70.1)	783 (65.5)	794 (70.7)
Private	813 (41.8)	239 (26.9)	354 (29.6)	284 (25.3)
No known insurance	49 (2.5)	14 (1.6)	30 (2.5)	22 (2.0)
Unknown	31 (1.6)	12 (1.4)	29 (2.4)	23 (2.1)
Housing status					.10
Stable	1,707 (87.7)	759 (85.6)	1,048 (87.6)	966 (86.0)
Unstable	101 (5.2)	65 (7.3)	68 (5.7)	71 (6.3)
Homeless	34 (1.8)	6 (0.7)	17 (1.4)	12 (1.1)
Unknown	105 (5.4)	57 (6.4)	63 (5.3)	74 (6.6)
Employment statusc					<.0001
Employed	556 (28.6)	170 (19.2)	269 (22.5)	300 (26.7)
Unemployed	429 (22.0)	266 (30.0)	324 (27.1)	339 (30.2)
Other	106 (5.4)	85 (9.6)	66 (5.5)	89 (7.9)
Unknown	856 (44.0)	366 (41.3)	537 (44.9)	395 (35.2)
HIV viral load <200 copies/mLd	1,748 (90.0)	828 (93.7)	1,103 (92.2)	1,010 (89.9)	.0029
CD4 cell countd					.12
<200 cells/μL	111 (5.7)	40 (4.5)	69 (5.8)	69 (6.2)
200–499 cells/μL	502 (25.9)	254 (28.7)	290 (24.3)	318 (28.4)
≥500 cells/μL	1,324 (68.4)	590 (66.7)	835 (69.9)	734 (65.5)
Years since HIV dx, median (IQR)d	11.5 (6.3–18.9)	16.7 (10.0–22.9)	15.1 (9.4–22.4)	15.8 (9.8–22.7)	<.0001e
Has current ART prescription	1,830 (94.0)	845 (95.3)	1,128 (94.3)	1,082 (96.4)	.029
Years since ART initiationf	8.4 (4.8–12.7)	9.7 (6.8–15.6)	9.5 (6.8–14.7)	9.7 (7.2–15.7)	<.0001e
Smoking history					<.0001
Current	689 (35.4)	350 (39.5)	489 (40.9)	449 (40.0)
Prior/former	248 (12.7)	176 (19.8)	184 (15.4)	197 (17.5)
Never	1,010 (51.9)	361 (40.7)	523 (43.7)	477 (42.5)
Alcohol use disorder dx	131 (6.7)	99 (11.2)	114 (9.5)	115 (10.2)	.0002
Cannabis use disorder dx	66 (3.4)	23 (2.6)	29 (2.4)	26 (2.3)	.24
Opioid use disorder dx	26 (1.3)	45 (5.1)	39 (3.3)	35 (3.1)	<.0001
Stimulant use disorder dx	105 (5.4)	65 (7.3)	89 (7.4)	65 (5.8)	.059
Psychiatric disorder dx	820 (42.1)	458 (51.6)	561 (46.9)	525 (46.8)	<.0001
Diabetes dx	146 (7.5)	279 (31.5)	266 (22.2)	268 (23.9)	<.0001
HLD dx	467 (24.0)	423 (47.7)	507 (42.4)	476 (42.4)	<.0001
CKD dx					<.0001
None	1,857 (95.4)	717 (80.8)	1,017 (85.0)	936 (83.4)
Stages I − IV	83 (4.3)	129 (14.5)	147 (12.3)	147 (13.1)
Stage V/ESRD	7 (0.4)	41 (4.6)	32 (2.7)	40 (3.6)

Characteristics are reported as of the date of the most recent BP result. p-Values were calculated using chi-square testing.

^a Calculated using Monte Carlo simulation of Fisher's exact testing.

^b Public insurance includes Medicare, Medicaid, Ryan White/AIDS Drug Assistance Program, DC Alliance, or other public. No known insurance includes insurance terminated, self-pay/fee for service, or other.

^c Employed status includes full- and part-time employment. Other employment status includes retired, student, disabled, termination of student, and other.

^d Some participants were missing values for HIV viral load (7 missing), CD4 cell count (17 missing), and years since HIV dx (21 missing).

^e Calculated using the Kruskal–Wallis test.

^f Reported only among 3,468 of 4,885 participants with a current ART prescription who had known ART initiation dates.

ART, antiretroviral therapy; BP, blood pressure; CKD, chronic kidney disease; dx, diagnosis; ESRD, end stage renal disease; HLD, hyperlipidemia; HTN, hypertension; IQR, interquartile range.

