Open Forum Infectious Diseases BRIEF REPORT finally by HIV-infected adults aged 18 years and older who had Hypertension Among Persons Living at least 1 medical care visit in a participating facility during With HIV in Medical Care in the January–April of the referent year. United States—Medical Monitoring Data were collected via face-to-face or telephone interviews and medical record abstractions. A total of 10 184 participants Project, 2013–2014 were interviewed and had a medical record abstracted during 1 1 2 3 1 Oluwatosin Olaiya, John Weiser, Wen Zhou, Pragna Patel, and Heather Bradley this period. Medical records were abstracted for the 2 years 1 2 3 Division of HIV/AIDS Prevention and ICF International, Atlanta, Georgia; Division of Global preceding a respondent’s interview. A more detailed descrip- HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia tion of the MMP methods is provided elsewhere . In 2013, response rates were 100% among states/territories, 85.0% Hypertension is a leading modifiable risk factor for cardiovascu- lar disease (CVD), and persons living with HIV are at increased among facilities, and 54.9% among participants with both risk for both hypertension and CVD. er Th efore, using data from interview and medical record abstraction (MRA data). In 2014, a nationally representative sample of patients living with HIV, response rates were 100% (states/territories), 86.5% (facilities), we assessed missed opportunities for the optimal management and 55.7% (participants). Information on diagnoses, medica- of hypertension. tions, and blood pressure readings were collected during MRAs. Keywords. HIV; hypertension; cardiovascular disease; prevalence; Medical Monitoring Project. MEASUREMENTS Hypertension was defined using 3 criteria: diagnosis (docu- Cardiovascular disease (CVD) is a leading cause of morbid- mented diagnosis of hypertension), treatment (prescription of ity and mortality among people living with HIV (PLWH) [1, antihypertensive medication), and high blood pressure readings 2], and hypertension is a primary modifiable risk factor for (an average of the last 2 systolic blood pressures ≥140 mm Hg CVD. Some studies suggest that the prevalence of hypertension or diastolic readings ≥90 mm Hg). These criteria were com- among PLWH is higher than among the general population, bined such that a participant was classified as hypertensive if possibly explained by a higher prevalence of smoking and HIV- they met both diagnosis and treatment criteria or they met high specific factors such as immune activation, inflammation, and blood pressure reading criteria. Hypertension was categorized long-term effects of antiretroviral therapy [3–5]. It is impor - as “undiagnosed and untreated,” “diagnosed and treated,” and tant to optimize hypertension screening and management in “unclassified.” Patients who were “diagnosed and treated” were this at-risk group in order to decrease complications including further classified as controlled or uncontrolled (Supplementary CVD. We estimated prevalence of hypertension overall, as well appendix figure). as by diagnosis, treatment, and control status in a nationally If a diagnosis of hypertension (or synonyms such as “high representative sample of patients receiving HIV medical care in blood pressure” and “essential hypertension”) was abstracted the United States. from the medical records, the respondent met the diagno- sis criterion. Respondents who had no diagnoses of any kind METHODS abstracted (eg, participants for whom a detailed MRA could not The Medical Monitoring Project (MMP) is a surveillance system be conducted) were considered missing diagnosis information. designed to produce nationally representative estimates of the An extensive list of antihypertensive medication was used to behavioral and clinical characteristics of HIV-infected adults in classify respondents for the treatment criterion (Supplementary the United States. For the 2013 and 2014 data collection cycles, Appendix 1). Respondents who had no medications of any US states and territories were sampled, followed by outpatient kind abstracted were considered to be missing treatment facilities providing HIV care within those jurisdictions, and information. Respondents were classified as having high blood pressure readings based on the