Prevalence and Factors Associated with Hypertension Among HIV Positive Patients on Antiretroviral Therapy: A Hospital-Based Cross-Sectional Study in Rwanda

Introduction

The Human Immunodeficiency Virus (HIV) poses a significant global public health threat, with its increasing association with cardiovascular complications, cerebral-vascular incidents, and vasculopathy over the past two decades.¹ These HIV-related complications contribute to elevated mortality and morbidity rates in both developed and developing countries.^2,3 Hypertension, a top contributor to cardiovascular diseases and a global leading cause of death, is notably prevalent among individuals with diabetes, with over 45% of diabetic patients succumbing to complications related to hypertension.^4–6 To combat this health concern, antiretroviral therapy (ART) plays a essential role in enhancing the quality of life for people living with HIV (PLWH).^7,8 Globally, recent reports indicated 38.4 million people living with HIV (PLWH) of which 25.4 million PLWH access to ART. This pandemic remains harmful in Sub-Saharan African (SSA) region where one in 25 adults has been living with HIV accounting two-thirds of global cases.^9,10 Prior studies stated that hypertension remains inadequately addressed and diagnosed within the rural areas from SSA.^7,8 Additionally, studies have shown that individuals on ART are prone to alterations in lipoprotein density cholesterol (HDL) or high-density lipoprotein levels, elevating their hypertension risk.¹¹ The target to achieve the third Sustainable Development Goal (SDG-3) is to reduce HIV/AIDS prevalence by 90% by 2030. This necessitates intensive efforts on hypertension management and the spread of sexually transmissible infections.¹²

Although the prevalence of hypertension among PLWH is relatively lower in SSA and Asia compared to North America, Europe, and South America, the impact is more pronounced in SSA.^8,13 The World Health Organization (WHO) forecasts an increase in non-communicable diseases (NCDs), with hypertension driving complications such as diabetes, stroke, and ischemic heart diseases.⁸ While only 16.2% of individuals in SSA countries have hypertension, a significant proportion consists of HIV-positive patients.^7,14 In Rwanda, hypertension prevalence was 15.6%, rising with age.^15,16

Earlier research has comprehensively documented a range of factors that contribute to hypertension among PLWH. These factors encompass various behavioural aspects, including poor nutritional habits, non-compliance with prescribed treatments, alcohol consumption, and smoking.^17,18 Moreover, the frequencies of clinical visits and engagement in physical activity, including sports participation, have been recognized as contributing factors.^19,20 Socio-demographic factors, such as place of residence or urbanization, age, gender, education, and marital status, also influence the occurrence of hypertension among PLWH. For instance, hypertension tends to be more prevalent among adult PLWH compared to their younger counterparts.²¹ This health concern is intricately linked with clinical factors, such as longer duration of HIV infection, a family history of hypertension, low CD₄ cell count, elevated viral loads, diabetes, an extended duration of HIV infection, and specific medication use, often in conjunction with ART.^22,23 Additionally, a higher body mass index has been identified as another risk factor for hypertension. Notably, the utilization of ART has previously been acknowledged as a contributing factor underlying hypertension among PLWH.^7,24

Previous studies underscore the fact that a considerable number of individuals are unaware of their hypertension status.^19,25 Rwanda is positioned among countries undergoing developmental transitions, with a heightened focus on the epidemiology of hypertension. This health concern has been recognized as a multifaceted catalyst for diverse health complications, contributing to increased morbidity and mortality in the absence of early preventive measures and treatments. Within the Rwandan population, a study conducted in 2013 revealed a prevalence of 36.1% of cardiovascular disease (CVD) among workers, of which approximately 33% were unaware of their hypertension diagnosis.¹⁵ Moreover, the context of HIV infection has shown associations with subclinical atherosclerosis indicators, including markers of endothelial dysfunction, escalated arterial stiffness, and atherosclerotic progression.^26,27 These factors collectively increase the vulnerability of individuals to hypertension, particularly when combined with other recognized hypertension risk factors, such as being aged 45 years and above, being male, engaging in smoking and alcohol use, grappling with obesity and diabetes, maintaining a sedentary lifestyle, and possessing a family history of hypertension.^28–30

