Blood pressure, T cells, and mortality in people with HIV in Tanzania during the first 2 years of antiretroviral therapy

A study protocol to engage religious leaders to reduce blood pressure in Tanzanian communities: A cluster randomized trial

BACKGROUND

Most people with hypertension in Sub-Saharan Africa are unaware of their status. Low perceived need for hypertension screening, low trust in biomedical health care, unhealthy norms for diet and exercise, and prioritization of spiritual over physical health are key barriers to blood pressure (BP) control in Tanzanian communities. We seek to determine whether engaging religious leaders to screen for hypertension and educate communities on cardiovascular health can lead to a sustained community BP reduction.

METHODS

This trial aims to determine the efficacy of an intervention that engages religious leaders to reduce BP in Tanzanian communities. After refinement of the intervention following pilot testing, a hybrid type I randomized control trial will be conducted across 20 rural communities (10 intervention and 10 control communities). The intervention will consist of educational sessions for religious leaders, equipping them to provide community cardiovascular health teachings, and BP screening organized jointly by religious leaders and health care workers. We will measure the reduction in mean community BP and changes in hypertension awareness and treatment, diet, physical activity, body mass index, and waist circumference after one year. Key elements that contribute to the intervention's implementation and effectiveness to strengthen its adoption and broader use during and after the intervention up to 24 months will be evaluated.

DISCUSSION

Community-level barriers to BP control inhibit awareness and treatment of hypertension in Tanzania. Through innovative partnerships with trusted religious leaders, we seek to study an intervention with the potential to reduce BP and improve overall community health.

CD4+ T Cells Expressing Viral Proteins Induce HIV-Associated Endothelial Dysfunction and Hypertension Through Interleukin 1α-Mediated Increases in Endothelial NADPH Oxidase 1

BACKGROUND

Although combination antiretroviral therapy has increased life expectancy in people living with HIV, it has led to a marked increase in the prevalence of hypertension, the cause of which is unknown. Despite combination antiretroviral therapy, HIV-derived proteins remain expressed and produced by CD4+ T lymphocytes in people living with HIV. However, their contribution to HIV-associated hypertension and impaired endothelium-dependent relaxation remains ill defined.

METHODS

Here, we tested the hypothesis that CD4+ T cells expressing viral proteins contribute to endothelial dysfunction and hypertension using the Tg26 mouse model of HIV that expresses 7 of the 9 HIV proteins under the long terminal repeat promoter. We used male and female mice, bone marrow transplantation (BMT), adoptive transfer of CD4+ T cells, and aorta specimen discarded from people living with HIV.

RESULTS

We reported that intact Tg26 mice and mice receiving BMT (Tg26→WT) or CD4+ T cells from Tg26 mice display impaired endothelium-dependent relaxation and hypertension. Conversely, BMT from WT mice into Tg26 mice, inhibition of T cell activation, and CD4+ T cell depletion restored endothelial function and blood pressure in Tg26 mice. Cytokine profiling revealed that Tg26 mice, Tg26→WT, and Tg26 CD4+ T cells consistently exhibit high interleukin 1α (IL-1α) levels with no significant increase in other cytokines, whereas BMT from WT mice into Tg26 mice reduced IL-1α levels. IL-1α neutralization reduced blood pressure and restored endothelial function in Tg26 mice. To investigate the role of CD4+ T cells and IL-1α in endothelial dysfunction, we developed an aorta-immune cell coculture system. Exposure of WT aortas to Tg26 CD4+ T cells impaired endothelium-dependent relaxation, which was blocked by IL-1α-neutralizing antibody. While investigating the mechanisms of endothelial dysfunction, we reported that Tg26 mice, Tg26→WT aorta exhibit high NADPH oxidase (NOX) 1 expression. IL-1α exposure increased NOX1 in human microvascular endothelial cells, and NOX1 blockade restored endothelial function in Tg26 and Tg26→WT arteries, whereas NOX1 deficiency protected against Tg26 BMT-induced impaired endothelium-dependent relaxation and hypertension. Aortas from people living with HIV exhibit high NOX1 levels, and exposure of human aorta to Tg26 T cells increased NOX1 expression.