average of the last 2 readings. Those who Received 12 September 2017; editorial decision 22 January 2018; accepted 29 January 2018. had only 1 set of blood pressure readings or those who had no Correspondence: J. Weiser, MD, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road NE MS E-46, Atlanta, GA 30329 (email@example.com). blood pressure documented were considered to be missing Open Forum Infectious Diseases blood pressure information. Published by Oxford University Press on behalf of Infectious Diseases Society of America 2018. Respondents who had hypertension were subclassified as This work is written by (a) US Government employee(s) and is in the public domain in the US. DOI: 10.1093/ofid/ofy028 follows: BRIEF REPORT • OFID • 1 Downloaded from https://academic.oup.com/ofid/article-abstract/5/3/ofy028/4830141 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Undiagnosed and untreated hypertension—met high blood e p Th revalence of undiagnosed and untreated hyperten- pressure readings criterion but not diagnosis and treatment sion decreased with increasing age: 39.1%, 27.0%, 16.2%, and criteria; 9.4% among PLWH aged 18–29, 30–39, 40–49, and ≥50 years, Treated and controlled hypertension—met diagnosis and respectively. There were no significant differences in the preva- treatment criteria but not the high blood pressure readings lence of untreated hypertension by race/ethnicity. Undiagnosed criterion; and untreated hypertension was more prevalent among recently Treated and uncontrolled hypertension—met all 3 criteria; incarcerated patients (25.7%) than among others (12.8%). Unclassiefi d hypertension —respondents who did not fall PLWH who had no health insurance had a higher prevalence into any of the above categories and were missing informa- of untreated hypertension than those with health coverage. tion on any of the 3 criteria, or who met treatment and high Undiagnosed and untreated hypertension was more preva- blood pressure readings criteria but did not have a diagno- lent among PLWH who were not virally suppressed at last sis (because antihypertensives can also be used to treat other test (17.0%) than among those who were (12.4%) and, though conditions). not statistically significant, was more prevalent among those who did not have a sustained viral suppression over the past DATA ANALYSES 12 months (15.9%) than among those who had a sustained viral suppression (12.1%). Respondents were excluded if there was not enough informa- tion to classify them as hypertensive or nonhypertensive using DISCUSSION the aforementioned 3 criteria. We estimated the weighted prevalence and associated 95% confidence intervals (CIs) of The prevalence of hypertension among people receiving HIV hypertension, overall and by subcategory (undiagnosed and care in the United States was 42.4%, which is within the range untreated, treated and controlled, treated and uncontrolled, of previously published estimates (13.0%–49.0%) [3, 4, 9, 10]. and unclassified). We estimated the prevalence of overall and We found that about 1 in 8 patients had undiagnosed and undiagnosed and untreated hypertension stratified by sociode- untreated hypertension. Providers may be missing opportuni- mographic, behavioral, and clinical characteristics. Rao-Scott ties for diagnosing and treating hypertension among patients chi-square tests were used to assess differences in the preva- who are younger, male, uninsured, and recently incarcerated. lence of hypertension by characteristics. Data were weighted for As PLWH may be at increased risk for hypertension and its unequal selection probabilities and nonresponse. complications, including CVD, the importance of hypertension In accordance with the federal human subjects protection screening by providers, with the intent to effectively treat, can- regulations at 45 Code of Federal Regulations 46.101c and not be overemphasized. 