Poorly controlled hypertension stands as a significant contributor to cardiovascular disease not only in HIV patients but also general population of sub-Sahara Africa.^31,32 This exerts a profound impact on overall health outcomes.³³ The increasing adoption and adherence to ART among PLWH might hold potential in addressing this prevalent health issue. As hypertension is a substantial risk factor of cardiovascular disease, understanding its prevalence and its determinants among PLWH assumes paramount importance for policymakers and the affected community. Yet, despite the awareness of hypertension as a public health concern, a critical research gap persists particularly in the rural settings of Rwanda. This study aims to fill this critical gap by rigorously examining the prevalence of hypertension and its associated factors among HIV patients at Gicumbi District Hospital. By researching into this underexplored area, our purpose is to establish a deeper understanding and potentially uncover essential insights that can inform targeted interventions and healthcare strategies tailored to this specific population.

Methods

Study Design

A hospital-based cross-sectional study was conducted among all people with HIV attending ART in the department of HIV at the Byumba District Hospital located in Gicumbi District.

Study Settings and Participants

The study was conducted at Byumba District Hospital in Gicumbi District whereas this District is located in Northern Province of Rwanda. Byumba District Hospital oversees 25 health centres; this District Hospital is located in Byumba District, Northern Province of Rwanda, which accommodates a population of 428,203 segmented into 21 administrative Sectors. As for the inclusion criteria, the study encompassed PLWH who were at least 14 years of age and had been on ART for a minimum of 6 months within the study area. Those who declined participation for any reason, and individuals with incomplete information in their medical records were also excluded.

Sample Size

We used Cochran formula to determine a sample size for this study.³⁴ This formula was applied in consideration of the following statistical parameters; 95% of confidence intervals (zα/₂=1.96), 5% of statistical significance (d = 0.05), 5% non-response rate, and taking the prevalence (50%) of hypertension (p = 0.50, q = 1-p). Hence, the total sample size of 406 participants was randomly enrolled in this study from 669 HIV positive on ART who were under ART at Byumba District Hospital.

Data Collection

Data collection was performed by the general nurse under supervision of the first author of this study. In addition to that, a simple random sampling technique was used to recruit study participants during their follow-up visits; the study participants were drawn by lottery from the total patients on follow-up from their registries.

Study Variables

Dependent variable of the study is hypertension status (having hypertension according to the definition or not having hypertension). Hypertension is according to self-reported ongoing antihypertensive treatment, or systolic blood pressure (SBP ≥ 140 mmHg) and diastolic blood pressure (DBP ≥ 90 mmHg).³⁵ Our independent variables included socio-demographic variables (such as age, sex, religion, education level, marital status, occupation and social category,³⁶ behavioral variables such as smoking and alcohol use. Social category (also known as Ubudehe category) refers to a traditional classification system in Rwanda used to categorize households based on socio-economic status. This classification helps in identifying vulnerable households and allocating resources and support accordingly. The categories range from 1 to 4, with the first category representing the most economically challenged households and the fourth category representing the most prosperous ones. This system also plays a significant role in various aspects of social welfare, resource allocation, and development programs in Rwanda.³⁷ Smokers were defined as those who had consumed at least one cigarette or other local tobacco product within the previous 24 months before the data collection. Based on the frequency and volume of alcohol consumed during a normal drinking week, alcohol consumption was dichotomously classified as yes (for those who consume alcohol) and no (who never consume alcohol).