Comparing the four groups, many demographic factors were statistically significantly different. For example, a higher proportion of participants <50 years had no HTN, 50–59 years had Stage II HTN, and ≥60 years had controlled HTN (p < .0001). There was a higher proportion of Black individuals in the Stage II HTN group (p < .0001 between groups).

A larger percentage of cisgender males were in the controlled HTN and Stage II HTN groups compared with cisgender females (p < .0001). The majority of individuals that received care at community-based clinics had their HTN in Stage II compared with those receiving care at hospital-based clinic (p < .0001). A significant number of individuals who had diabetes, HLD, CKD, ESRD dialysis dependent were in the controlled HTN group (p < .0001).

Factors associated with superior HTN control

The comparison is made between the controlled HTN group and the group with both Stage I and Stage II to evaluate the factors associated with HTN control among hypertensive PWH per new guidelines, as illustrated in Table 2. Compared with individuals younger than 40 years, individuals aged 60–69 were more likely to have controlled HTN [adjusted odds ratio (aOR): 1.429, 95% confidence interval (CI): 1.033–1.976, p = .03].

Table 2.

Factors Associated with Hypertension Control Among Patients with Hypertension Based on New Guidelines, DC Cohort, January 2018 to June 2019 (n = 3,206).

	Recent BP ≤129/≤79 mm Hg (n = 887) vs. ≥130/≥80 mm Hg (n = 2,319)
	Unadjusted OR (95% CI)	p	aOR (95% CI)a	p
Age group
<40 years old	Ref.		Ref.
40–49 years old	1.039 (0.749–1.440)	.82	1.021 (0.727–1.433)	.91
50–59 years old	1.262 (0.949–1.680)	.11	1.103 (0.809–1.505)	.53
60–69 years old	1.755 (1.314–2.344)	.0001	1.429 (1.033–1.976)	.031
≥70 years	1.991 (1.389–2.853)	.0002	1.470 (0.974–2.219)	.067
Race/ethnicity
Non-Hispanic Black	Ref.		Ref.
Non-Hispanic White	1.148 (0.875–1.505)	.32	1.137 (0.846–1.528)	.40
Hispanic	1.231 (0.874–1.734)	.23	1.495 (1.041–2.148)	.030
Other/unknown	0.773 (0.482–1.239)	.29	0.809 (0.495–1.322)	.40
Gender
Cisgender male	Ref.		Ref.
Cisgender female	0.940 (0.795–1.112)	.47	0.993 (0.829–1.189)	.94
Transgender	0.795 (0.433–1.458)	.46	0.907 (0.485–1.695)	.76
Hospital-based clinic (vs. community-based)	1.208 (1.035–1.411)	.017	1.214 (1.003–1.471)	.047
Insurance status
Public	Ref.		Ref.
Private	0.950 (0.797–1.132)	.21	1.014 (0.815–1.262)	.90
No known insurance	0.683 (0.376–1.241)	.56	0.866 (0.472–1.588)	.64
Unknown	0.586 (0.311–1.104)	.098	0.639 (0.333–1.227)	.18
Housing status
Stable	Ref.		Ref.
Unstable	1.241 (0.914–1.685)	.17	1.362 (0.985–1.884)	.062
Homeless	0.549 (0.227–1.328)	.18	0.572 (0.234–1.402)	.22
Unknown	1.104 (0.802–1.520)	.54	1.110 (0.794–1.551)	.54
Employment status
Employed	Ref.		Ref.
Unemployed	1.343 (1.075–1.678)	.0095	1.424 (1.109–1.827)	.0055
Other	1.836 (1.339–2.516)	.0002	1.432 (1.020–2.010)	.038
Unknown	1.314 (1.066–1.621)	.011	1.311 (1.046–1.642)	.019
HIV viral load <200 copies/mL	0.694 (0.511–0.942)	.019	0.784 (0.564–1.088)	.15
CD4 cell count
<200 cells/μL	0.771 (0.535–1.110)	.16	0.846 (0.572–1.251)	.40
200–499 cells/μL	1.111 (0.933–1.323)	.24	1.065 (0.887–1.279)	.50
≥500 cells/μL	Ref.		Ref.
Years since HIV dx (per 5 years)	1.007 (0.998–1.017)	.11	1.000 (0.990–1.010)	.96
Not currently prescribed ART	1.008 (0.700–1.451)	.97	0.978 (0.672–1.421)	.91
Smoking history
Current	1.034 (0.870–1.227)	.71	1.043 (0.862–1.261)	.67
Prior/former	1.280 (1.032–1.587)	.025	1.138 (0.907–1.427)	.26
Never	Ref.		Ref.
Alcohol use disorder dx	1.147 (0.893–1.472)	.28	1.029 (0.778–1.360)	.84
Cannabis use disorder dx	1.096 (0.669–1.794)	.72	1.048 (0.619–1.775)	.86
Opioid use disorder dx	1.622 (1.110–2.369)	.012	1.303 (0.859–1.976)	.21
Stimulant use disorder dx	1.112 (0.823–1.502)	.49	0.988 (0.704–1.388)	.95
Psychiatric disorder dx	1.212 (1.038–1.415)	.015	1.169 (0.988–1.382)	.069
Diabetes dx	1.534 (1.292–1.821)	<.0001	1.359 (1.130–1.635)	.0011
HLD dx	1.239 (1.061–1.447)	.0069	1.074 (0.906–1.273)	.41
CKD dx
None	Ref.		Ref.
Stages I − IV	1.195 (0.955–1.495)	.12	1.015 (0.802–1.285)	.90
Stage V/ESRD	1.551 (1.047–2.298)	.029	1.333 (0.883–2.012)	.17