CONCLUSIONS

We provide the first evidence that CD4+ T cells expressing HIV viral proteins induced hypertension through IL-1α-mediated increases in vascular NOX1, which impairs endothelial function in males and females.

Comparing Life's Simple Seven between newly diagnosed, ART-naive people living with HIV and HIV-uninfected adults in Tanzania: clues for cardiovascular disease prevention

Cardiovascular disease (CVD) represents a major cause of premature mortality in people living with HIV (PLWH). There is a need to characterize the cardiovascular health profiles of PLWH to appropriately guide primary prevention efforts, particularly in settings like Sub-Saharan Africa, where there is a high burden of HIV and limited resources. A cross-sectional analysis was conducted on a cohort of newly diagnosed PLWH and HIV-uninfected adults recruited from three HIV clinics in Mwanza, Tanzania. Modified Life's Simple 7 definitions were applied to the cohort to compare cardiovascular health profiles between the two study groups using Poisson regressions. Pooled cohort equation (PCE) scores were also calculated to compare the distribution of CVD risk between the two groups. Our study included 995 study participants (492 PLWH, 503 HIV-uninfected). PLWH had a higher prevalence of ideal body mass index (75%), ideal blood pressure (56%), and ideal total cholesterol but a lower prevalence of ideal smoking (84%) and ideal physical activity (39%) than HIV-uninfected counterparts. PCE scores were low throughout the study population (76.5%), regardless of HIV status. Primary prevention of CVD in newly diagnosed people living with HIV in Africa may need to focus on smoking cessation and optimization of physical activity levels.

Causes and Consequences of Persistent Anemia after 6 Months of Antiretroviral Therapy in Tanzania: An Observational Comparative Cohort Study

Anemia is common among people living with HIV (PLWH), particularly in Africa. Outcomes for PLWH on modern antiretroviral therapy (ART) regimens are not well documented. We conducted an observational study to determine the outcomes and predictors of anemia after ART initiation in Tanzania. We enrolled and followed ART-naïve PLWH and HIV-uninfected individuals at three clinics in Tanzania. We grouped participants into four longitudinal categories based on hemoglobin concentration measured at baseline and 6 months after ART initiation (normal, resolved anemia, incident anemia, and persistent anemia) and followed them for 24 months. There were 991 study participants (494 PLWH, 497 HIV uninfected). After 6 months of ART, 33.9% of PLWH had persistent anemia and 9.9% had incident anemia compared with 12.6% and 9.6% for HIV-uninfected controls. Female sex (adjusted odds ratio [aOR]: 2.62; 95% CI: 1.91-6.75) and low income (aOR: 3.10; 95% CI: 1.36-7.20) were strong predictors of persistent anemia for both PLWH and HIV-uninfected individuals. For PLWH, having a CD4+ T cell count of less than 350 cells/mm3 (aOR: 0.34; 95% Cl: 0.15-0.73) was significantly associated with anemia resolution. Mortality was higher for PLWH who had persistent anemia or incident anemia than for PLWH who had normal hemoglobin or improved anemia (hazard ratio: 4.0, 95% Cl 1.3-12.2). One-third of adults in Tanzania had persistent anemia after 6 months on ART, and persistent anemia was associated with increased mortality. PLWH with persistent or incident anemia after 6 months on modern ART deserve close follow-up, particularly women and low-income adults.

HIV and CKD in the Tenofovir Era: A Prospective Parallel-Group Cohort Study From Tanzania

Rationale & Objective

Longitudinal research on chronic kidney disease (CKD) in sub-Saharan Africa is sparse, especially among people living with HIV (PLWH). We evaluated the incidence of CKD among PLWH compared with HIV-uninfected controls in Tanzania.

Study Design

Prospective cohort study.

Setting & Participants

A total of 495 newly diagnosed PLWH who initiated antiretroviral therapy (ART) and 505 HIV-uninfected adults enrolled from public HIV clinics and followed from 2016-2021. The control group was recruited from HIV treatment partners from the same HIV clinics.

Exposures

Untreated HIV (at baseline), ART, sociodemographic information, health behaviors, hypertension, and diabetes.

