Abstract
Background
While antiretroviral therapy (ART) reduces AIDS-related morbidity and mortality, it is unclear if prolonged ART use among people living with HIV (PLHIV) increases the risk of hypertension.
Objective
We assessed the association between the duration of ART use and hypertension in the Rakai Community Cohort Study (RCCS).
Design
We conducted a cross-sectional study among PLHIV (35–49 years old) on ART in the RCCS who were surveyed between August 2016 and May 2018.
Methods
Systolic and diastolic blood pressure (BP) was measured twice, averaged, and classified as any hypertension (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg), severe or worse hypertension (systolic BP ≥ 160 mmHg or diastolic BP ≥ 100 mmHg), or hypertensive crisis (systolic BP ≥ 180 mmHg or diastolic BP ≥ 110 mmHg). ART duration was categorized as short (0–2 years), moderate (> 2–5 years), or prolonged (> 5 years). We used log-binomial regression to estimate the adjusted prevalence ratio (adjPR) of hypertension associated with ART duration.
Results
A total of 1,144 PLHIV on ART with documented BP information were identified in the RCCS, of whom 173 (15.1%) had any hypertension, 64 (5.6%) had at least severe hypertension, and 44 (3.8%) had hypertensive crisis. After controlling for age, sex, and body mass index, the prevalence of having all stages of high BP was increased by at least 42% in participants with more than five years of ART use (any hypertension adjPRs = 1.42 [95% CI = 0.99–2.03]; severe hypertension adjPRs = 1.79 [95% CI = 1.01–3.15]; and hypertensive crisis adjPRs = 2.56 [95% CI = 1.14–5.77]).
Conclusions
PLHIV on long-term ART have a higher burden of hypertension, highlighting the need for enhanced screening and integrated management in HIV programs.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12879-025-11004-3.
Keywords: Antiretroviral therapy (ART), HIV/AIDS, Hypertension, Non-communicable disease, Sub-Saharan Africa
Introduction
Hypertension rates are high globally and are a leading contributor to morbidity and mortality [1], although nearly half of people with hypertension are unaware of their condition [2]. In the general population, the main known risk factors of hypertension include non-modifiable factors such as age, genetics, and coexisting diseases like diabetes or kidney disease, and modifiable risk factors such as being overweight/obese, being physically inactive, smoking, consuming excessive amounts of alcohol, and having an unhealthy diet (diets high in salt, saturated, and trans fats, and low in fruits and vegetables) [3–6].
Among people living with HIV (PLHIV), hypertension was estimated to affect 25.2% overall, but was higher among antiretroviral therapy (ART)-experienced (34.7%) versus ART-naïve individuals (12.7%) [7]. Data from clinic-based studies suggest an excess risk of hypertension in PLHIV within the first year of ART use [8, 9] and that this risk may increase thereafter [10].
This finding could be explained by several factors. First, certain ART medications like older nucleoside reverse transcriptase inhibitors ([NRTIs]; e.g., AZT, ddI) have been associated with mitochondrial toxicity, which contributes to metabolic disturbances including hypertension [11]. Newer NRTIs (e.g., TDF) can also cause renal disturbances sometimes resulting in hypertension. Protease inhibitors (e.g., LPV/r and ATZ) have been associated with endothelial dysfunction, dyslipidemia, insulin resistance, and other features of metabolic syndrome. Even newer agents like integrase strand transfer inhibitors (e.g., DTG) have been linked to weight gain, which can subsequently increase blood pressure (BP) [8, 10, 12].
However, the observed association between ART and hypertension in PLHIV may be confounded by age since older persons are more likely to seek HIV care [13]. In addition, older PLHIV are at a higher risk of hypertension because of delayed ART initiation [14]. At the same time, PLHIV are living longer because of ART use [15–17]. Along with the success of extending the lives of PLHIV comes the increased risk of developing age-related diseases such as hypertension [18–20].
Some studies examining the association between HIV status/ART use and hypertension have found no association, including a large empirical study conducted with data from 44 countries in Africa [13]. In the setting of these conflicting findings, we note that the duration of ART use has not been well studied as a contributor to hypertension risk.
We conducted a retrospective cross-sectional study among PLHIV to study the independent association between ART duration and the burden of hypertension.