^a There were missing values for HIV viral load (n = 3), CD4 cell count (n = 7), and years since HIV dx (n = 11), leading to a sample size of n = 3,186 in the adjusted analysis. All characteristics in this table were adjusted for in the adjusted analysis.

aOR, adjusted odds ratio; ART, antiretroviral therapy; CI, confidence interval; dx, diagnosis; ESRD, end stage renal disease; OR, odds ratio.

Compared with non-Hispanic Black and White participants, Hispanics were more likely to have controlled HTN (aOR: 1.495, 95% CI: 1.041–2.148, p = .03). Individuals who received care in a hospital-based clinic had controlled HTN in comparison to a community-based clinic (aOR: 1.214, 95% CI: 1.003–1.471, p = .047). Unemployed participants were more likely to have controlled HTN compared with employed participants (aOR: 1.424, 95% CI: 1.109–1.827, p = .0055); however, participants with other and unknown employment status also had controlled HTN. Compared with dialysis-dependent individuals, diabetics were more likely to have controlled HTN (aOR: 1.359, 95% CI: 1.130–1.635, p = .0011).

HTN management

Table 3 demonstrates various classes of antihypertensive treatment among hypertensive PWH per new guidelines. Only 60.5% of hypertensive PWH were prescribed at least one anti-hypertensive medication. Among hypertensive PWH prescribed any anti-hypertensive drugs, 64.4% were in the controlled HTN group, 53.4% were in the Stage I HTN group, and 65.1% were in the Stage II HTN group. ACEI/ARB (42.6% vs. 33.7% vs. 42.7%) were prescribed the most followed by diuretic (33.5% vs. 27.6% vs. 36.8%), calcium channel blocker (26.6% vs. 21.3% vs. 31.5%), and beta-blocker (17.5% vs. 12.3% vs. 16%) for controlled HTN, Stage I HTN, and Stage II HTN groups. Hypertensive PWH were also on fixed drug combination pills across the spectrum of HTN.

Table 3.

Classes of Antihypertensive Treatment Among Patients with Hypertension Based on New Hypertension Guidelines, DC Cohort, January 2018 to June 2019

	Overall (n = 3,206)	By recent BP in mm Hg:
		≤129/≤79/Controlled HTN (n = 887)	130–139/80 − 89/Stage I (n = 1,196)	≥140/≥90/Stage II (n = 1,123)
	n (%)	n (%)	n (%)	n (%)	p
Any treatment	1,941 (60.5)	571 (64.4)	639 (53.4)	731 (65.1)	<.0001
Diuretic	1,040 (32.4)	297 (33.5)	330 (27.6)	413 (36.8)	<.0001
Beta blocker	482 (15.0)	155 (17.5)	147 (12.3)	180 (16.0)	.0024
ACEI/ARB	1,261 (39.3)	378 (42.6)	403 (33.7)	480 (42.7)	<.0001
Calcium channel blocker	845 (26.4)	236 (26.6)	255 (21.3)	354 (31.5)	<.0001
Alpha blockers	109 (3.4)	40 (4.5)	30 (2.5)	39 (3.5)	.044
Central sympatholytic	53 (1.7)	13 (1.5)	15 (1.3)	25 (2.2)	.16
Rauwolfia alkaloid	0 (0)	0 (0)	0 (0)	0 (0)	—
Vasodilator	65 (2.0)	20 (2.3)	17 (1.4)	28 (2.5)	.16
Renin inhibitor	0 (0)	0 (0)	0 (0)	0 (0)	—
Fixed drug combinations	421 (13.1)	115 (13.0)	143 (12.0)	163 (14.5)	.19

ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker.

