People-centred blood pressure management improves blood pressure in people with HIV

Three studies presented at the Conference on Retroviruses and Opportunistic Infections (CROI 2024) in Denver this week showed that innovative service models can successfully deliver drug treatment for high blood pressure to people with HIV through HIV clinics or community health workers, and reduce blood pressure.

High blood pressure (hypertension) is a major cause of heart attack and stroke. Blood pressure can be controlled through weight loss, reducing salt in the diet and cutting alcohol consumption, but for many people, medication to lower blood pressure is the most effective long-term means of lowering blood pressure.

Blood pressure is measured through two readings: systolic pressure and diastolic pressure. A healthy, or normal, blood pressure, is a systolic pressure below 120 and a diastolic pressure below 80. Measurements between 120 and 139 or 80 and 89 are classified as high-normal or pre-hypertension, and 140 or above or 90 or above as high blood pressure. Measurements above 180/120 are classified as a hypertensive crisis and require immediate treatment.

Life expectancy for people with HIV is greatly improved due to antiretroviral treatment. But clinics and health systems vary in their success in monitoring and treating risk factors for heart disease in people with HIV. Despite evidence that people with HIV have higher cardiovascular risks than the rest of the population, risk factors such as cholesterol, high blood pressure and smoking remain under-treated in people with HIV. Barriers to treatment include fragmented care, lack of awareness of cardiovascular risk factors among people with HV and healthcare providers, and social determinants of health such as income, diet and availability of high-quality healthcare.

“In the co-morbidities space we need implementation research. We’ve done the clinical epidemiology and the clinical trials and clinical guidelines on statin use. But there’s a lack of implementation to bridge that gap,” Dr Chris Longenecker of the University of Washington, Seattle, told a press briefing at CROI 2024.

Speaking at the press briefing, all three presenters stressed the importance of integrating blood pressure management into primary HIV care and building models around existing patterns of care for people with HIV rather than referring to hypertension specialists.

EXTRA-CVD

In the EXTRA-CVD study, Dr Longenecker and colleagues designed an intervention to address high blood pressure and elevated cholesterol, based on research into barriers to care for these conditions in primary HIV care. The study was carried out at university hospital HIV clinics in Ohio and North Carolina. It randomised 297 people with HIV with high blood pressure and elevated cholesterol to either nurse-led care with home blood pressure monitoring or standard care with prevention education. Participants were followed for 12 months. Nurses met with participants in the intervention arm approximately every two months during the study to assess progress and also followed up by phone, as well as liaising with doctors. Full details of the intervention are available in JAMA Network Open.

Participants had a median age of 59 years, 79% were male, 59% were Black and the median systolic blood pressure was 135mmHg. Just over one in five (22%) were taking at least three drugs to control blood pressure, 68% were taking a statin and the median non-HDL cholesterol was 139mg/dl.

Eighty-two percent of participants completed the study (76% in the intervention arm and 87% in the control arm). After one year, blood pressure was 4.2mmHg lower in the intervention group compared to the control group (p=0.04). At months 4 and 8, but not at month 12, the reduction in blood pressure was significantly greater in women than in men. After 12 months, those in the intervention group were 30% more likely to have been treated for hypertension and almost three times more likely to have reached the treatment goal of blood pressure below 130/80mmHg.

Non-HDL cholesterol was 0.4mmol (16mg/dl) lower in the intervention group after one year (p<0.001). People in the intervention group were no more likely to receive cholesterol-lowering medication but they were seven times more likely to achieve the treatment goal of non-HDL cholesterol below 130mg/dl (or below 100mg/dl if at high risk of cardiovascular disease).

The extent of blood pressure and cholesterol reduction seen in the intervention group would reduce the risk of cardiovascular events by 14% and 9% respectively, based on studies of the impact of blood pressure and cholesterol reduction in the general population, Dr Longenecker said.

“In the era of more aggressive blood pressure treatment guidelines, the EXTRA-CVD strategy worked to get most patients below 130mmHg,”, Dr Longenecker concluded.

Telehealth for blood pressure control in Kenya

Severe hypertension (160/100mmHg) raises the risk of cardiovascular events and in its acute form (blood pressure above 180/110), severe hypertension (also known as Stage 3 hypertension) can lead to kidney damage, stroke and damage to the blood vessels of the eye.

The SEARCH Consortium designed a study to test whether community health workers could manage severe hypertension in people with HIV in Kenya and Uganda. The randomised study compared management through home visits by community health workers and telehealth consultation with clinicians, with management in a clinic setting. During home visits, community health workers measured blood pressure and dispensed medication. They also facilitated a phone conversation for the participant with a clinician, who checked on symptoms or medication adherence, answered questions and prescribed medication.

The study randomised 200 people over the age of 40 with either severe hypertension or persistent high blood pressure above 140/90mmHg. The median age of participants was 62, 70% were women, 14% were living with HIV and 25% had blood pressure above 180/110mmHg.

The primary outcome of the study was hypertension control at week 24, when 77% of the intervention arm and 51% of the control arm had achieved hypertension control (blood pressure below 140/90) (p<0.001), a 26% difference. By week 48, 86% in the intervention arm and 44% in the control arm had achieved control (p<0.001).

The improvement was seen in both women and men, and at all stages of hypertension, although the proportion with stage 3 hypertension who achieved control was lower. But the intervention reduced the prevalence of severe hypertension by 17% at week 24 and 13% at week 48.

Dr Matthew Hickey told the conference that one of the biggest barriers to hypertension management in study participants was the distance they had to travel to attend the clinic, with participants reporting that it took them a median of one hour to get to the clinic. Less than 5% in the intervention arm reported clinic access as a barrier to managing their blood pressure by week 48, compared with more than 70% in the control arm.

Pre-hypertension control in Haiti

Pre-hypertension (systolic blood pressure between 120 and 139, diastolic pressure between 80 and 89mmHg) is not routinely indicated for treatment unless people have diabetes or chronic kidney disease, where the World Health Organization recommends starting treatment if the systolic pressure is above 130 or the diastolic pressure is above 90.

However, a recently published meta-analysis of 51 trials of blood pressure-lowering treatment found that even in people with pre-hypertension, a 5mmHg reduction in systolic pressure was associated with a 10% reduction in the risk of a major cardiovascular event.

The impact of treating pre-hypertension in people with HIV is unknown, but to test the feasibility and efficacy of treating blood pressure at this stage, Dr Lily Yan from Weill Cornell Medicine in New York and researchers at GHESKIO in Haiti carried out a randomised study in 250 people with HIV and pre-hypertension.

The study compared immediate treatment with deferral of treatment until blood pressure reached 140/90mmHg. After 12 months, people in the early treatment group had reductions of 10mmHg in systolic and 8mmHg in diastolic blood pressure and their mean blood pressure was 5mmHg below that of the deferred group on both measures. They were 59% more likely to achieve blood pressure control after 12 months compared to the deferred treatment group (57% vs 36%). Thirty-nine per cent in the immediate treatment group developed hypertension (140/80) compared to 64% in the deferred treatment group.