Methods
Study population
The study participants were PLHIV ages 35–49 with a known ART initiation date and who participated in the 18th survey round of the Rakai Community Cohort Study (RCCS) that was conducted between 2016 and 2018. The RCCS has been described elsewhere [21–23]. In brief, it is an open, population-based community cohort study that has been operated by the Rakai Health Sciences Program since 1994 in up to 40 agrarian, trading, and fishing communities located in Rakai and the neighboring districts of south-central Uganda. To identify eligible participants, the RCCS conducts a household census and then interviews consenting individuals ages 15–49 (the upper age limit was lifted in 2022). An extensive questionnaire is used to collect individual data in the RCCS that includes self-reported demographic and behavioral data, HIV testing history, and a section focused on non-communicable diseases, including the questions used in this study, which are shown in the supplementary file. Data on ART use is obtained from the HIV treatment clinics database through anonymized linkage that ensures participant confidentiality.
Measurement and classification of blood pressure (BP)
BP is measured only among RCCS participants aged 35 and above. Two BP measurements are performed during the RCCS individual participant interview at approximately one hour apart. The BP measurements are typically taken on the left arm with the participant in a seated position using a digital BP machine and a fitting cuff that is selected based on mid-upper-arm circumference (Omron) [22, 23].
In this study, BP was obtained by averaging the two readings of systolic and diastolic BP, which were then classified as hypertension (high BP stage 1), severe hypertension (high BP stage 2), and hypertensive crisis (high BP stage 3). Participants using BP medications were also classified as meeting criteria for any hypertension, severe hypertension, and hypertensive crisis (Table 1) [22, 23].
Table 1.
Classification of hypertension risk (adapted from the International Society of Hypertension [ISH] Global Hypertension Practice Guidelines) [1]
| BP category | Systolic (mmHg) | Diastolic (mmHg) | BP medications | ||
|---|---|---|---|---|---|
| Normal BP: Stage 0 | ≤ 139 | and/or | ≤ 89 | and | No |
| Hypertension (High BP Stage 1) | 140–159 | and/or | 90–99 | and/or | Yes |
| Severe Hypertension (High BP Stage 2) | 160–179 | and/or | 100–109 | and/or | Yes |
| Hypertensive Crisis (High BP Stage 3) | ≥ 180 | and/or | ≥ 110 | and/or | Yes |
Statistical analysis
We described the distribution of demographic and select health characteristics of eligible participants using proportions. We used log-binomial regression models to estimate univariable unadjusted prevalence ratios (PRs) and multivariable adjusted prevalence ratios (adjPRs) with corresponding 95% confidence intervals associated with high BP and with the primary exposure: the duration of ART defined as short (0–2 years), moderate (> 2–5 years), or prolonged (> 5 years). The primary outcomes were categorized as hypertension (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg), severe or worse hypertension (systolic BP ≥ 160 mmHg or diastolic BP ≥ 100 mmHg), or hypertensive crisis only (systolic BP ≥ 180 mmHg or diastolic BP ≥ 110 mmHg). Potential risk factors for hypertension included sex, age (categorized as 35–39 years, 40–44 years, and 45–49 years), marital status, body mass index (BMI) categorized as underweight (< 18.5 kg/m2), normal (18.5–24.9 kg/m2), or overweight + obese (≥ 25.0 kg/m2), and current smoking and alcohol use status. We also performed a sensitivity analysis to assess if ART regimen type modifies the association of ART duration and the prevalence of hypertensive crisis among study participants that had documented ART regimen types. Analyses were done with STATA, version 14.
Results
Participant characteristics
We identified 1,555 PLHIV that reported ART use, of whom 1,144 (73.6%) had documented ART duration information and were included in the analysis, while those with no documented ART duration were excluded. Of the 1,144 included, the majority were women (59%) and had normal BMIs (67%). Over one-third (450, 39.3%) had been on ART for up to two years, 417 (36.5%) for up to five years, and 245 (21.4%) for more than five years. Participants were relatively young: 42% were ages 35–39, 37% were ages 40–44, and 21% were ages 45–49. Fifteen percent (15%) reported that they were currently smoking and 49% reported alcohol use. Also, 14% were categorized as having any hypertension, 7% as having severe or worse hypertension, and 4% as having a hypertensive crisis (Table 2).
Table 2.