After at least 15 minutes of relaxation, we adopted a sitting position and used an automatic or validated oscillometer device to measure (OMRON HEM-7322U) SBP and DBP. In accordance with the 2018 ESC recommendations, three measures were made in each arm at 5-minute intervals.³⁵ Weight of the study participant was measured in light clothing and without shoes, and height was calculated to the nearest 0.1 cm using a stadiometer. Weight (kg)/height was used to determine the body mass index (BMI) (m²). BMI was divided into four categories: underweight (BMI = 18.5 kg/m²), normal weight (18.5–24.9 kg/m²), overweight (BMI=25-29.9 kg/m²), and obese (BMI = 30 kg/m²). According to the WHO 2020 guidelines, adequate physical activity is defined as 150 minutes of moderate or vigorous activity each week, or at least 75 minutes of each.⁸ In our study, we used “Physical Activity Logs or Diaries” to gauge the physical activities of our research participants. These logs served as a means for participants to meticulously document their daily or weekly activities, noting the duration and intensity of each. This method enabled us to ascertain whether individuals were actively involved in physical activities (recorded as 1 = active) or not (recorded as 0 = less active). The assessment of these logs involved specific criteria: (a) the frequency of participation in physical activities, (b) the duration of each activity session, (c) the intensity level of the activities, (d) ensuring that the recorded activities aligned with the definition of physical activity (eg, exercises, sports, recreational pursuits, household chores, walking), and (e) the consistency of participants in engaging in physical activities within a predetermined timeframe (eg, weekly) to qualify as regular practitioners. Further, we categorized individuals as physically active if they met the following conditions: (a) involvement in physical activities on a minimum of 3 days per week, (b) each activity session lasting at least 20 minutes, and (c) participation in activities ranging from moderate to vigorous intensity. In addition to physical activity, diabetes was defined as having a fasting blood glucose level of 126 mg/dL (7 mmol/L)³⁸ or higher, or if you are currently taking diabetes medication. Clinical data such as HIV infection duration, ART duration, HIV clinical stages, and ART regimen types were collected. Respondents with viral loads of 1000 copies/mL were considered to have viral suppression, whereas viral loads of 50 copies/mL are considered undetectable Further, a self-report questionnaire was used to collect socio-demographic and behavioural variables. Clinical examinations and laboratory tests (such as viral loads, CD₄, and ART regimen) were performed. Clinical data were extracted from the medical records from HIV unit.

Statistical Analyses

The data from the field was entered into an excel sheet. The STATA version 13 was used for descriptive and analytical analyses. Descriptive statistics were used to summarize, organize sample characteristics, describe research variables and document response rate where frequency tables were presented. Cross tabulations and proportions between independent and dependent variables were performed. Bivariate logistic regression analysis was performed based on crude odds ratios (COR) to examine the significant variables of hypertension among study participants. Additionally, all statistical significant variables in bivariate logistic regression analysis were exported into multivariate logistic regression models that determined the adjusted odds ratios for the factors associated with hypertension. The significance of the findings was set at p < 0.05 and 95% of confidence intervals was considered.

Results

Basic Characteristics of the Study Participants

A total of 406 PLWH took part in this study. The average age of the participants was 37.91 age (SD = 2.12). A notable proportion (50.5%) of these participants fell into the age group of 40 years or younger. The sex distribution showed that the majority (52.2%, n = 212) were females, while approximately three-quarters (75.4%) were engaged in farming activities as their primary source of income. In terms of religious affiliation, a significant percentage (84.4%) identified as Christians, and more than half (56.9%) were married. Educational background analysis revealed that nearly 68% of the PLWH had received primary school education. Additionally, findings indicated that 35.9% of the participants were consumers of alcohol, 7.4% were smokers, 28.6% reported being physically inactive, and 46.1% were classified as overweight or obese. Furthermore, the study unveiled that 62.3% of the participants had been living with HIV for more than 3 years, and 67.5% had been on ART for over a year. Ultimately, the study reported a prevalence of hypertension at 22.4% (Table 1).

Table 1 Descriptive Statistics of Socio-Demographic, Lifestyle and Clinical Characteristics of the Study Participants (n=406)

Prevalence and Bivariate Analysis of Factors Associated with Hypertension

Our results from the bivariate logistic regression analyses revealed significant associations between hypertension and variables including that age, BMI, smoking, alcohol use, living with diabetes and family history of hypertension. Being aged over 41 years was notably associated with an increase hypertension risk [COR =  3.29; 95% CI = 1.98–5.46] compared to those under 41 years. Smoking [COR = 12.24; 95% CI (5.23; 28.63)] and alcohol use [COR = 2.33; 95% CI = 1.45–3.75] were significantly associated with hypertension. Further, PLWH with overweight or obesity presented a significant association with hypertension [COR =  3.29; 95% CI = 1.98–5.46] relative to those without excess weight. Individuals with a history of diabetes were more prone to hypertension [COR = 2.1; 95% CI = 1.83–5.8] than their counterparts without such a diagnosis (Table 2).

