title: Blood pressure level impacts risk of death among HIV seropositive adults in Kenya: a retrospective analysis of electronic health records.
abstract: BACKGROUND
  Mortality among people with human immunodeficiency virus (HIV) infection is increasingly due to non-communicable causes. This has been observed mostly in developed countries and the routine care of HIV infected individuals has now expanded to include attention to cardiovascular risk factors. Cardiovascular risk factors such as high blood pressure are often overlooked among HIV seropositive (+) individuals in sub-Saharan Africa. We aimed to determine the effect of blood pressure on mortality among HIV+ adults in Kenya.
  
  
  METHODS
  We performed a retrospective analysis of electronic medical records of a large HIV treatment program in western Kenya between 2005 and 2010. All included individuals were HIV+. We excluded participants with AIDS, who were <16 or >80 years old, or had data out of acceptable ranges. Missing data for key covariates was addressed by inverse probability weighting. Primary outcome measures were crude mortality rate and mortality hazard ratio (HR) using Cox proportional hazards models adjusted for potential confounders including HIV stage.
  
  
  RESULTS
  There were 49,475 (74% women) HIV+ individuals who met inclusion and exclusion criteria. Mortality rates for men and women were 3.8 and 1.8/100 person-years, respectively, and highest among those with the lowest blood pressures. Low blood pressure was associated with the highest mortality incidence rate (IR) (systolic <100 mmHg IR 5.2 [4.8-5.7]; diastolic <60 mmHg IR 9.2 [8.3-10.2]). Mortality rate among men with high systolic blood pressure without advanced HIV (3.0, 95% CI: 1.6-5.5) was higher than men with normal systolic blood pressure (1.1, 95% CI: 0.7-1.7). In weighted proportional hazards regression models, men without advanced HIV disease and systolic blood pressure ≥140 mmHg carried a higher mortality risk than normotensive men (HR: 2.39, 95% CI: 0.94-6.08).
  
  
  CONCLUSIONS
  Although there has been little attention paid to high blood pressure among HIV+ Africans, we show that blood pressure level among HIV+ patients in Kenya is related to mortality. Low blood pressure carries the highest mortality risk. High systolic blood pressure is associated with mortality among patients whose disease is not advanced. Further investigation is needed into the cause of death for such patients.
authors.affiliation: Duke Clinical Research Institute, Duke University, 2400 Pratt Street, Durham, NC 27705, USA. gerald.bloomfield@duke.edu.
authors.forename: Gerald S
authors.initials: GS
authors.lastname: Bloomfield
authors.forename: Joseph W
authors.initials: JW
authors.lastname: Hogan
authors.forename: Alfred
authors.initials: A
authors.lastname: Keter
authors.forename: Thomas L
authors.initials: TL
authors.lastname: Holland
authors.forename: Edwin
authors.initials: E
authors.lastname: Sang
authors.forename: Sylvester
authors.initials: S
authors.lastname: Kimaiyo
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Velazquez
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001794:Blood Pressure; D057286:Electronic Health Records; D005260:Female; D015658:HIV Infections / Q000097:blood / Q000401:mortality; D006679:HIV Seropositivity / Q000401:mortality*; D006801:Humans; D006973:Hypertension / Q000453:epidemiology*; D015994:Incidence; D007630:Kenya / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D055815:Young Adult