Discussion

HTN continues to be a major public health concern in the United States due to an increase in cardiovascular mortality in PWH, as well as in the general population. The seriousness of the situation lies in the fact that HTN is not only the most important cardiovascular risk factor but also a modifiable one. Hence, it is of paramount significance that we identify the prevalence of HTN with the updated ACC/AHA guidelines and take a strategic approach to control HTN.

Our study adds to the increasingly important HTN and HIV medical literature by showing that PWH diagnosed with HTN increased by around 22% with the re-defined HTN update and among all participants with HTN under the new guidelines, less than 20% have their BP controlled; also, that hypertensive PWH who are younger and belong to non-Hispanic Black race have poorer BP control compared with the controlled HTN group.

There were two-thirds of hypertensive PWH that were prescribed anti-hypertensive medications. There may be a multitude of reasons for this. First, the remaining one-third diagnosed with HTN may have their BP controlled with lifestyle measures such as diet and exercise. Second, some HIV care specialists providing care to hypertensive PWH may not have started to implement new HTN guidelines to their practice yet.

Third, some HIV care specialists may be deferring the HTN management to the primary care physician despite consistent elevated BP readings and did not record these medications in the HIV care record. To reiterate, not all traditional risk factors explain HTN risk in PWH. There are several other mechanisms causing HTN in PWH related to HIV-related factors and ART such as microbial gut translocation, chronic inflammation of HIV infection, immune reconstitution, lipodystrophy, role of adipocytokines, and HIV-related CKD.²³ That being said, HTN management should be integrated into routine HIV care and strongly considered to be added to the HIV quality measures.

Of note, in our study, HTN in the younger to middle-aged PWH (<60 years old) is more poorly controlled compared with 60 years old and older where it is better controlled. This differs from literature that showed a lower rate of HTN control in older PWH in Africa.²⁴ If younger and older individuals are treated by the same HIV specialist, older hypertensive individuals may have been started on anti-hypertensive medications for different indications such as CKD, myocardial infarction (MI), or congestive heart failure (CHF) to name a few. On the other hand, if the younger and older hypertensive individuals are treated for HTN equally, lack of adherence, motivation are some of the very few reasons for poor HTN control in the young to middle-aged PWH.

Our study showed that Hispanics have better HTN control compared with African Americans and non-Hispanic Whites. African Americans are disproportionately affected by HTN (83.2% among 3,206 hypertensive PLWH) compared with Whites and Hispanics. Racial disparity continues to exist in terms of prevalence and control of HTN.^25,26

Burkholder et al. conducted a cross-sectional study of 1,664 HIV outpatients in Alabama that showed higher prevalence of HTN and lower BP control (<140/90 mm Hg) in African Americans in 2013, despite being on anti-hypertensive treatment.²⁶ In addition, Kent et al. noted a higher prevalence of sleep-masked HTN in African Americans (57%) compared with Whites (18%) in Alabama in 2015.²⁵

Richardson et al. showed that Blacks had a lower rate of HTN control compared with their White counterparts in Iowa in 2013.²⁷ These racial differences in HTN prevalence and control are likely multifactorial: Low rate of viral control, poor adherence with diet and medications, race-related differences such as salt-sensitive HTN, or poor sleep quality in African Americans to name a few.

In our study, hypertensive PWH who received care in a hospital-based clinic had better HTN control compared with those attending a community-based clinic. In the past, studies^28,29 have shown that HIV care did not differ between academic clinics and community clinics; however, HTN control was not studied. Possible explanations could be access to more specialty care at hospital-based clinics such as referral to nephrology for evaluation and treatment of secondary causes of HTN or may be deficiency in resources in the community for HTN education and management or may be both. This disparity needs further research.

The presence of diabetes was associated with better HTN control in PWH compared with other co-morbidities such as CKD, ESRD dialysis dependent, HLD, stimulant use, alcohol use, and smoking (p < .0011). It is unclear from our study whether ACEI/ARBs are used to manage HTN in diabetic individuals specifically; however, they are the most common anti-hypertensive agents prescribed to hypertensive HIV individuals in general.