Demographic characteristics of the study participants
| Variable | Population (%) | |
|---|---|---|
| Overall | 1,144 | |
| Gender | ||
| Female | 675(59%) | |
| Male | 469(41%) | |
| Age (years): median (IQR) = 40 (37–44) years | ||
| 35–39 | 482(42%) | |
| 40–44 | 417(37%) | |
| 45–49 | 245(21%) | |
| Marital status | ||
| Never married | 40(4%) | |
| Married | 676(59%) | |
| Previously married | 428(37%) | |
| Smoking | ||
| No | 969(85%) | |
| Yes | 175(15%) | |
| Alcohol use | ||
| No | 584(51%) | |
| Yes | 560(49%) | |
| Body Mass Index (BMI): median (IQR) = 22.1 (20.1 − 25.0) | ||
| < 18.5 | 88(8%) | |
| 18.5–24.9 | 770(67%) | |
| ≥ 25.0 | 286(25%) | |
| ART Duration: median (IQR) = 3.8 (2.3—6.7) years | ||
| < 2 years | 450(39%) | |
| 2–5 years | 361(32%) | |
| > 5 years | 333(29%) | |
| Hypertensive | ||
| No | 979(86%) | |
| Yes | 165(14%) | |
| Severe hypertensive | ||
| No | 1066(93%) | |
| Yes | 78(7%) | |
| Hypertensive crisis | ||
| No | 1100(96%) | |
| Yes | 44(4%) | |
Association of ART duration and hypertension
The prevalence of any hypertension was greater among females than males in all stages of hypertension. Also, the prevalence of all stages of hypertension increased with longer ART duration regardless of sex differences (Fig. 1). In the bivariable analysis (Tables 3, 4, and 5), the prevalence of having all stages of hypertension increased after five years of ART use. Compared to the prevalence of hypertension in participants with no more than two years of ART use, any hypertension increased by 56% (PR = 1.56 [95%CI = 1.11–2.18]), severe hypertension or worse increased two-fold (PR = 1.99 [95% CI = 1.17–3.41]), and hypertensive crisis increased more than three-fold (PR = 3.11 [95% CI = 1.50–6.44]). These significant increases in hypertension prevalence after five years of ART use were sustained after controlling for potential risk factors in the multivariable analysis (Tables 3, 4, and 5). Compared to the prevalence of hypertension in participants with no more than two years of ART use, any hypertension increased by 42% (adjPRs = 1.42 [95% CI = 0.99–2.03]); severe hypertension or worse increased by approximately 79% (adjPRs = 1.79 [95% CI = 1.01–3.15]); and hypertensive crisis remained high at more than a two-fold increase (adjPRs = 2.56 [95% CI = 1.14–5.77]).
Fig. 1.
Association between ART duration and hypertension
Table 3.
Association between ART duration and any hypertension (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg) in people living with HIV
| Variable | Prevalence (n/N) | PR (95% CI) | p-value | adjPR (95% CI) | p-value |
|---|---|---|---|---|---|
| ART duration | |||||
| 0–2 years | 11.78(53/450) | Ref | - | Ref | - |
| > 2–5 years | 16.34(59/361) | 1.39(0.98–1.96) | 0.062 | 1.34(0.95–1.89) | 0.095 |
| > 5 years | 18.32(61/333) | 1.56(1.11–2.18) | 0.011 | 1.42(0.99–2.03) | 0.056 |
| Gender | |||||
| Female | 17.04(115/675) | Ref | - | Ref | - |
| Male | 1237(58/469) | 0.73(0.54–0.97) | 0.032 | 1.15(0.80–1.66) | 0.458 |
| Age (years) | |||||
| 35–39 | 11.62(56/482) | Ref | - | Ref | - |
| 40–44 | 16.79(70/417) | 1.44(1.04–2.00) | 0.027 | 1.34(0.97–1.86) | 0.080 |
| 45–49 | 19.18(47/245) | 1.65(1.16–2.36) | 0.006 | 1.60(1.11–2.32) | 0.011 |
| Marital status | |||||
| Never married | 20.00(8/40) | Ref | - | Ref | - |
| Married | 12.13(82/676) | 0.61(0.32–1.16) | 0.133 | 0.63(0.32–1.21) | 0.165 |
| Previously married | 19.39(83/428) | 0.97(0.51–1.86) | 0.926 | 0.95(0.50–1.80) | 0.870 |
| Smoking | |||||
| No | 15.79(153/969) | Ref | - | Ref | - |
| Yes | 11.43(20/175) | 0.72(0.47–1.12) | 0.148 | 0.87(0.55–1.39) | 0.567 |
| Alcohol use | |||||
| No | 16.27(95/584) | Ref | - | Ref | - |
| Yes | 13.93(78/560) | 0.86(0.65–1.13) | 0.271 | 0.93(0.70–1.23) | 0.608 |
| Body Mass Index (BMI) | |||||
| < 18.5 | 9.09(8/88) | Ref | - | Ref | - |
| 18.5–24.9 | 12.21(94/770) | 1.34(0.68–2.67) | 0.401 | 1.52(0.75–3.08) | 0.241 |
| ≥ 25.0 | 24.83(71/286) | 2.73(1.37–5.45) | 0.004 | 3.10(1.51–6.37) | 0.002 |
PR prevalence rate ratio, adjPR adjusted prevalence rate ratio
Table 4.
