Human immunodeficiency virus (HIV) infection affects approximately 1 million people in Brazil and approximately 21 million worldwide.^1,2 With the advent of antiretroviral therapy, there has been a significant improvement in the quality of life of infected patients, allowing many who previously progressed to end-stage immunodeficiency to regain normal quality of life.^3,4 This improvement has resulted in increased life expectancy, but it has also brought to light problems related to chronic non-communicable diseases, among which hypertension stands out.³

Hypertension is one of the most common chronic diseases among people living with HIV, with an estimated occurrence of approximately 17.8%, which can reach 25%, depending on the population sample analyzed.^5–7 This high incidence can be attributed to the virus's inflammatory activity, which can lead to endothelial dysfunction and increase the risk of elevated blood pressure.³ Furthermore, the development of hypertension may also be associated with antiretroviral therapy, whose side effects may contribute to this condition, as well as other comorbidities, including dyslipidemia, diabetes mellitus, and HIV-related kidney disease.⁸

Hypertension imposes substantial costs on public health systems and further compromises the health of people living with HIV.⁵ Furthermore, as an independent cardiovascular risk factor, it increases the risk of adverse events, such as acute myocardial infarction and stroke.^3,4 Among the population living with HIV, hypertension has also been related to the development of chronic kidney disease.⁷

Survival of individuals living with HIV has been a topic of growing interest in medical research. With the effective use of antiretroviral therapy, many patients experience a significant improvement in quality of life and an increase in life expectancy, thereby reducing mortality associated with acquired immunodeficiency syndrome (AIDS).⁹ However, this population faces not only complications related to the infection itself, but also an increased incidence of chronic comorbidities, including cardiovascular disease, diabetes, and hypertension.¹⁰ Studies show that the presence of comorbidities can complicate treatment and negatively impact patient survival, since the coexistence of multiple health conditions can result in higher hospitalization and mortality rates.¹¹ Thus, investigating the relationship between hypertension prior to HIV diagnosis and patient survival becomes essential for developing strategies that promote integrated care and improve health outcomes in this vulnerable population.¹²

In this context, it is crucial to understand whether hypertension diagnosed before HIV diagnosis affects these patients’ survival, potentially acting as a predictive risk factor for death and influencing therapeutic decision-making. The literature on this correlation is still scarce, which makes this question even more relevant.

Given the above, the objective of this study was to analyze how hypertension, diagnosed before HIV diagnosis, impacts the survival of people living with HIV. This study also aimed to analyze other variables related to hypertension, to calculate the risk associated with the variables of death and hypertension, and to evaluate patient survival by means of survival curves.

The Central Illustration summarizes the main study findings. The sociodemographic profile of people living with HIV was predominantly heterosexual, with low education level, concentrated in the 18 to 40 age range, and an average age of 37.2 years. A substantial proportion was married or in a stable relationship. Male predominance was also observed, along with a majority of White individuals and patients who contracted HIV through sexual transmission. This profile is similar to that found in previous studies, especially in samples from the South Region of Brazil, which portray a predominantly White, heterosexual, and young population, although the prevalence of men is more pronounced in other locations.¹⁷ In addition, some studies have indicated a higher prevalence of men compared to women, varying with the population's racial profile of the population.¹⁸

The prevalence of hypertension before HIV infection in the study population was 13.17%. It is worth emphasizing that this frequency occurred among individuals who already had hypertension at the time of HIV diagnosis, which may partly explain differences compared with studies reporting around 33%.⁶ However, the majority of individuals with elevated blood pressure levels were between 41 and 50 years old, indicating age as an independent risk factor for the development of hypertension.¹⁹ The younger age of the sample raises questions about a potential increase in the prevalence of hypertension in younger age groups, especially in individuals between 30 and 39 years old.²⁰ Furthermore, the profile of patients with hypertension as predominantly White men with sexual transmission is a common trend observed among the majority of studies including people living with HIV.²¹

During the study period, 52 patients died. The risk association was higher among those with hypertension compared to those without. The increase in mortality from cardiovascular causes in people living with HIV signals a change in the mortality profile of this population, especially after the introduction of highly active antiretroviral therapy, which has promoted greater survival but also led to the emergence of comorbidities, including chronic non-communicable diseases, such as hypertension.^22,23

The elevated risk ratio between hypertension and death in this group highlights the importance of this comorbidity, which has a high prevalence among people living with HIV. It is estimated that about 35% of individuals on antiretroviral therapy and approximately 13% of those not undergoing this therapy suffer from hypertension.^24,25 This emphasizes the need for effective management of blood pressure levels in this population, especially considering that the advent of antiretroviral therapy has brought about a shift toward mortality from causes unrelated to immunosuppression, and cardiovascular diseases, with hypertension as one of the main risk factors, has been a growing concern.²⁴