Outcomes

Incident CKD, defined as a follow-up estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m2 with ≥25% reduction from baseline; annual eGFR change; incident albuminuria; 3-year all-cause mortality.

Analytical Approach

Multivariable Poisson and linear regression determined the association between HIV and other factors with a baseline prevalent reduced eGFR and albuminuria, incident CKD and albuminuria, and annual eGFR change. Cox hazard regression assessed the association between baseline CKD and mortality.

Results

Median age was 35 years and 67.5% were women. There were 101 incident CKD cases, 71 among PLWH and 30 among HIV-uninfected participants, equivalent to a CKD incidence of 57.9 per 1,000 person-years (95% CI, 44.4-71.4) and 26.2 per 1,000 person-years (95% CI, 16.8-35.5), respectively. PLWH had a more rapid eGFR decline (-6.65 vs -2.61 mL/min/1.73 m2 per year). Female sex and older age were positively associated with incident CKD. Albuminuria incidence did not differ by HIV status. PLWH with albuminuria at baseline had higher mortality (HR, 2.13; 95% CI, 1.08-4.21).

Limitations

As an observational cohort study, there was no comparison group of HIV-positive participants on a nontenofovir disoproxil fumarate-based ART regimen.

Conclusions

PLWH receiving tenofovir disoproxil fumarate-based ART had a very high incidence of CKD and rapid eGFR decline. Conversely, albuminuria stabilized with ART use. Expanding access to less-nephrotoxic ART, such as tenofovir alafenamide, is urgently needed throughout sub-Saharan Africa.

Incidence and Progression of Diastolic Dysfunction in People With HIV in Tanzania: A Comparative Cohort

Background

People living with HIV (PLWH) have a higher prevalence of diastolic dysfunction and left ventricular hypertrophy (LVH) in cross-sectional studies. Longitudinal data are lacking, especially from Africa.

Objectives

The aim was to examine: 1) the incidence of diastolic dysfunction in PLWH compared to community controls in Tanzania; 2) the progression of diastolic function and LVH in PLWH after antiretroviral therapy initiation; and 3) traditional, endemic, and HIV-specific risk factors for diastolic function and LVH.

Methods

This was a prospective longitudinal cohort of PLWH and HIV-uninfected controls who had an echocardiogram at enrollment and in follow-up. Adjusted Cox proportional HR models were used to determine the incidence of diastolic dysfunction, and multivariable mixed effects regressions were used to determine the progression and risk factors for diastolic function.

Results

A total of 781 participants (367 PLWH) were followed for up to 5 years. There was no difference in incidence of diastolic dysfunction by HIV serostatus (aHR: 0.93 [95% CI: 0.61-1.42]). Baseline differences in echo parameters prior to antiretroviral therapy initiation resolved within 3 years of treatment for LVH (baseline difference = 3.57 g/m2 [95% CI: 0.87-6.26]; no difference after 3 years) and other diastolic dysfunction markers. Hypertension and obesity were important modifiable risk factors for diastolic dysfunction (both P < 0.001), while subclinical kidney disease, anemia, and manual labor were predictors of LVH and diastolic dysfunction.

Conclusions

The incidence of diastolic dysfunction was similar in PLWH and HIV-uninfected controls. Efforts to prevent diastolic heart failure in Africa must focus on addressing hypertension and obesity while also investigating nontraditional risk factors.

Exposure to toxic chemical elements among people living with HIV/AIDS in Northern Tanzania

