Hypertension in People Living with HIV (PLHIV): A Comparative Analysis Before and After Test-and-Treat Policy Implementation

Abstract Background The universal test-and-treat (T&T) policy has improved HIV outcomes but may influence hypertension (HTN) risk due to prolonged antiretroviral therapy (ART) exposure. We compared HTN prevalence and risk factors among PLHIV before and after T&T implementation in Zambia. Methods A retrospective cohort study analyzed 6,409 PLHIV (2,920 pre-T&T and 3,489 post-T&T) from 12 Southern Province districts. Data on demographics, ART regimens, blood pressure, and laboratory measures were extracted from electronic (SmartCare) and paper records. Multivariable logistic regression identified HTN-associated factors (p<0.05). Results HTN prevalence increased from 8.8% pre-T&T to 10.2% post-T&T. Each year of age increased HTN odds by 5–6% in both cohorts (adjusted odds ratio [AOR]: 1.06 pre-T&T, 1.05 post-T&T p<0.0001). Urban residence was protective (AOR: 0.72 pre-T&T, 0.67 post-T&T p≤0.041), while males had higher HTN risk than females (12.2% vs. 8.8% post-T&T p=0.0015). Post-T&T, higher hemoglobin marginally increased HTN odds (AOR: 1.08; p=0.049). INSTI-based regimens rose from 26.3% to 41.5% post-T&T but showed no significant association with hypertension on multivariate analysis. Rural residents had higher HTN prevalence (11.5% vs. 8.4% urban post-T&T p=0.0027). Conclusions HTN prevalence increased post-T&T, and was driven by aging and potentially ART-related metabolic effects. Urban residence was unexpectedly protective, possibly due to better healthcare access. The hemoglobin-HTN link post-ART warrants further study. Strengths include a large, representative sample, though unmeasured confounders (e.g., lifestyle factors) and retrospective design limit causal inferences. Integrated HTN screening in HIV programs is critical to address this growing burden.