The relationship between hypertension and death suggests a higher probability of death in patients with hypertension compared to those without. This result is consistent with other studies that have associated hypertension with a higher probability of death, although they have not demonstrated that hypertension increases mortality or loss to follow-up in combined outcomes.²⁶ When assessing stratified subgroups, women presented elevated HR, reaching statistical significance. This finding contradicts the conclusion of the aforementioned study, which described the female sex as protective.²⁶ In the present study, men showed a lower risk of death compared to women. In the United States, analyses focused solely on the female sex revealed a higher risk ratio among women with hypertension compared to those without.²⁷ Although stratified analysis could suggest a difference between the sexes, the multivariate model showed that, after adjusting for other variables, male sex presented a tendency towards higher risk (HR = 1.7), but without reaching statistical significance (p = 0.088). This indicates that sex, in isolation, may not be as strong a determinant of death as ethnicity or mode of transmission in this specific population.²⁶ It is worth underscoring the wide CI obtained in the sample of women; this occurred in other analyses as well, which may indicate high variability in the sample and a small number of events in these subgroups. Accordingly, some of these estimates, the p value shows statistical significance, may present some uncertainty, given the wide CI observed.

In this study, White people living with HIV presented hypertension as a more significant predictor of death compared to those who were not White. This result contrasts with the existing literature, which suggests that White individuals generally have a lower compared risk of mortality.²⁷ For example, a study by Weng et al.²⁸ highlighted that the racial disparity in mortality from cardiovascular diseases is often more pronounced in non-White populations, who face additional challenges such as limited access to medical care and inadequate management of chronic diseases. This data was reinforced by multivariate analysis, which showed that non-White patients had a twofold risk of death compared to White patients. This is an alarming finding that corroborates previous studies on structural inequalities in access to healthcare.^27,28

Furthermore, when focusing solely on survival analysis, White patients tend to have more favorable rates, suggesting that hypertension could act as a survival marker in this group.²⁹ Other studies have corroborated this observation, indicating that White patients with hypertension may have better control of blood pressure levels and, consequently, greater survival compared to patients who are not White.^29,30

Survival curves revealed that hypertension had a significant negative impact on the overall population's survival, with hypertensive patients showing lower survival rates compared to those without hypertension. This finding is consistent with several studies showing reduced life expectancy among patients with hypertension, especially those living with HIV.²⁹ However, since the follow-up period was long, changes in antiretroviral treatment may have contributed to differences in the survival curve, particularly after 72 months, which may suggest a time-dependent effect resulting from changes in Brazilian guidelines on HIV/AIDS treatment.

The data indicated that White patients with hypertension demonstrated lower survival, which contrasts with other studies suggesting that blood pressure control is more effective among White patients, resulting in lower mortality and, consequently, better survival.²⁸ The literature frequently highlights that the disparity in hypertension control may be linked to unequal access to healthcare and variations in clinical management across different racial groups, which may explain the increased mortality among White patients with hypertension in this particular context.³¹

The results of this study indicate that women with hypertension had lower survival rates compared to non-hypertensive women; this finding differs from several reports in the literature. It has traditionally been observed that women tend to die from cardiovascular diseases at older ages than men, a dynamic that generally places female sex as a protective factor in relation to mortality, especially in populations living with HIV.^26,30 A possible explanation for the increased cardiovascular risk in women living with HIV and hypertension may be the complex interaction between these conditions, which can exacerbate traditional cardiovascular risk factors. Furthermore, the stigma associated with HIV can hinder access to adequate care, leading to inadequate control of hypertension and, consequently, higher cardiovascular mortality among these women.

These results underscore the complexity of the interaction between hypertension, sex, and race in the mortality of patients living with HIV. There is an increasingly evident need for specific management strategies that consider the nuances of these interactions in order to improve health outcomes in these vulnerable groups. The discussion regarding the impact of comorbidities, such as hypertension, on the population living with HIV is fundamental to informing clinical practices and health policies that seek to reduce inequalities and improve these patients’ quality of life.

This study's strengths include comprehensive analysis of the relationship between hypertension and mortality in patients living with HIV, using a large database and a diverse sample, as well as the inclusion of sociodemographic variables that elucidate aspects of inequality in health outcomes. The use of survival curves provides a clear visualization of hypertension's impact on mortality, strengthening the conclusions.

The study limitations include the fact that it relied on secondary data, originating from the medical records of patients under treatment at the service, which may compromise the accuracy of the information. This study did not consider some relevant factors, such as the patients’ lifestyle and treatment adherence. Additional study limitations include the observational design which does not establish causality, difficulties in isolating influencing factors, and the study's limited generalizability.

This study has highlighted the importance of understanding the relationship between hypertension and mortality in patients living with HIV, demonstrating that sociodemographic factors, such as race and sex, influence these outcomes. The results suggest that hypertension was a significant predictor of mortality among the population analyzed. However, this study's limitations, including its observational design and reliance on secondary data, underscore the need for future research exploring causal relationships and additional contributing factors. These findings may help inform clinical management strategies and public health interventions aimed at improving quality of life and survival in this vulnerable population.