46.102d  and with the Guidelines for Defining Public Health While the proportion with hypertension was lowest among Research and Public Health Non-Research , MMP was deter- younger patients (aged 18–29 years), they were more than 4 mined to be a nonresearch, public health surveillance activ- times as likely to be undiagnosed and untreated as older patients ity used as a disease control program or for policy purposes. (aged ≥50 years). Because young PLWH are least likely to be As such, MMP is not subject to federal investigational review virally suppressed , it is possible that providers are more board review. Participating states or territories and facilities focused on attaining viral suppression than addressing comor- obtained local institutional review board approval to conduct bidities, such as hypertension, in this group. With PLWH living MMP if required locally. Informed consent was obtained from longer lives as a result of highly active antiretroviral therapy all interviewed participants. , younger patients with undiagnosed and untreated hyper- tension potentially have many years to accrue complications of RESULTS untreated and uncontrolled hypertension and therefore would The analytic sample included 8631 persons. Overall, 42.4% benefit from early diagnosis and treatment. (95% CI, 40.4–44.5) of PLWH in medical care had hyperten- Patients who experience difficulty accessing health care sion. Of those, 13.3% (95% CI, 11.7–14.9) were undiagnosed such as those who were recently incarcerated or have no health and untreated, 48.9% (95% CI, 46.7–51.1) were treated and insurance were more likely than others to have undiagnosed controlled, 26.3% (95% CI, 24.2–28.3) were treated and uncon- and untreated hypertension. We found that patients who were trolled, and 11.5% (95% CI, 10.4–12.6%) were unclassified. not virally suppressed at last test were more likely to have their Hypertension was associated with age, gender, race/ethnicity, hypertension undiagnosed and untreated. Because HIV viremia education, income, and body mass index (Table 1). For example, is associated with increased risk of CVD , patients with hypertension was more prevalent among PLWH aged ≥50 years undiagnosed and untreated hypertension who are not virally than among younger age groups. About half of non-Hispanic suppressed may have compounded risk for CVD. These patients blacks had hypertension compared with 38.9% of non-Hispanic may need additional support to ensure that their HIV infection whites and 33.5% of Hispanics/Latinos. and comorbidities are successfully managed. 2 • OFID • BRIEF REPORT Downloaded from https://academic.oup.com/ofid/article-abstract/5/3/ofy028/4830141 by Ed 'DeepDyve' Gillespie user on 16 March 2018 BRIEF REPORT • OFID • 3 Downloaded from https://academic.oup.com/ofid/article-abstract/5/3/ofy028/4830141 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Table 1. Sociodemographic and Clinical Characteristics of HIV-Infected Adults With Hypertension in the United States, Medical Monitoring Project 2013–2014 Total Rao Scott Chi-square Undiagnosed and Untreated Rao Scott Chi-square Weighted % Weighted % Characteristics Sample Size, No. (95% CI) P Value Sample Size With Hypertension, No. (95% CI) P Value Total 8631 42.4 (40.4–44.5) N/A 3650 13.3 (11.7–14.9) N/A Age, y <.001 <.001 18–29 720 10.7 (8.0–13.4) 80 39.1 (25.2–53.0) 30–39 1326 23.1 (18.8–27.3) 308 27.0 (20.7–33.3) 40–49 2520 37.0 (33.8–40.3) 927 16.2 (13.9–18.6) ≥50 4065 58.5 (55.8–61.3) 2335 9.4 (7.7–11.2) Gender <.001 .006 Male 6158 41.2 (39.1–43.2) 2525 14.4 (12.6–16.3) Female 2353 46.3 (43.2–49.4) 1076 10.8 (8.6–13.1) Transgender 120 37.1 (28.3–45.9) 49 6.5 (0.2–12.9) Race/ethnicity <.001 .059 White non-Hispanic 2498 38.9 (36.7–41.1) 956 15.3 (12.4–18.3) Black non-Hispanic 3693 49.8 (48.0–51.7) 1856 11.4 (9.1–13.6) Hispanic/Latino 2079 33.5 (31.1–36.0) 700 15.4 (11.9–18.9) Other 361 39.6 (32.8–46.4) 138 15.0 (8.4–21.6) c a Homeless (past 12 mo) .027 .174 No 7899 42.8 (40.6–45.1) 3365 13.1 (11.4–14.7) Yes 731 38.0 (34.7–41.3) 284 16.2 (11.5–21.0) a,d Poverty status .001 .018 Above poverty level 4070 41.2 (39.1–43.3) 1670 15.0 (12.7–17.3) At or below poverty level 4165 44.3 (41.8–46.7) 1831 11.8 (10.0–13.6) Education <.001 .045 <High school 1799 46.1 (43.5–48.7) 827 10.8 (8.0–13.5) High school 2390 43.7 (41.1–46.4) 1036 12.2 (9.6–14.7) >High school 4438 40.2 (38.0–42.5) 1785 15.2 (12.6–17.7) Incarceration (past 12 mo) .024 .001 No 8246 42.7 (40.6–44.8) 3513 12.8 (11.2–14.5) Yes 383 36.7 (32.0–41.5) 136 25.7 (16.2–35.1) Health insurance coverage <.001 .003 Any private insurance 2357 38.5 (36.0–41.0) 905 16.9 (13.3–20.5) Public insurance only 4856 47.5 (44.8–50.2) 2290 11.4 (9.9–12.9) RW only 1135 30.4 (26.4–34.5) 336 15.9 (12.3–19.5) No insurance 117 35.0 (24.6–45.5) 41 19.7 (9.6–29.9) Unspecified 152 48.3 (39.7–56.9) 72 10.6 (0.3–20.9) Smoking status .273 .042 Never smoked/former smoker 5397 42.8 (40.8–44.9) 2318 12.3 (10.5–14.1) Current smoker 3201 41.7 (39.2–44.3) 1317 15.1 (12.6–17.5) 4 • OFID • BRIEF REPORT Downloaded from https://academic.oup.com/ofid/article-abstract/5/3/ofy028/4830141 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Table 1. Continued Total Rao Scott Chi-square Undiagnosed and Untreated Rao Scott Chi-square Weighted % Weighted % Characteristics Sample Size, No. (95% CI) P Value Sample Size With Hypertension, No. (95% CI) P Value BMI <.001 .062 Underweight 192 32.2 (25.1–39.2) 59 11.9 (2.2–21.6) Normal/healthy weight 2613 31.7 (29.3–34.1) 832 13.7 (11.7–15.8) Overweight 2551 41.6 (39.3–43.9) 1064 14.6 (12.5–16.7) Obese 2032 60.2 (57.0–63.4) 1211 11.0 (9.1–12.9) .003 .063 Lowest CD4 count (past 12 mo), cells/µL 0–49 243 37.9 (31.2–44.6) 89 22.1 (12.2–32.0) 50–199 860 37.0 (33.7–40.2) 325 15.5 (11.7–19.2) 200–349 1444 43.1 (40.1–46.1) 625 12.1 (9.4–14.8) 350–499 1883 42.9 (40.2–45.6) 805 13.4 (11.0–15.8) ≥500 3863 43.7 (41.2–46.2) 1672 12.3 (10.1–14.5) f,g Virally suppressed at last test .508 .040 No 1068 41.1 (37.5–44.7) 438 17.0 (12.5–21.5) Yes 7063 42.4 (40.3–44.6) 2992 12.4 (10.7–14.1) f,h Sustained viral suppression .026 .057 No 2093 39.2 (36.5–42.0) 826 15.9 (12.6–19.3) Yes 6038 43.3 (40.9–45.8) 2604 12.1 (10.0–14.1) Abbreviations: ART, antiretroviral therapy; BMI, body mass index; CI, confidence interval; HIV, human immunodeficiency virus; No., sample size of each stratum of variables. Variabes obtained from interview. Hispanics/Latinos could be of any race. McKinney-Vento definition of homelessness: living on the street, living in a shelter, living in a single room occupancy hotel, temporarily staying with friends or family, or living in a car. A person is categorized as homeless if that person lacks a fixed, regu- lar, adequate night-time residence or has a steady night-time residence that is (1) a supervised publicly or privately operated shelter designed to provide temporary living accommodation, (2) an institution that provides a temporary residence for persons intended to be institutionalized, or (3) a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings (eg, in an automobile or under a bridge; Stewart B. McKinney Homeless Assistance Act, 42 U.S.C. §11301, et seq; 1987). US Department of Health and Human Services. Available at: http://aspe.hhs.gov/poverty/09poverty.shtml. Includes general education development credential. Variables obtained from medical records. HIV RNA undetectable or <200 copies/mL at last test. HIV RNA undetectable or <200 copies/mL at all tests in the last 12 months. Disclaimer. e fin Th dings and conclusions in this report are those of This study has limitations. We were unable to directly com- the authors and do not necessarily represent the views of the Centers for pare hypertension prevalence among PLWH (42%) with prev- Disease Control and Prevention. alence in the general US population (29%) as measured by Potential conifl cts of interest. All authors: no reported conflicts of the National Health and Nutrition Examination Survey  interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to because of methodologic differences between the 2 population the content of the manuscript have been disclosed. surveys. We were conservative in our definition of hypertension by requiring both diagnosis and pharmacological treatment or References high blood pressure readings; therefore, our prevalence may 1. Smith CJ, Ryom L, Weber R, et al; D:A:D Study Group. Trends in underlying causes of death in people with HIV from 1999 to 2011 (D:A:D): a multicohort represent an underestimation of burden of hypertension among collaboration. Lancet 2014; 384:241–8. PLWH. MMP data do not indicate whether a patient is receiving 2. Feinstein MJ, Bahiru E, Achenbach C, et al. Patterns of cardiovascular mortality for HIV-infected adults in the United States: 1999 to 2013. Am J Cardiol 2016; lifestyle modification counseling. If this information were avail- 117:214–20. able and we had considered lifestyle modification as treatment, 3. Baekken M, Os I, Sandvik L, Oektedalen O. Hypertension in an urban HIV- positive population compared with the general population: influence of combin- our estimates of the overall prevalence of hypertension and ation antiretroviral therapy. J Hypertens 2008; 26:2126–33. the prevalence of those who were “treated and uncontrolled” 4. Jericó C, Knobel H, Montero M, et al. Hypertension in HIV-infected patients: or “treated and controlled” might have been higher. Similarly, prevalence and related factors. Am J Hypertens 2005; 18:1396–401. 