Association between ART duration and severe or worse hypertension (systolic BP ≥ 160 mmHg or diastolic BP ≥ 100 mmHg) in people living with HIV
| Variable | Prevalence (n/N) | PR (95% CI) | p-value | adjPR (95% CI) | p-value |
|---|---|---|---|---|---|
| ART duration | |||||
| 0–2 years | 4.67(21/450) | Ref | - | Ref | - |
| > 2–5 years | 7.20(26/361) | 1.54(0.88–2.70) | 0.128 | 1.48(0.84–2.59) | 0.171 |
| > 5 years | 9.31(31/333) | 1.99(1.17–3.41) | 0.012 | 1.79(1.01–3.15) | 0.045 |
| Gender | |||||
| Female | 8.44(57/675) | Ref | - | Ref | - |
| Male | 4.48(21/469) | 0.53(0.33–0.86) | 0.011 | 0.95(0.50–1.78) | 0.870 |
| Age (years) | |||||
| 35–39 | 5.19(25/482) | Ref | - | Ref | - |
| 40–44 | 7.19(30/417) | 1.39(0.83–2.32) | 0.213 | 1.23(0.73–2.08) | 0.433 |
| 45–49 | 9.39(23/245) | 1.81(1.05–3.12) | 0.033 | 1.72(0.99–2.98) | 0.054 |
| Marital status | |||||
| Never married | 7.50(3/40) | Ref | - | Ref | - |
| Married | 4.44(30/676) | 0.59(0.19–1.86) | 0.369 | 0.59(0.18–1.94) | 0.388 |
| Previously married | 10.51(45/428) | 1.40(0.46–4.31) | 0.556 | 1.24(0.40–3.84) | 0.712 |
| Smoking | |||||
| No | 7.12(69/969) | Ref | - | Ref | - |
| Yes | 5.14(9/175) | 0.72(0.37–1.42) | 0.345 | 0.99(0.48–2.04) | 0.980 |
| Alcohol use | |||||
| No | 7.02(41/584) | Ref | - | Ref | - |
| Yes | 6.61(37/560) | 0.94(0.61–1.45) | 0.782 | 1.06(0.69–1.64) | 0.793 |
| Body Mass Index (BMI) | |||||
| < 18.5 | 2.27(2/88) | Ref | - | Ref | - |
| 18.5–24.9 | 5.06(39/770) | 2.23(0.55–9.08) | 0.263 | 2.58(0.62–10.76) | 0.194 |
| ≥ 25.0 | 12.94(37/286) | 5.69(1.40–23.16) | 0.015 | 6.08(1.43–25.82) | 0.014 |
PR prevalence rate ratio, adjPR adjusted prevalence rate ratio
Table 5.