Table 2 Prevalence of Hypertension by Socio-Demographic, Lifestyle and Clinical Characteristics and Bivariate Analysis of Factors Associated Hypertension

Multivariate Logistic Regression Models for the Associated Factors of Hypertension

The findings from multivariate logistic regression models demonstrated that BMI, age, family history of hypertension, smoking, and living with diabetes were noteworthy risk factors associated with hypertension. Specifically, individuals aged 41 years and older showed significantly greater odds of hypertension in comparison to those aged between 14 and 40 years [AOR = 4.49; 95% CI = 2.45–8.21, p < 0.001]. Further, smokers were more likely to be hypertensive [AOR = 12.12; 95% CI = 4.48–32.74, p < 0.001] compared to non-smokers counterparts. Those who reported alcohol consumption were nearly six times more likely to experience hypertension [AOR = 5.5; 95% CI = 2.75–10.9, p < 0.001] than non-consumers of alcohol. Similarly, individuals with a family history of hypertension were at higher likelihoods to be hypertensive [AOR = 4.28; 95% CI = 1.01–18.13, p = 0.049] than those without such a history. Additionally, diabetics were nearly 6 times more likely to experience hypertension [AOR = 4.50; 95% CI = 2.55–7.95, p = 0.018] than their counterparts. Lastly, PLWH with overweight or obesity presented almost more likelihoods to be hypertensive [AOR = 1.91; 95% CI = 1.11–3.3, p = 0.020] compared to those with normal BMI. Regarding clinical data, the results on CD₄ indicated that patients with >400 copies/mL [AOR = 0.84; 95% CI = 0.71–0.99, p < 0.001] and 200–400 copies/mL [AOR = 0.62; 95% CI = 0.43–0.89, p < 0.001] had lower likelihoods of hypertension compared to those with <200 copies/mL. However, our findings showed that hypertension was not associated with VL and ART regimen (Table 3).

Table 3 Multivariate Analysis for the Associated Factors of Hypertension in PLWH

Discussion

The prevalence of hypertension was 22.4% which is higher than the prevalence reported in Burundi, Tanzania, Uganda, among individuals living with HIV.^5,7,38,39 The prevalence was significantly highly prevalent in men than in females. Further, our results indicated that the prevalence of hypertension is higher among people aged more than 41 years. These results are comparable to the previous documented a high prevalence of hypertension among HIV positive patient.^40–42 These results highlight the disparity in the magnitude of hypertension among persons living with HIV in SSA countries which may associated with a number of reasons such as genetic and socio-economic conditions, duration of disease and clinical outcomes, behavioural issues, types of therapies received and study settings. These results collaborated with the prior studies.^7,22,43

Among the participants whose blood pressure was measured before the survey, approximately 15% exhibited elevated hypertension levels, falling within a risky weight range. Notably, individuals categorized as overweight or obese demonstrated a higher likelihood of hypertension in comparison to those with a normal BMI. These findings are consistent with earlier research that reported that individuals with a obesity or overweight were more likely to be hypertensive^26,44 whereas those with underweight were a lower risk to experience hypertension compared those with normal weight.^7,26,45 These outcomes align with prior studies that have also highlighted an increased hypertension risk among HIV patients who are overweight or obese when contrasted with those with a normal BMI.^46,47 Moreover, the prevalence of hypertension was significantly higher among participants aged 40 and above. These results were in concurrence with the conclusions drawn by several other researchers.^29,48 This implies that individuals aged 41 or older greater likelihoods of developing hypertension than those who were younger, aligning with the observations of other researchers who also noted a substantial rise in blood pressure starting from the age of 40.^43,49

