title: HIV, antiretroviral treatment, hypertension, and stroke in Malawian adults: A case-control study.
abstract: OBJECTIVE
  To investigate HIV, its treatment, and hypertension as stroke risk factors in Malawian adults.
  
  
  METHODS
  We performed a case-control study of 222 adults with acute stroke, confirmed by MRI in 86%, and 503 population controls, frequency-matched for age, sex, and place of residence, using Global Positioning System for random selection. Multivariate logistic regression models were used for case-control comparisons.
  
  
  RESULTS
  HIV infection (population attributable fraction [PAF] 15%) and hypertension (PAF 46%) were strongly linked to stroke. HIV was the predominant risk factor for young stroke (≤45 years), with a prevalence of 67% and an adjusted odds ratio (aOR) (95% confidence interval) of 5.57 (2.43-12.8) (PAF 42%). There was an increased risk of a stroke in patients with untreated HIV infection (aOR 4.48 [2.44-8.24], p < 0.001), but the highest risk was in the first 6 months after starting antiretroviral therapy (ART) (aOR 15.6 [4.21-46.6], p < 0.001); this group had a lower median CD4(+) T-lymphocyte count (92 vs 375 cells/mm(3), p = 0.004). In older participants (HIV prevalence 17%), HIV was associated with stroke, but with a lower PAF than hypertension (5% vs 68%). There was no interaction between HIV and hypertension on stroke risk.
  
  
  CONCLUSIONS
  In a population with high HIV prevalence, where stroke incidence is increasing, we have shown that HIV is an important risk factor. Early ART use in immunosuppressed patients poses an additional and potentially treatable stroke risk. Immune reconstitution inflammatory syndrome may be contributing to the disease mechanisms.
authors.affiliation: From the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., A.C., R.S.H.) and the Department of Medicine (L.A.B., H.M., S.K., R.S.H., T.J.A.), College of Medicine, University of Malawi, Blantyre; the Brain Infections Group (L.A.B., T.S.), Institute of Infection and Global Health, University of Liverpool (L.A.B., H.C.A.E., T.S.); the Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool; the Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine; the NHS Borders and Division of Clinical Neuroscience (M.D.C.), University of Edinburgh, UK; the School of Public Health (M.D.C.), University of the Witwatersrand, Johannesburg, South Africa; the Royal Liverpool Hospital (M.H.); the Royal Preston Hospital (H.C.A.E.), Liverpool, UK; the Department of Medicine (A.B.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; the Liverpool School of Tropical Medicine (B.F.); the Division of Infection and Immunity (R.S.H.), University College London; and the National Institute for Health Research (T.S.), Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, UK. l.benjamin@liverpool.ac.uk.
authors.forename: Laura A
authors.initials: LA
authors.lastname: Benjamin
authors.affiliation: From the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., A.C., R.S.H.) and the Department of Medicine (L.A.B., H.M., S.K., R.S.H., T.J.A.), College of Medicine, University of Malawi, Blantyre; the Brain Infections Group (L.A.B., T.S.), Institute of Infection and Global Health, University of Liverpool (L.A.B., H.C.A.E., T.S.); the Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool; the Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine; the NHS Borders and Division of Clinical Neuroscience (M.D.C.), University of Edinburgh, UK; the School of Public Health (M.D.C.), University of the Witwatersrand, Johannesburg, South Africa; the Royal Liverpool Hospital (M.H.); the Royal Preston Hospital (H.C.A.E.), Liverpool, UK; the Department of Medicine (A.B.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; the Liverpool School of Tropical Medicine (B.F.); the Division of Infection and Immunity (R.S.H.), University College London; and the National Institute for Health Research (T.S.), Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, UK.
authors.forename: Elizabeth L
authors.initials: EL
authors.lastname: Corbett
authors.affiliation: From the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., A.C., R.S.H.) and the Department of Medicine (L.A.B., H.M., S.K., R.S.H., T.J.A.), College of Medicine, University of Malawi, Blantyre; the Brain Infections Group (L.A.B., T.S.), Institute of Infection and Global Health, University of Liverpool (L.A.B., H.C.A.E., T.S.); the Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool; the Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine; the NHS Borders and Division of Clinical Neuroscience (M.D.C.), University of Edinburgh, UK; the School of Public Health (M.D.C.), University of the Witwatersrand, Johannesburg, South Africa; the Royal Liverpool Hospital (M.H.); the Royal Preston Hospital (H.C.A.E.), Liverpool, UK; the Department of Medicine (A.B.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; the Liverpool School of Tropical Medicine (B.F.); the Division of Infection and Immunity (R.S.H.), University College London; and the National Institute for Health Research (T.S.), Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, UK.