Association between ART duration and hypertensive crisis (systolic BP ≥ 180 mmHg or diastolic BP ≥ 110 mmHg) in people living with HIV
| Variable | Prevalence (n/N) | PR (95% CI) | p-value | adjPR (95% CI) | p-value |
|---|---|---|---|---|---|
| ART duration | |||||
| 0–2 years | 2.22(10/450) | Ref | - | Ref | - |
| > 2–5 years | 3.05(11/361) | 1.37(0.59–3.19) | 0.464 | 1.27(0.54–3.01) | 0.587 |
| > 5 years | 6.91(23/333) | 3.11(1.50–6.44) | 0.002 | 2.56(1.14–5.77) | 0.023 |
| Gender | |||||
| Female | 5.04(34/675) | Ref | - | Ref | - |
| Male | 2.13(10/469) | 0.42(0.21–0.85) | 0.015 | 0.90(0.40–2.01) | 0.797 |
| Age (years) | |||||
| 35–39 | 2.49(12/482) | Ref | - | Ref | - |
| 40–44 | 3.84(16/417) | 1.54(0.74–3.22) | 0.250 | 1.28(0.60–2.75) | 0.521 |
| 45–49 | 6.53(16/245) | 2.62(1.26–5.46) | 0.010 | 2.27(1.04–4.95) | 0.040 |
| Marital status | |||||
| Never married | 7.50(3/40) | Ref | - | Ref | - |
| Married | 1.92(13/676) | 0.26(0.08–0.86) | 0.028 | 0.24(0.06–0.87) | 0.030 |
| Previously married | 6.54(28/428) | 0.87(0.28–2.74) | 0.815 | 0.69(0.21–2.22) | 0.529 |
| Smoking | |||||
| No | 4.13(40/969) | Ref | - | Ref | - |
| Yes | 2.29(4/175) | 0.55(0.20–1.53) | 0.254 | 0.80(0.29–2.23) | 0.671 |
| Alcohol use | |||||
| No | 3.60(21/584) | Ref | - | Ref | - |
| Yes | 4.11(23/560) | 1.14(0.64–2.04) | 0.653 | 1.45(0.82–2.56) | 0.205 |
| Body Mass Index (BMI) | |||||
| < 18.5 | 1.14(1/88) | Ref | - | Ref | - |
| 18.5–24.9 | 2.73(21/770) | 2.40(0.33–17.64) | 0.390 | 3.26(0.44–24.15) | 0.247 |
| ≥ 25.0 | 7.69(22/286) | 6.77(0.92–49.55) | 0.060 | 8.14(1.12–59.28) | 0.039 |
PR prevalence rate ratio, adjPR adjusted prevalence rate ratio
In the sensitivity analysis, we found that 55% and 44% of participants were initiated on ART regimens containing lamivudine/efavirenz (3TC/EFV) and lamivudine/nevirapine (3 C/NVP), respectively. When we compared five years of ART use to less than two years of ART use, we found a six-fold and four-fold increase in the prevalence of severe hypertension for 3TC/EFV and 3TC/NVP respectively (adjPR = 6.39 [95% CI = 1.21––33.87]) and (adjPR = 4.74 [[95% CI = 1.05––21.40]).
Discussion
In this population-based study, the prevalence of all stages of hypertension increased significantly after five years of ART treatment. The dose–response analyses in our study confirmed previous clinic-based findings that suggested higher levels of hypertension after ART initiation [9, 10, 20, 24]. Importantly, we controlled for age in our analyses. Furthermore, the associations we observed with severe hypertension and with hypertensive crisis further suggest that long-term ART is associated with the development of hypertension. Together, these findings highlight the need to screen for hypertension in PLHIV as they live longer on ART.
The prevalence of any hypertension in our study was 15.1%, which is similar to the prevalence found in other studies in Uganda and elsewhere in Africa [9, 10, 25–27], but with variations between different settings. For example, in Uganda, the earlier reported rates of hypertension among PLHIV ranged from 8 to 11% in rural-based populations [25, 28] to a high of 27.2% among hospitalized patients in the capital city of Kampala [29]. In South Africa, hypertension prevalence ranged from 38.6% to as high as 50.1% among PLHIV [30, 31]. First, these results suggest a relatively high burden of hypertension among PLHIV in sub-Saharan Africa. Second, the differences in hypertension prevalence among PLHIV may be attributed to some studies choosing to use different guidelines for hypertension cut-offs, duration of ART exposure, duration and status of HIV infection, type of ART exposure, study design, or lifestyle differences [29, 32]. Furthermore, it may be a result of differences in age distribution; for example, our study population was relatively young (median age of 40 and no older than 49 years) compared to the reference studies that included older age groups (50 years and above).
In our study, hypertension was more prevalent in females than males, contrary to previous studies that reported higher hypertension in males [10, 13, 26, 31, 33]. While we did not study the underlying cause of this finding, a previous study indicated that females in similar populations may experience pregnancy-related high BP risk factors such as sustained vascular disorders, overweight issues, and socioeconomic deprivations that predispose them to high BP [34].
High BMI (a modifiable risk factor) was associated with hypertension as found in other studies [4, 13, 35–37]. This is not surprising because being overweight or obese is known to contribute directly to incident cardiovascular risk factors, including dyslipidemia, hypertension, and type 2 diabetes, which may lead to the development of cardiovascular disease [38]. The effect of BMI on hypertension is mediated through increasing visceral adipose tissue [39, 40].
