PLHIV had lower HTN diagnosis and higher regression, including treatment discontinuation and loss of BP control, underscoring persistent gaps in longitudinal HTN management within HIV programmes and the need for integrated and targeted chronic care models that ensure treatment continuity and sustained control.
Key Findings
Results
People living with HIV (PLHIV) were substantially more likely to remain undiagnosed for hypertension compared with people not living with HIV (PNLHIV).
Adjusted rate ratio (aRR) of 3.40 (95% CI: 2.45, 4.73; p < 0.001) for remaining undiagnosed among PLHIV versus PNLHIV.
The study included 23,855 participants, of whom 78.5% were PLHIV.
Participants were adults (≥18 years) receiving chronic care at nine public primary healthcare clinics in Johannesburg.
Data were collected from the iHEART-SA trial between August 2022 and May 2024, with follow-up through May 2025.
The median SBP across the full cohort was 132 mmHg (IQR: 120–145 mmHg).
Results
Among those treated for hypertension, PLHIV were less likely to achieve blood pressure control compared with PNLHIV.
Adjusted rate ratio (aRR) of 0.85 (95% CI: 0.75, 0.97; p = 0.012) for BP control among PLHIV versus PNLHIV.
This finding reflects a statistically significant disparity in treatment effectiveness or adherence between the two groups.
The analysis was conducted as a longitudinal secondary analysis using routinely collected clinical data.
Treatment ascertainment was based on documented medication use, which is noted as a study limitation.
Results
PLHIV experienced higher rates of regression from treated hypertension back to untreated hypertension during follow-up.
22% of PLHIV regressed to untreated HTN compared with 11% of PNLHIV.
Adjusted rate ratio (aRR) of 1.51 (95% CI: 1.03, 2.23; p = 0.037) for regression to untreated HTN among PLHIV.
This indicates a higher rate of treatment discontinuation among PLHIV.
Regression was assessed across the full HTN care cascade during longitudinal follow-up.
Results
PLHIV experienced higher rates of regression from controlled to uncontrolled blood pressure during follow-up.
Adjusted rate ratio (aRR) of 1.10 (95% CI: 1.02, 1.18; p = 0.010) for regression from controlled to uncontrolled BP among PLHIV versus PNLHIV.
This finding indicates a statistically significant loss of sustained BP control among PLHIV.
The result highlights challenges in maintaining long-term hypertension control within HIV care programmes.
Follow-up duration was variable across participants, which is noted as a study limitation.
Methods
The study population was predominantly female and relatively young, with the majority being PLHIV attending public primary healthcare clinics.
Of 23,855 participants, 78.5% were PLHIV.
Among PLHIV, the median age was 42 years (IQR: 36–49) and 69% were female.
Participants were recruited from nine public primary healthcare clinics in Johannesburg.
Inclusion criteria required adults ≥18 years with known HIV status and a completed medical file review.
The study period ran from August 2022 to May 2024, with follow-up through May 2025.
Background
South Africa faces a dual public health burden of high hypertension prevalence and high HIV prevalence, with limited longitudinal evidence on how individuals move through the HTN care cascade.
Hypertension is described as 'a major and growing public health challenge in South Africa.'
HIV prevalence in South Africa 'remains high,' creating a dual burden with hypertension.
The authors note that 'longitudinal evidence describing how individuals move through the HTN care cascade particularly comparing PLHIV and PNLHIV remains limited.'
Understanding cascade progression and regression is described as 'essential to inform health system strategies for integrated chronic disease management.'
Conclusions
The study identified persistent gaps in longitudinal hypertension management within HIV programmes, highlighting the need for integrated chronic care models.
The authors conclude that findings underscore 'persistent gaps in longitudinal HTN management within HIV programmes.'
The authors call for 'integrated and targeted chronic care models that ensure treatment continuity and sustained control.'
Key study limitations included use of routinely collected clinical data, variable follow-up duration, and treatment ascertainment based on documented medication use.
The iHEART-SA trial framework was used as the data source for this longitudinal secondary analysis.
What This Means
This research examined how people with and without HIV move through the stages of hypertension (high blood pressure) care — from being undiagnosed, to receiving a diagnosis, starting treatment, and achieving blood pressure control — over time in South Africa. Using data from nearly 24,000 adults attending public clinics in Johannesburg, the study found that people living with HIV (PLHIV) faced significant disadvantages at multiple points along this care pathway. They were more than three times as likely to remain undiagnosed for hypertension, and even when treated, they were less likely to achieve controlled blood pressure compared to people without HIV.
The study also tracked what happened over time, finding that PLHIV were more likely to 'fall back' in their care — for example, going from being on hypertension treatment back to being untreated (22% vs. 11%), and losing blood pressure control after having achieved it. These patterns of backward movement through the care cascade were statistically significant and suggest that existing HIV care programmes are not fully meeting the chronic disease needs of patients who also have hypertension.
This research suggests that the integration of hypertension management into HIV care programmes in high-burden settings like South Africa requires deliberate and targeted strategies to ensure patients are not only diagnosed and started on treatment, but also supported to remain in treatment and maintain blood pressure control over the long term. The findings point to a need for health systems to address continuity of care for people managing both HIV and hypertension simultaneously.
Gumede S, Manne-Goehler J, Kelechi Oladimeji E, Bulled N, Brennan A, Lalla-Edward S. (2026). The longitudinal care cascade for hypertension in people with and without HIV in South Africa: A clinic-based observational study.. PLoS medicine. https://doi.org/10.1371/journal.pmed.1004957