authors.forename: Myles D
authors.initials: MD
authors.lastname: Connor
authors.affiliation: From the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., A.C., R.S.H.) and the Department of Medicine (L.A.B., H.M., S.K., R.S.H., T.J.A.), College of Medicine, University of Malawi, Blantyre; the Brain Infections Group (L.A.B., T.S.), Institute of Infection and Global Health, University of Liverpool (L.A.B., H.C.A.E., T.S.); the Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool; the Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine; the NHS Borders and Division of Clinical Neuroscience (M.D.C.), University of Edinburgh, UK; the School of Public Health (M.D.C.), University of the Witwatersrand, Johannesburg, South Africa; the Royal Liverpool Hospital (M.H.); the Royal Preston Hospital (H.C.A.E.), Liverpool, UK; the Department of Medicine (A.B.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; the Liverpool School of Tropical Medicine (B.F.); the Division of Infection and Immunity (R.S.H.), University College London; and the National Institute for Health Research (T.S.), Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, UK.
authors.forename: Henry
authors.initials: H
authors.lastname: Mzinganjira
authors.affiliation: From the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., A.C., R.S.H.) and the Department of Medicine (L.A.B., H.M., S.K., R.S.H., T.J.A.), College of Medicine, University of Malawi, Blantyre; the Brain Infections Group (L.A.B., T.S.), Institute of Infection and Global Health, University of Liverpool (L.A.B., H.C.A.E., T.S.); the Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool; the Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine; the NHS Borders and Division of Clinical Neuroscience (M.D.C.), University of Edinburgh, UK; the School of Public Health (M.D.C.), University of the Witwatersrand, Johannesburg, South Africa; the Royal Liverpool Hospital (M.H.); the Royal Preston Hospital (H.C.A.E.), Liverpool, UK; the Department of Medicine (A.B.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; the Liverpool School of Tropical Medicine (B.F.); the Division of Infection and Immunity (R.S.H.), University College London; and the National Institute for Health Research (T.S.), Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, UK.
authors.forename: Sam
authors.initials: S
authors.lastname: Kampondeni
authors.affiliation: From the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., A.C., R.S.H.) and the Department of Medicine (L.A.B., H.M., S.K., R.S.H., T.J.A.), College of Medicine, University of Malawi, Blantyre; the Brain Infections Group (L.A.B., T.S.), Institute of Infection and Global Health, University of Liverpool (L.A.B., H.C.A.E., T.S.); the Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool; the Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine; the NHS Borders and Division of Clinical Neuroscience (M.D.C.), University of Edinburgh, UK; the School of Public Health (M.D.C.), University of the Witwatersrand, Johannesburg, South Africa; the Royal Liverpool Hospital (M.H.); the Royal Preston Hospital (H.C.A.E.), Liverpool, UK; the Department of Medicine (A.B.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; the Liverpool School of Tropical Medicine (B.F.); the Division of Infection and Immunity (R.S.H.), University College London; and the National Institute for Health Research (T.S.), Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, UK.
authors.forename: Augustine
authors.initials: A
authors.lastname: Choko
authors.affiliation: From the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., A.C., R.S.H.) and the Department of Medicine (L.A.B., H.M., S.K., R.S.H., T.J.A.), College of Medicine, University of Malawi, Blantyre; the Brain Infections Group (L.A.B., T.S.), Institute of Infection and Global Health, University of Liverpool (L.A.B., H.C.A.E., T.S.); the Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool; the Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine; the NHS Borders and Division of Clinical Neuroscience (M.D.C.), University of Edinburgh, UK; the School of Public Health (M.D.C.), University of the Witwatersrand, Johannesburg, South Africa; the Royal Liverpool Hospital (M.H.); the Royal Preston Hospital (H.C.A.E.), Liverpool, UK; the Department of Medicine (A.B.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; the Liverpool School of Tropical Medicine (B.F.); the Division of Infection and Immunity (R.S.H.), University College London; and the National Institute for Health Research (T.S.), Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, UK.
authors.forename: Mark
authors.initials: M
authors.lastname: Hopkins
authors.affiliation: From the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., A.C., R.S.H.) and the Department of Medicine (L.A.B., H.M., S.K., R.S.H., T.J.A.), College of Medicine, University of Malawi, Blantyre; the Brain Infections Group (L.A.B., T.S.), Institute of Infection and Global Health, University of Liverpool (L.A.B., H.C.A.E., T.S.); the Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool; the Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine; the NHS Borders and Division of Clinical Neuroscience (M.D.C.), University of Edinburgh, UK; the School of Public Health (M.D.C.), University of the Witwatersrand, Johannesburg, South Africa; the Royal Liverpool Hospital (M.H.); the Royal Preston Hospital (H.C.A.E.), Liverpool, UK; the Department of Medicine (A.B.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; the Liverpool School of Tropical Medicine (B.F.); the Division of Infection and Immunity (R.S.H.), University College London; and the National Institute for Health Research (T.S.), Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, UK.
