Commentary: Impact of new hypertension guideline among people living with HIV in Ghana

In this issue of The Journal of Clinical Hypertension, Sarfo and colleagues' article titled “Characteristics of Hypertension among People Living with HIV in Ghana: Impact of New Hypertension Guideline” examines the effect of the 2017 American College of Cardiology/American Heart Association (2017 ACC/AHA) guideline1 on classification and prevalence of hypertension among people living with HIV (PLWH) in Ghana. The authors found a substantial increase in the prevalence of hypertension among PLWH both receiving and not receiving combination antiretroviral therapy (cART) due to change in blood pressure (BP)‐lowering goal as per the 2017 ACC/AHA guideline. The prevalence of hypertension would increase from 36.9% to 57.2% and from 23.4% to 42.3% among PLWH on cART and PLWH cART naïve, respectively. These findings are timely and of great significance because of the relatively high burden of HIV and paucity of data on the prevalence of and risk factors for hypertension among PLWH in Ghana. Not surprisingly, a large proportion of PLWH would be classified as having hypertension if the 2017 ACC/AHA guideline is adopted in Ghana. However, more considerations are needed before the implementation of this guideline among Ghanaian population in which there is no solid evidence supporting a more aggressive BP‐lowering target especially among PLWH.

HIV infection and frailty—a clinical syndrome characterized by reduced resilience to stressors—have biological similarities. Although the biological underpinning and natural history of frailty are not completely understood, the common belief is that frailty results from aging‐related declines across multiple physiological systems such as immunologic dysregulation and sarcopenia.2, 3 In addition, the clinical signs of frailty—slowness, loss of muscle strength, low level of physical activity and energy, and wasting—resemble to symptoms observed among PLWH. A large body of empirical evidence suggests that PLWH have an accelerated aging process and HIV infection is associated with premature development of frailty.4, 5, 6 The prevalence of frailty among HIV‐infected patients is much higher than the general population.7

The appropriate treatment of hypertension among older adults, especially those who are very old or frail, has been hotly debated. Evidence from randomized controlled trials and observational studies suggests that the ideal BP target for treatment is likely to be multiple‐choice question with more than one correct answer. Results from the Hypertension in the Very Elderly Trial (HYVET) and the Systolic Blood Pressure Intervention Trial (SPRINT) have demonstrated that some older adults will benefit from blood pressure lowering.8, 9 On the contrary, there has been a large body of epidemiological evidence showing that markers of frailty or functional status including gait speed,10 grip strength,11 disability in activities of daily living,12 physical limitation,13 and cognitive function14 could modify the association between BP and adverse outcomes such as mortality, cardiovascular disease, and falls. One possible explanation for the discrepancy in evidence from clinical trials and observational studies is that older patients in trials are selective because of stringent inclusion and exclusion criteria. Therefore, results from trials may not be generalizable to the general older population. The HYVET participants had lower levels of cardiovascular comorbidity than participants in the National Health and Nutrition Examination Survey.15 In addition, only 19.5% and 34.6% of US adults aged 60‐74 and 75+ years were eligible for the SPRINT, respectively.16

PLWH, like older adults, are a highly diverse and complex population. It is unlikely that there is a universal BP goal in this population, and therefore, the scientific community should strive to establish the ideal target for each patient individually. Clinical trials with predefined subgroup analyses based on participants' functional status may help us reach the goal of treating patients who may benefit the most from BP lowering. In consideration of the many difficulties of including PLWH in trials, observational studies, when conducted appropriately to address confounding and bias, could add to the body of evidence among those who are ineligible for a clinical trial.

CONFLICT OF INTEREST

Dr Chenkai Wu provides paid consultative services to HealthkeeperS, a health data analytics company in China.