Environmental exposure to toxic chemicals including cadmium (Cd), lead (Pb), and mercury (Hg), are known risk factors for cardiovascular (CVD) and kidney disease. In people living with HIV (PLWH), CVD and kidney disease are the leading cause of death. Neither traditional risk factors nor markers of HIV infection fully explain such an increased risk. It is of paramount importance to establish the epidemiology of toxic chemicals exposure in PLWH, to inform screening and prevention interventions in this vulnerable population. This cross-sectional study compares toxic chemical levels (T-Cd, T-Pb, and T-Hg) among PLWH and HIV-uninfected adults in Northwestern Tanzania. A total of 495 PLWH and 505 HIV-uninfected subjects were analyzed. Spearman's rank correlations were used to examine the relationship between toxic chemical elements by HIV status. Linear regression models were used to determine the association between exposures and outcomes of interest among study participants. In both PLWH and HIV-uninfected adults, blood T-Cd, T-Pb, and T-Hg levels were frequently found at levels above the reference value of 5, 50, and 20 μg/L, respectively. Overall, factors associated with blood toxic chemical levels included vegetable servings per week, obesity, untreated water sources, use of alcohol, and HIV. Among PLWH, weekly vegetable intake provided a protective effect against T-Cd (Coeff = -0.03, 95%CI = -0.06, -0.01) and T-Pb (Coeff = -0.05, 95%CI = -0.09, -0.01) exposure among PLWH. Alcohol intake (Coeff = 0.10, 95%CI = 0.06, 0.13), obesity (Coeff = 0.08, 95%CI = 0.02, 0.13), longer duration to indoor smoke exposure (Coeff = 0.003, 95%CI = 0.001, 0.004), and HIV infection (Coeff = 0.11, 95%CI = 0.07, 0.15) were associated with increased individuals blood T-Hg levels. Individuals in northwestern Tanzania, including PLWH, have high blood levels for T-Cd, T-Pb, and T-Hg. Factors associated with higher blood levels include water sources, obesity, use of alcohol, exposure to indoor smoke, and HIV infection.

Persistent Depression and Suicidal Ideation in People Living with HIV in Tanzania: A Longitudinal Cohort Study

Suicidal ideation and depression are common in people living with HIV (PLWH) in sub-Saharan Africa, but longitudinal data on their persistence in the modern antiretroviral therapy era are lacking. We examined the prevalence of persistent suicidal ideation and depression symptoms using the PHQ-9 in a well-characterized cohort of PLWH and HIV-uninfected community controls. Multivariable logistic regression models were used to determine the relationship between HIV and persistent depression and suicidal ideation. Persistent suicidal ideation was more common in PLWH but there was no difference in persistent depression by HIV status. Approximately one out of five participants with depression at baseline had persistent depression after 12-24 months and only about one out of four participants reporting suicidal ideation at baseline had persistent suicidal ideation after 12-24 months. HIV was associated with suicidal ideation at baseline. Persistent suicidal ideation was significantly associated with HIV immune non-response (p = 0.022). These findings highlight the need for integration of mental health services into HIV care in sub-Saharan Africa with a focus on suicide prevention.

Immune mechanisms in the pathophysiology of hypertension

Hypertension is a leading risk factor for morbidity and mortality worldwide. Despite current anti-hypertensive therapies, most individuals with hypertension fail to achieve adequate blood pressure control. Moreover, even with adequate control, a residual risk of cardiovascular events and associated organ damage remains. These findings suggest that current treatment modalities are not addressing a key element of the underlying pathology. Emerging evidence implicates immune cells as key mediators in the development and progression of hypertension. In this Review, we discuss our current understanding of the diverse roles of innate and adaptive immune cells in hypertension, highlighting key findings from human and rodent studies. We explore mechanisms by which these immune cells promote hypertensive pathophysiology, shedding light on their multifaceted involvement. In addition, we highlight advances in our understanding of autoimmunity, HIV and immune checkpoints that provide valuable insight into mechanisms of chronic and dysregulated inflammation in hypertension.

Development of Anti-HIV Therapeutics: From Conventional Drug Discovery to Cutting-Edge Technology

The efforts to discover HIV therapeutics have continued since the first human immunodeficiency virus (HIV) infected patient was confirmed in the 1980s. Ten years later, the first HIV drug, zidovudine (AZT), targeting HIV reverse transcriptase, was developed. Meanwhile, scientists were enlightened to discover new drugs that target different HIV genes, like integrase, protease, and host receptors. Combination antiretroviral therapy (cART) is the most feasible medical intervention to suppress the virus in people with HIV (PWH) and control the epidemic. ART treatment has made HIV a chronic infection rather than a fatal disease, but ART does not eliminate latent reservoirs of HIV-1 from the host cells; strict and life-long adherence to ART is required for the therapy to be effective in patients. In this review, we first discussed the scientific history of conventional HIV drug discovery since scientists need to develop more and more drugs to solve drug-resistant issues and release the side effects. Then, we summarized the novel research technologies, like gene editing, applied to HIV treatment and their contributions to eliminating HIV as a complementary therapy.

