High Blood Pressure Increases Mortality Among HIV Seropositive Individuals Without AIDS in Western Kenya Gerald S. Bloomfield 1, Joseph W. Hogan 2, Alfred Keter 3, Thomas L. Holland 1, James Osanya 3, Edwin Sang 3, Sylvester Kimaiyo 3, Eric J. Velazquez 1 1 Duke University, Durham, NC, USA; 2 Brown University, Providence, RI, USA; 3 Moi University School of Medicine, Eldoret, Kenya AHA Scientific Sessions 2012 Abstract # 10909

Financial Disclosures NoneNone

Background HIV is associated with cardiovascular (CV) diseaseHIV is associated with cardiovascular (CV) disease Most (>60%) HIV+ patients reside in Africa but CV risk in this population is not well- studiedMost (>60%) HIV+ patients reside in Africa but CV risk in this population is not well- studied Call for integration of communicable / non- communicable disease care in low- and middle-income countriesCall for integration of communicable / non- communicable disease care in low- and middle-income countries -United Nations High Level Meeting 2011

Rationale Despite importance of CV disease globally and large HIV burden in Africa, no studies examining CV disease and mortality in HIV in the regionDespite importance of CV disease globally and large HIV burden in Africa, no studies examining CV disease and mortality in HIV in the region

Among Kenyan HIV+ patients without AIDS:Among Kenyan HIV+ patients without AIDS: –High blood pressure is associated with higher risk of death –The blood pressure-mortality relationship varies with World Health Organization HIV clinical stage Hypotheses

Methodology Retrospective analysis of clinically-obtained patient medical recordsRetrospective analysis of clinically-obtained patient medical records Large HIV treatment program in KenyaLarge HIV treatment program in Kenya –Academic Model Providing Access to Healthcare (AMPATH) –>115,000 adults enrolled from >20 clinics –Blood pressure from electronic medical record

Study Site

Methodology Included data for , ≥16 years oldIncluded data for , ≥16 years old Excluded those with AIDS, missing blood pressure,CD4 count or pregnantExcluded those with AIDS, missing blood pressure,CD4 count or pregnant Categorized age, CD4, and blood pressureCategorized age, CD4, and blood pressure –Systolic BP: <100, , , ≥ 140 Calculated:Calculated: –Unadjusted mortality incidence rate –Risk of death with proportional hazards regression models

Results 30,231 patients30,231 patients Median age 33.5 years (28-41), 75% female, CD4 396 ( ), 60% on HIV therapyMedian age 33.5 years (28-41), 75% female, CD4 396 ( ), 60% on HIV therapy Incidence rate (IR) of death higher if SBP ≥140Incidence rate (IR) of death higher if SBP ≥140 SBP in mmHg Person years (pyrs) DeathsIR per 100 pyrs (95% CI) < ( ) ( ) ( ) ≥ ( ) Overall ( )

Proportional Hazard of Death Other covariates: age, diastolic BP, creatinine, body mass index, hemoglobin, anti-retroviral therapy, residence, marital status, sex in combined analysis VariableWomen (n=16489) Men (n=5507) Combined (n=22356) Systolic BP in mmHg < ( )1.3 ( )1.3 ( ) ref ( )0.8 ( )0.9 ( ) ≥ ( )2.0 ( )1.8 ( ) WHO HIV Stage 1ref 21.5 (1.2 – 1.8)1.4 (1.1 – 1.8)1.4 (1.2 – 1.7) 32.3 (1.9 – 2.9)2.0 (1.5 – 2.7)2.2 (1.8 – 2.6) CD4 < (1.8 – 2.6)1.6 (1.3 – 2.1)1.9 (1.7 – 2.3)

Mortality Rate Stratified by SBP & WHO Stage Mortality Systolic BP --- < ≥140 Time in Years SBP, Stage 1SBP, Stage 2SBP, Stage

Conclusions High blood pressure is associated with high death rate in HIV+ Kenyans without AIDSHigh blood pressure is associated with high death rate in HIV+ Kenyans without AIDS The effect of high blood pressure on mortality is comparable to that of HIV immune statusThe effect of high blood pressure on mortality is comparable to that of HIV immune status Greater effect of SBP on mortality with worse clinical stage of HIVGreater effect of SBP on mortality with worse clinical stage of HIV Limitations: Observational study, clinically- obtained dataLimitations: Observational study, clinically- obtained data

Implications Blood pressure control is a missed opportunity to modify health in HIV+Blood pressure control is a missed opportunity to modify health in HIV+ There is need for expansion of HIV programs to address CV diseases (IOM report 2010)There is need for expansion of HIV programs to address CV diseases (IOM report 2010)