5. Thiébaut R, El-Sadr WM, Friis-Møller N, et al; Data Collection of Adverse events our estimate of the prevalence of untreated hypertension might of anti-HIV Drugs Study Group. Predictors of hypertension and changes of blood have been lower. pressure in HIV-infected patients. Antivir Ther 2005; 10:811–23. 6. Bradley H, Frazier E, Huang P, et al. Behavioral and Clinical Characteristics In conclusion, PLWH who received medical care in the of Persons Receiving Medical Care for HIV Infection Medical Monitoring United States had a high prevalence of hypertension. Providers Project, United States, 2010. Atlanta, GA: Centers for Disease Control and Prevention; 2014. may be missing opportunities to diagnose and treat hyper- 7. US Department of Health and Human Services. Protection of Human Subjects, tension among their HIV patients, especially those who are US Federal Code Title 45 Part 46. 2009. Available at: https://www.hhs.gov/ohrp/ regulations-and-policy/regulations/45-cfr-46/index.html younger or have less access to care. It is important to improve 8. Centers for Disease Control and Prevention. Distinguishing Public Health hypertension screening and management to prevent CVD out- Research and Public Health Nonresearch. 2010. Available at: https://www. comes, for which PLWH have high risk. cdc.gov/od/science/integrity/docs/cdc-policy-distinguishing-public-health- research-nonresearch.pdf 9. Gazzaruso C, Bruno R, Garzaniti A, et al. Hypertension among HIV patients: Supplementary Data prevalence and relationships to insulin resistance and metabolic syndrome. J Hypertens 2003; 21:1377–82. Supplementary materials are available at Open Forum Infectious Diseases 10. Ritchwood TD, Bishu KG, Egede LE. Trends in healthcare expenditure among online. Consisting of data provided by the authors to benefit the reader, the people living with HIV/AIDS in the United States: evidence from 10 years of posted materials are not copyedited and are the sole responsibility of the nationally representative data. Int J Equity Health 2017; 16:188. authors, so questions or comments should be addressed to the corresponding 11. Bradley H, Mattson CL, Beer L, et al; Medical Monitoring Project. Increased anti- author. retroviral therapy prescription and HIV viral suppression among persons receiv- ing clinical care for HIV infection. AIDS 2016; 30:2117–24. 12. Lewden C, Bouteloup V, De Wit S, et al; Collaboration of Observational Acknowledgments HIVEREiE. All-cause mortality in treated HIV-infected adults with CD4 ≥500/ mm3 compared with the general population: evidence from a large European e a Th uthors would like to thank the participating Medical Monitoring Project observational cohort collaboration. Int J Epidemiol 2012; 41:433–45. (MMP) participants, facilities, project areas, and Provider and Community 13. Lang S, Mary-Krause M, Simon A, et al; French Hospital Database on HIV Advisory Board members. We also acknowledge the Clinical Outcomes Team, (FHDH)–ANRS CO4. HIV replication and immune status are independent the Behavioral and Clinical Surveillance Branch at the Centers for Disease predictors of the risk of myocardial infarction in HIV-infected individuals. Clin Control and Prevention, and the MMP Study Group Members: (https://www. Infect Dis 2012; 55:600–7. cdc.gov/hiv/statistics/systems/mmp/resources.html#StudyGroupMembers). 14. Yoon SS, Fryar CD, Carroll MD. Hypertension Prevalence and Control Among Financial support. Funding for the Medical Monitoring Project is pro- Adults: United States, 2011–2014. NCHS Data Brief, No. 220. Hyattsville, MD: vided by the Centers for Disease Control and Prevention. National Center for Health Statistics; 2015. BRIEF REPORT • OFID • 5 Downloaded from https://academic.oup.com/ofid/article-abstract/5/3/ofy028/4830141 by Ed 'DeepDyve' Gillespie user on 16 March 2018
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