Age was also associated with hypertension as expected for the general population. Age in our study was an independent predictor of hypertension that was consistent with other studies reporting that middle-aged individuals (45–49 years) have more than twice the risk of developing hypertension compared to 35–39 year olds [4, 29, 32, 35]. This is expected because middle- and older-aged people are known to have a much higher risk of developing non-communicable diseases compared to younger people [4, 10, 35, 41]. The increased life expectancy due to ART and the increased risk of developing age-related non-communicable diseases [4, 9, 13, 26, 27, 33, 35, 42, 43] underscores the importance of monitoring and managing hypertension and its risk factors in PLHIV.
We did not find an association between hypertension and smoking or alcohol use, as was reported in another study conducted in similar settings [26]. In fact, globally, smoking and alcohol use are well known risk factors of hypertension [44, 45]. We believe the lack of association was a result of low smoking rates in the study population and a lack of data on the frequency or patterns of use, which inhibited our ability to accurately measure the burden of smoking or alcohol use [26].
Our study had some limitations. First, we were unable to ascertain a temporal association (i.e., whether hypertension developed before or after ART initiation). Our study was a secondary analysis of a retrospective, population-based study that was not primarily designed to study the research question. We also had limited data on known confounding factors such as vegetable intake, exercise, and quantities of smoking and alcohol intake. Pertinent modifiable risk factors like diet (salt, saturated/trans-fat, fruit and vegetable consumption) and physical activity were not available in the study. Also, assessing the association of ART duration and hypertension for specific drugs or drug classes was complicated by the fact that patients are taking multiple ART drugs whose combined effects are unclear, and regimens may change with time. Lastly, our study lacked data for older individuals (> 49 years) who constitute an important proportion of PLHIV who are at risk for hypertension.
Conclusions
The prevalence of hypertension increased with prolonged duration of ART, highlighting the need for integrating hypertension screening and management in HIV programs. Further studies are needed to elucidate the mechanism through which prolonged ART use is associated with a higher burden of hypertension.
Supplementary Information
Acknowledgements
We thank the Rakai Community Cohort Study participants, staff, and local community leaders who have made this study possible.
Disclaimer
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the funding agencies.
Abbreviations
- ART
Antiretroviral therapy
- PLHIV
People living with HIV
- RCCS
Rakai Community Cohort Study
- BP
Blood pressure
- AIDS
Acquired Immune Deficiency Syndrome
- NRTI
Nucleoside reverse transcriptase inhibitors
- AZT
Zidovudine
- ddI
Didanosine
- LPV/r
Lopinavir/Ritonavir
- TDF
Tenofovir disoproxil fumarate
- DTG
Dolutegravir
- ISH
International Society of Hypertension
- IRB
Institutional Review Board
- JHU
Johns Hopkins University
- 3 TC
Lamivudine
- EFV
Efavirenz
- NVP
Nevirapine
Authors’ contributions
GMB and SJR led conceptualization of the study. GMB and VS analyzed and interpreted data and wrote the manuscript. AN, DN, JB, ENK, FN, GN, JK, LWC, TCQ, RHG, MJW, GK, and SJR provided oversight for study coordination, data collection, and laboratory testing. LWC, JB, WP and SJR supported concept development, data interpretation, and manuscript editing. All authors participated in data interpretation, manuscript revisions, and final manuscript approval.
Funding
The study was funded by the National Institutes of Health (NIH), Division of Extramural Research, National Institute of Allergy and Infectious Diseases. Support for HIV care and treatment was provided by The President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (cooperative agreement number NU2GGH000817). We also thank the cohort participants, staff, and local community leaders who have made this study possible. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the funding agencies, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.
This project has been funded in whole or in part with federal funds from the National Cancer Institute, National Institutes of Health, under Contract No. 75 N910D00024, Task Order No. 75 N91019 F00131. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.
The project also benefited from the National Heart, Lung, and Blood Institute (R01HL107275), Fogarty International Center (D43 TW010557).
Data availability
De-identified data that underlie the results reported in this article can be requested through the corresponding author for approved research concepts.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the Declaration of Helsinki and was approved by the Uganda Virus Research Institute’s Research Ethics Committee (No: GC/127/19/11/137) and the Uganda National Council for Science and Technology (HS 540). Approval was also obtained from institutional review boards (IRBs) of collaborating institutions, including the Committee for Human Research at the Johns Hopkins University School of Public Health and School of Medicine (JHU NA_00069085) and the Western University IRB. All participants provided written informed consent for the RCCS that included conduct of future studies using de-identified data to answer research questions that inform routine patient care management. The data on ART use was obtained under a protocol approval to conduct evaluations using the ART program data.
Consent for publication
Not applicable.
Clinical trial
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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