Characterizing blood pressure trajectories in people living with HIV following antiretroviral therapy: A systematic review

OBJECTIVES

The advent of antiretroviral therapy (ART) has reduced AIDS-related morbidity and mortality among people living with HIV (PLWH). Due to increased survival, PLWH have now been found to be at risk of chronic conditions related to ageing, such as cardiovascular disease (CVD). Hypertension is common in PLWH and is a major risk factor for the development of CVD. We conducted a systematic literature review to evaluate the research evidence on longitudinal blood pressure (BP) trajectories following ART initiation in PLWH.

METHODS

We searched the following databases: PubMed, CINHAL, Scopus, and Web of Science (up to 15 March 2021) for peer-reviewed published studies that reported BP trajectories following ART initiation in PLWH. Three reviewers independently screened all studies by title and abstract. We included articles in English, published up to March 2021, that report office BP trajectories in PLWH initiating ART. A total of 10 publications met our inclusion criteria. Eight studies were prospective cohorts and two were retrospective.

RESULTS

Nine out of 10 studies in the literature reported an increase in systolic BP (4.7-10.0 mmHg in studies with a follow-up range of 6 months to 8 years, and 3.0-4.7 mmHg/year in time-averaged studies). In addition, four out of 10 studies reported increases in diastolic BP (2.3-8.0 mmHg for a 6 month to 6.8-year follow-up range and 2.3 mmHg/year).

CONCLUSION

Systolic BP consistently increases while diastolic BP changes are more heterogeneous following ART initiation in PLWH. However, the studies were highly variable with respect to population demographics, ART regimen and duration, and follow-up time. Nevertheless, given the risks of CVD complications, such as stroke, heart failure and myocardial infarction, associated with elevated BP, results highlight the importance of future research in this area. It will be important to better characterize BP trajectories over time, identify the most critical times for interventions to reduce BP, determine the long-term CVD consequences in PLWH with elevated BP, and understand how different ART regimens may or may not influence BP and CVD disease.

Brief Report: Changes in Nocturnal Heart Rate Variability in People Living With HIV During the First Year of Antiretroviral Therapy Compared With HIV-Uninfected Community Controls

BACKGROUND

Higher nocturnal heart rate and lower nocturnal heart rate variability (HRV) is associated with increased cardiovascular disease mortality. Longitudinal studies on nocturnal HRV in people living with HIV (PLWH) are lacking.

METHODS

We conducted a 1-year prospective cohort study of adult PLWH and HIV-uninfected community controls in northwestern Tanzania. At enrollment, we collected data on cardiovascular risk factors and tested blood samples for hemoglobin, insulin, CD4 cell count, and C-reactive protein. We measured nocturnal HRV and heart rate at baseline and first-year follow-up. Mixed effect linear regression was used to determine predictors of lower HRV.

RESULTS

Of the 111 enrolled participants (74 PLWH and 37 HIV-uninfected adults), 57.7% were female and the median age was 40 years. Over 1 year of follow-up, the average nocturnal heart rate was 4.5 beats/minute higher in PLWH ( P = 0.006). In the fully adjusted model (with age, sex, nocturnal heart rate, and diabetes), average nocturnal HRV was 10.5 milliseconds lower in PLWH compared with HIV-uninfected adults ( P = 0.03). Unlike with nocturnal heart rate, nocturnal HRV did not improve after 1 year of ART in PLWH or HIV-uninfected adults (fully adjusted change = -2.5 milliseconds, P = 0.45). Lower educational attainment, lesser pancreatic β-cell function, and anemia were associated with higher HRV.

CONCLUSIONS

Nocturnal parasympathetic nervous system function was persistently lower in PLWH compared with HIV-uninfected adults even after antiretroviral therapy initiation. Improving nocturnal autonomic nervous system function could be a target for cardiovascular disease prevention in PLWH.