Our findings indicated that smokers were at a higher likelihoods developing hypertension than the non-smokers. These results are consistent with previous research,^41,50,51 although they differ from the findings of a study conducted in Burundi.⁷ Further, our results revealed that participants with diabetes had greater odds to be hypertensive than their counterparts. These results are in alignment with findings from earlier studies.^7,48,52 Interestingly, our study did not identify a noteworthy association between hypertension and factors such as gender, education, marital status, and social category. Nevertheless, these factors have been previously published as risk factors for hypertension.^23,41 It is plausible that the absence of such an association could be attributed to the limitations of a relatively small sample size and the nature of our cross-sectional institutional study. While prior studies reported that duration under ART contribute as a factor of hypertension,⁵³ our study found no association between duration and hypertension.

Our findings uncovered a surprising inverse relationship between CD₄ counts and hypertension among our HIV patient cohort, wherein individuals with CD₄ counts exceeding 400 copies/mL and those within the range of 200–400 copies/mL exhibited a notably reduced likelihood of hypertension compared to those with counts below 200 copies/mL. These results align with previous studies⁵⁴ that have suggested a potential link between higher CD₄ counts and a diminished risk of hypertension. Additionally, our analysis of VL revealed no significant association with hypertension, contrary to some prior research.⁵⁵ Despite existing literature proposing ART regimens as potential contributors to hypertension among HIV patients,⁵⁶ our study did not establish a significant correlation between specific ART regimens and hypertension. Understanding these divergent trends between VL and CD₄ counts concerning hypertension in HIV patients could benefit from an exploration of existing literature focused on the intricate interplay between immune status, VL, and cardiovascular health outcomes within similar populations. Comparatively, exploring studies that examine the influence of VL and varied ART strategies on hypertension in HIV populations might offer additional perspectives or confirmatory evidence to contextualize our findings.

Strengths and Limitations

This study has a significant strength due to its substantial sample size and its innovative nature within the health facility from the rural area. Notably, our research derives its conclusions from a sample that is representative of individuals aged between 14 and 41 years in the study area. While these strengths are commendable, it is essential to acknowledge certain limitations that warrant discussion. Firstly, the authors could not generalise the findings to all people with HIV in Rwanda because it was a hospital-based study. Secondly, a cross-sectional design of this study impedes its capacity to establish causal relationships between hypertension and its associated factors. Thirdly, certain crucial factors such as socio-demographic variables (eg, place of residence), comorbidities, clinical aspects (such as stroke, viral loads, ART regimen, CD₄ counts), psychological influences, socio-cultural factors, and nutritional considerations were not included in our data collection. Lastly, the limitation lies in the small count of participants below the age of 40. This resulted in the formation of two age brackets: one encompassing 14 to 40-year-olds as adolescents and young adults, and the other involving individuals above 40 years old categorized as adults. This grouping of adolescents and adults within the first age group is conceded as a limitation.

Conclusions

Our study constitutes the initial documentation of a significantly heightened occurrence of hypertension among individuals living with HIV. Our findings have illuminated the jeopardy that hypertension imposes upon HIV-positive individuals in the investigated region. The results we have derived signify that hypertension stands as a formidable public health concern for PLWH within the rural facility where our study was conducted. We have founded that age, smoking, alcohol consumption, smoking, overweight and obesity, as well as living with diabetes, emerge as pivotal factors contributing to the prevalence of hypertension in this population. These findings accentuate the importance for the integration of hypertension management into the routine care provided to individuals with HIV. Such integration holds the potential to mitigate adverse ramifications and enhance cardiovascular well-being among those undergoing ART. Besides, longitudinal studies are recommended to explore how incidence of hypertension changes over-time, and examine causality of hypertension and identify additional factors of hypertension. There is a need of the research on the impact of specific ART regimens on the development, management of hypertension. This could involve investigating whether certain types of antiretroviral medications or combinations are more strongly linked to hypertension, as well as considering how the duration of ART might affect hypertension. This will provide valuable insights for healthcare providers in tailoring treatment plans and interventions for HIV-positive patients with hypertension.