Global health solidarity in the HIV and hypertension disease response

A person-centered perspective on the burden of the HIV epidemic clearly indicates that the consequences of the epidemic are far from resolved. In addition to the ongoing challenges related to HIV care, which disproportionately affect individuals in low-income and middle-income countries, people with HIV (PWH) are increasingly facing the burden of noncommunicable diseases. Hypertension is a significant concern because of its global prevalence, the severe risks associated with untreated cases, its asymptomatic progression, and the unique tendency for individuals with PWH to develop it [1]. Moreover, managing hypertension is technically straightforward, although effectively implementing treatment can be challenging. PWH in recipient countries of the President's Emergency Plan for AIDS Relief (PEPFAR) program are at an advantage owing to the health system strengthening efforts of the early HIV epidemic that can be leveraged for other conditions. As Rabkin and El-Sadr [2] advised over a decade ago, we, therefore, do not need to ‘reinvent the wheel’ to tackle noncommunicable diseases among PWH in these areas.

Numerous studies, including some of our own work [3], have shown a high prevalence of hypertension in PWH but prevalence estimates are inadequate for designing effective public health strategies. The fragmented approach to data collection in many HIV care programs generally hinders the capacity to track ecological trends in blood pressure for PWH in most sub-Saharan Africa (SSA) settings. In this issue of AIDS, Suvada et al.[4] address this notable gap by examining 20 years of clinically obtained blood pressure measurements from PWH in the Coptic Hope Center clinics in Kenya. In a carefully designed analysis of prevalence and incident cases, the authors chief findings are that 42% of PWH had high blood pressure at entry into HIV care, nearly 40% develop incident high blood pressure over 20 years and average high blood pressure at entry into care has trended upward. The annual incidence of high blood pressure among PWH after reaching a steady state was approximately 1500 per 100 000 population.

The authors handled these clinically obtained data carefully. It is noteworthy that when more blood pressure measures were included in their sensitivity analyses (as opposed to once per year), the trends in high blood pressure were attenuated suggesting that adjustment for regression to the mean should be incorporated in future analyses. There was no HIV-uninfected comparator group to contextualize the raw trends. However, the prevalence of high blood pressure in the Coptic cohort in 2015, which exceeded 50%, was higher than that observed in the Kenyan general population during the same period (24%).

Although there are myriad causes of high blood pressure in PWH, the relevance of antiretroviral therapy, particularly dolutegravir (DTG), warrants further exploration. Suvada et al. observed an increase in the prevalence of high blood pressure that aligned temporally with the introduction of DGT in antiretroviral therapy (ART) regimens in Kenya. Observational and randomized studies examining the relationship between DTG and high blood pressure have had inconsistent findings [5–7]. The present study is far from confirmatory on this issue, however, the authors shine a critical light on the need to measure and manage cardiometabolic disturbances associated with DTG, such as high blood pressure, in the SSA region where the ravages of unknown, untreated, and uncontrolled blood pressure run rampant.

These findings highlight that our cardiovascular risk reduction approaches in HIV care have not sufficiently addressed high blood pressure. The Randomized Trial to Prevent Vascular Events in HIV (REPRIEVE) demonstrated the life-saving benefits of managing low-to-moderate cardiovascular risk in PWH through lipid-lowering therapy [8]. Additionally, REPRIEVE revealed that beyond lipid control, numerous other aspects of cardiovascular health promotion, including high blood pressure management, physical activity, and healthy diet, receive inadequate attention [9]. Importantly, the mean age at entry into care at Coptic (38 years) was below the threshold for which we traditionally apply atherosclerotic cardiovascular disease risk calculators to determine eligibility for statin therapy (40 years). We must pay attention to cardiovascular risk reduction even when the intervention extends beyond statin therapy. The findings of Suvada et al. support a more capacious perspective on cardiovascular risk reduction, extending beyond statin therapy alone.

So, how might we do something as simple as measuring and managing blood pressure more frequently in PWH in settings like Coptic? The World Health Organization HEARTS Technical package provides some guidance. In addition to modules related to clinical practice, access to medications, and the structures of teams, the HEARTS package accentuates the role of a well designed electronic medical record (EMR). Where one exists and is operational, a CVD module could be included in the EMR. Leveraging EMRs, and strengthening existing health systems (policy and financing) to facilitate integration of linkages between HIV service delivery and multimorbidity management, are crucial steps towards whole-person-health with significant impact for aging PWH [10,11].

Kenya is ahead of the curve in some ways. Significant investments by the Ministry of Health and private entities have yielded integrated EMRs that extend beyond facility-level HIV care delivery. Guided by a national eHealth strategy, several EMR systems have been deployed across public health facilities to enhance data portability, interoperability, and thereby improve operational efficiencies and health outcomes. EMRs established through several PEPFAR supported HIV care programs have been at the forefront of these efforts and facilitated the evolution of the digital health ecosystem towards a focus on population health, with an emphasis on management of risk factors such as high blood pressure [12]. This is a valuable initial step. A whole-health-system response to the contemporary HIV epidemic requires that we respond to the trends in prevalence and incidence uncovered by Suvada et al. to address the critical unmet need for managing high blood pressure in PWH as a vital component of cardiovascular health for the SSA region.

Acknowledgements

Conflicts of interest

There are no conflicts of interest.