Sex differences in hypertension among people living with HIV after initiation of antiretroviral therapy

Background

Hypertension is common in people living with HIV (PLWH) on antiretroviral therapy (ART). In the general population and in experimental animal models, the incidence of hypertension is greater in males than in females, especially during the premenopausal period. However, it is not known whether there are sex differences in hypertension associated with HIV and ART, and the factors contributing to incident hypertension among PLWH have not been well characterized. In this study, we aimed to determine the time course, sex differences and factors associated with incident hypertension in PLWH initiating ART.

Methods and results

We conducted a retrospective study in which we used programmatic data from the ART registry to identify sex differences in the determinants of incident hypertension among PLWH initiating the ART regimen from Livingstone University Teaching Hospital in Zambia and followed for 8 years. Males developed hypertension earlier, 2 years after initiating ART, compared to 6 years in females. In multivariable analysis, increasing age, baseline systolic blood pressure and baseline mean arterial pressure (MAP) were associated with increased risk for developing incident hypertension. Also, participants who switched to the integrase strand transfer inhibitor, dolutegravir (DTG) or the protease inhibitor, lopinavir boosted with ritonavir were 2 and 3 times more likely to develop hypertension when compared to those on non-nucleoside reverse transcriptase inhibitors (NNRTIs). However, these relationships were abrogated by sex, as self-reported male sex was the major contributor in predicting incident hypertension. While none of the factors remained significantly associated with incident hypertension upon multivariate analysis among females, body mass index (BMI), and use of protease inhibitors remained strongly associated with hypertension among males.

Conclusion

Our results indicate that the use of protease inhibitors and BMI are important predictors of incident hypertension among males. Thus, blood pressure and BMI should be closely monitored, particularly in males living with HIV on protease inhibitors. In addition, identifying specific factors that protect females from developing hypertension early is important but remains to be determined.

Blood Pressure and Body Composition During First Year of Antiretroviral Therapy in People With HIV Compared With HIV-Uninfected Community Controls

BACKGROUND

Body composition changes may explain the rapid increase in blood pressure (BP) in people with HIV (PWH) during the first year of antiretroviral therapy.

METHODS

We analyzed data from a cohort of PWH and HIV-uninfected adults from the same communities in Mwanza, Tanzania. Blood pressure (BP, mm Hg) and body composition data were collected at baseline and 12-month follow-up. We used multivariable linear regression to compare BP changes in PWH and HIV-uninfected adults, and the relationship between changes in body composition and changes in BP.

RESULTS

BP data were available for 640 PWH and 299 HIV-uninfected adults. Sixty-four percent were women and the mean age was 38 years. In PWH, systolic BP (SBP) increased (114-118) whereas SBP decreased (125-123) in HIV-uninfected participants. Fat mass increased by 1.6 kg on average in PWH and was strongly associated with the change in BP (P < 0.001). The greater increase in SBP in PWH was partly explained by the lower baseline SBP but PWH still experienced a 2.2 (95% CI: 0.3-4.2) greater increase in SBP after adjustment. Weight gain partially mediated the relationship between HIV and SBP increase in PWH; a 1-kg increase in fat mass accounted for 0.8 (95% CI: 0.6-1.1) increase in SBP.

CONCLUSIONS

Weight and fat mass increase rapidly in PWH during the first 12 months of antiretroviral therapy and contribute to a rapid increase in SBP. Interventions to prevent excessive increase in fat mass are needed for PWH.

Sex-dependent correlates of arterial stiffness in Tanzanian adults

OBJECTIVE

Arterial stiffness is a known indicator for cardiovascular disease. However, the factors that lead to arterial stiffening have primarily been studied in participants from high-income countries. Here, we examine clinical and lifestyle metrics in relation to arterial stiffness in Tanzanian adults.

METHODS

We performed pulse wave velocity (PWV), the gold standard measure of arterial stiffness, on 808 Tanzanian adults (ages 18-65) enrolled in a longitudinal cohort studying trends in blood pressure.

RESULTS

As expected, PWV was strongly associated with age, blood pressure and sex. We controlled for these factors in our statistical analysis. Lifestyle metrics were compared across multiple PWV quantiles. We found that determinants of PWV varied by sex: in female participants, PWV was associated with common obesity metrics and menopause, while in male participants, PWV was associated with HIV status and duration of anti-retroviral therapy (ART). Further clinical and lifestyle factors such as marriage status and type of occupation were also significantly associated with PWV and moderated by sex.