authors.forename: Hedley C A
authors.initials: HC
authors.lastname: Emsley
authors.affiliation: From the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., A.C., R.S.H.) and the Department of Medicine (L.A.B., H.M., S.K., R.S.H., T.J.A.), College of Medicine, University of Malawi, Blantyre; the Brain Infections Group (L.A.B., T.S.), Institute of Infection and Global Health, University of Liverpool (L.A.B., H.C.A.E., T.S.); the Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool; the Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine; the NHS Borders and Division of Clinical Neuroscience (M.D.C.), University of Edinburgh, UK; the School of Public Health (M.D.C.), University of the Witwatersrand, Johannesburg, South Africa; the Royal Liverpool Hospital (M.H.); the Royal Preston Hospital (H.C.A.E.), Liverpool, UK; the Department of Medicine (A.B.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; the Liverpool School of Tropical Medicine (B.F.); the Division of Infection and Immunity (R.S.H.), University College London; and the National Institute for Health Research (T.S.), Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, UK.
authors.forename: Alan
authors.initials: A
authors.lastname: Bryer
authors.affiliation: From the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., A.C., R.S.H.) and the Department of Medicine (L.A.B., H.M., S.K., R.S.H., T.J.A.), College of Medicine, University of Malawi, Blantyre; the Brain Infections Group (L.A.B., T.S.), Institute of Infection and Global Health, University of Liverpool (L.A.B., H.C.A.E., T.S.); the Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool; the Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine; the NHS Borders and Division of Clinical Neuroscience (M.D.C.), University of Edinburgh, UK; the School of Public Health (M.D.C.), University of the Witwatersrand, Johannesburg, South Africa; the Royal Liverpool Hospital (M.H.); the Royal Preston Hospital (H.C.A.E.), Liverpool, UK; the Department of Medicine (A.B.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; the Liverpool School of Tropical Medicine (B.F.); the Division of Infection and Immunity (R.S.H.), University College London; and the National Institute for Health Research (T.S.), Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, UK.
authors.forename: Brian
authors.initials: B
authors.lastname: Faragher
authors.affiliation: From the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., A.C., R.S.H.) and the Department of Medicine (L.A.B., H.M., S.K., R.S.H., T.J.A.), College of Medicine, University of Malawi, Blantyre; the Brain Infections Group (L.A.B., T.S.), Institute of Infection and Global Health, University of Liverpool (L.A.B., H.C.A.E., T.S.); the Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool; the Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine; the NHS Borders and Division of Clinical Neuroscience (M.D.C.), University of Edinburgh, UK; the School of Public Health (M.D.C.), University of the Witwatersrand, Johannesburg, South Africa; the Royal Liverpool Hospital (M.H.); the Royal Preston Hospital (H.C.A.E.), Liverpool, UK; the Department of Medicine (A.B.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; the Liverpool School of Tropical Medicine (B.F.); the Division of Infection and Immunity (R.S.H.), University College London; and the National Institute for Health Research (T.S.), Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, UK.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Heyderman
authors.affiliation: From the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., A.C., R.S.H.) and the Department of Medicine (L.A.B., H.M., S.K., R.S.H., T.J.A.), College of Medicine, University of Malawi, Blantyre; the Brain Infections Group (L.A.B., T.S.), Institute of Infection and Global Health, University of Liverpool (L.A.B., H.C.A.E., T.S.); the Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool; the Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine; the NHS Borders and Division of Clinical Neuroscience (M.D.C.), University of Edinburgh, UK; the School of Public Health (M.D.C.), University of the Witwatersrand, Johannesburg, South Africa; the Royal Liverpool Hospital (M.H.); the Royal Preston Hospital (H.C.A.E.), Liverpool, UK; the Department of Medicine (A.B.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; the Liverpool School of Tropical Medicine (B.F.); the Division of Infection and Immunity (R.S.H.), University College London; and the National Institute for Health Research (T.S.), Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, UK.
authors.forename: Theresa J
authors.initials: TJ
authors.lastname: Allain
authors.affiliation: From the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., A.C., R.S.H.) and the Department of Medicine (L.A.B., H.M., S.K., R.S.H., T.J.A.), College of Medicine, University of Malawi, Blantyre; the Brain Infections Group (L.A.B., T.S.), Institute of Infection and Global Health, University of Liverpool (L.A.B., H.C.A.E., T.S.); the Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool; the Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine; the NHS Borders and Division of Clinical Neuroscience (M.D.C.), University of Edinburgh, UK; the School of Public Health (M.D.C.), University of the Witwatersrand, Johannesburg, South Africa; the Royal Liverpool Hospital (M.H.); the Royal Preston Hospital (H.C.A.E.), Liverpool, UK; the Department of Medicine (A.B.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; the Liverpool School of Tropical Medicine (B.F.); the Division of Infection and Immunity (R.S.H.), University College London; and the National Institute for Health Research (T.S.), Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, UK.
authors.forename: Tom
authors.initials: T
authors.lastname: Solomon
mesh_terms: D000328:Adult; D000368:Aged; D019380:Anti-HIV Agents / Q000009:adverse effects*; D016022:Case-Control Studies; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy / Q000453:epidemiology*; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000453:epidemiology*; D054019:Immune Reconstitution Inflammatory Syndrome / Q000150:complications / Q000453:epidemiology; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology* / Q000209:etiology
chemical_list: D019380:Anti-HIV Agents