PWH has increased renin angiotensin-aldosterone system (RAAS) activity^30,31 responsible for HTN and viral replication.^32,33 Further, the addition of direct renin inhibitor has been shown to decrease the production of HIV viral proteins.³³ Our study showed that no patient was prescribed a direct renin inhibitor but patients were most commonly prescribed other RAAS antagonists such as ACEI/ARBs. An open-label, interventional pilot study in California showed that 17 hypertensive PWH treated with Telmisartan had a significant improvement in endothelial function among protease inhibitor-treated and abacavir-treated individuals.³⁴

Ucciferi et al. showed a major reduction in BP [9.2 ± 3.4 mm Hg (p = .006) for SBP and 11.9 ± 2.9 mm Hg (p = .001) for DBP] at week 144 when 13 Caucasian male hypertensive patients with HIV were longitudinally followed for 3 years on Telmisartan.³⁵ Vecchiet et al. showed that Telmisartan decreased both SBP and DBP in a prospective study of 18 HIV individuals with HTN at 6 months.³⁶ However, a few other studies have a different antihypertensive prescribed most commonly; Kwarisiima et al. showed that the most commonly prescribed anti-hypertensives were Bendroflumethiazide, nifedipine, atenolol, and captopril in that order among 2,038 PWH patients with HTN in Uganda, Africa in 2019.²⁴ The study defined HTN based on old guideline cut offs.

In this study describing HTN prevalence and control in a large longitudinal cohort, we found that the prevalence of HTN increased from 50.9% to 62.2% (22.2% increase), with the re-defined 2017 update in PWH. This was similar to the increases in HTN prevalence shown in other studies: Hyde et al. demonstrated a 44.3% increase in HTN prevalence, from 47.6% to 68.7% with the updated guidelines in Texas.³⁷ Sarfo et al. noted a 51.1% PWH with HTN per the new definition of HTN in Ghana⁹; however, the percentage increase in the HTN cases was not computed.

There was a disproportionate increase in the prevalence of HTN³⁸ and decreased HTN control²⁷ among African Americans with HIV compared with other races despite Blacks accounting for only 13% of the U.S. population.³⁹

There were a few limitations in our study. First, a hypothetical point in time was chosen immediately after the release of the new HTN guidelines, which could have contributed to increased prevalence of HTN. Second, our study cohort primarily consisted of non-Hispanic Blacks, which lowered the impact of evaluating racial differences in HTN prevalence and treatment. Third, there may be inconsistencies in BP measurement across the participating sites.

Fourth, we do not have data documenting adherence to medications. Fifth, employment status is not known in the majority of participants. The category “unknown” might be employed or unemployed. Fourth, there may be discrepancies in capturing co-variates across the participating sites. Sixth, our study included individuals who were engaged in care and therefore may have been more highly motivated in their HIV care. Hence, the generalizability of the study findings should be applied to similar cohorts.

In conclusion, we found that nearly two-thirds of PWH had HTN. Among PWH with HTN, less than one-third of those met new guideline criteria for having controlled HTN; and two-thirds were on anti-hypertensive medications. We also found that PWH less than 60 years old and African Americans have poorer HTN control. HTN treatment should be integrated into HIV management and may be incorporated into HIV treatment guidelines.

Community outreach programs should address the barriers to health care in PWH with special attention to younger population and African Americans and implement inexpensive interventions. Further, physicians managing HIV-infected patients should manage, educate, and counsel on compliance and HTN control in this vulnerable population.

Authors' Contributions

V.P.M.: Conceptualization, Methodology, Writing—original draft (lead), and Writing—review and editing (equal); M.L.: Methodology, Data curation, Formal analysis, Software, and Writing—original draft (supporting); M.B.: Formal Analysis, Software, Resources, and Writing—review and editing; A.M.: Conceptualization, Methodology, Writing—review and editing, and Supervision; L.P.H.: Formal Analysis, Software, and Resources; L.R.M.: Writing—review and editing (supporting); Amanda Castel: Writing—review and editing, Supervision; M.H.: Writing—review and editing, Supervision; R.W.: Conceptualization, Methodology, Writing—review and editing, and Supervision.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

The DC Cohort is funded by the National Institute of Allergy and Infectious Diseases, UM1 AI069503 and 1R24AI152598-01.

Supplementary Material

Supplementary Table S1