CONCLUSION

Together, our data demonstrate the importance of studying sex-specific causal pathways for arterial stiffness and of including under-represented populations in these studies.

Nocturnal dipping of heart rate and blood pressure in people with HIV in Tanzania

People with HIV (PWH) have a >2-fold greater risk for development of cardiovascular disease (CVD), which may be associated with abnormalities in 24-h ambulatory blood pressure measurement (ABPM) profile. We conducted a nested case-control study of ABPM in 137 PWH and HIV-uninfected controls with normal and high clinic blood pressure (BP) in Tanzania. Nocturnal non-dipping of heart rate (HR) was significantly more common among PWH than HIV-uninfected controls (p = .01). Nocturnal non-dipping of BP was significantly more common in PWH with normal clinic BP (p = .048). Clinical correlates of nocturnal non-dipping were similar in PWH and HIV-uninfected adults and included higher BMI, higher CD4⁺ cell count, and high C-reactive protein for HR and markers of renal disease for BP. In conclusion, nocturnal non-dipping of both BP and HR was more common in PWH but further research is needed to determine causes and consequences of this difference.

Hypertension: Do Inflammation and Immunity Hold the Key to Solving this Epidemic?

Elevated cardiovascular risk including stroke, heart failure, and heart attack is present even after normalization of blood pressure in patients with hypertension. Underlying immune cell activation is a likely culprit. Although immune cells are important for protection against invading pathogens, their chronic overactivation may lead to tissue damage and high blood pressure. Triggers that may initiate immune activation include viral infections, autoimmunity, and lifestyle factors such as excess dietary salt. These conditions activate the immune system either directly or through their impact on the gut microbiome, which ultimately produces chronic inflammation and hypertension. T cells are central to the immune responses contributing to hypertension. They are activated in part by binding specific antigens that are presented in major histocompatibility complex molecules on professional antigen-presenting cells, and they generate repertoires of rearranged T-cell receptors. Activated T cells infiltrate tissues and produce cytokines including interleukin 17A, which promote renal and vascular dysfunction and end-organ damage leading to hypertension. In this comprehensive review, we highlight environmental, genetic, and microbial associated mechanisms contributing to both innate and adaptive immune cell activation leading to hypertension. Targeting the underlying chronic immune cell activation in hypertension has the potential to mitigate the excess cardiovascular risk associated with this common and deadly disease.

Predictors of glucose metabolism and blood pressure among Ethiopian individuals with HIV/AIDS after one-year of antiretroviral therapy

OBJECTIVE

Better understanding of glucose metabolism in patients with HIV after initiating antiretroviral therapy (ART) is important to target treatment and follow-up for diabetes risk and other non-communicable diseases in resource-limited settings. The aim of this study was to assess the changes and predictors of glucose metabolism and blood pressure among patients with HIV on ART for 12 months.

METHODS

One-year follow-up of Ethiopian patients with HIV after initiation of ART was done. Outcomes were changes in fasting plasma glucose (FPG), and 30-minute (30mPG) and 2-hour plasma glucose (2hPG) after oral glucose tolerance test, glycated haemoglobin (HbA1c), fasting plasma insulin (p-insulin), homeostatic model assessment index for insulin resistance (HOMA-IR) and blood pressure.   RESULTS: The mean age was 33 years, and the majority were women. During the first 12 months, levels of all plasma glucose parameters decreased, while p-insulin (10^B 3.1; 95% CI2.4, 4.0), HOMA-IR (10^B 3.1; 95% CI2.3, 4.0) and systolic blood pressure (B 4.0; 95% CI2.5, 5.5) increased. Fat-free mass at baseline predicted higher increments in p-insulin, HOMA-IR and blood pressure; whereas, fat mass predicted higher increment in HbA1c.

CONCLUSIONS

Among Ethiopian patients with HIV, blood pressure and insulin increased, and all glucose parameters declined during 12-month of ART. Only longer-term follow-up will tell us whether insulin increase is due to insulin resistance or from recovering β-cells.