Mortality associated with hypertension among people living with HIV aged 40 years and older in Kenya, Uganda, and Tanzania

Abstract

Although mortality among people living with HIV (PLHIV) in sub-Saharan Africa has decreased markedly with the scale-up of antiretroviral therapy (ART), the demographic consequences of this success remain underexamined. Using ten years of longitudinal data from the African Cohort Study (AFRICOS; 2013–2023) in Kenya, Tanzania, and Uganda, we estimated the contribution of hypertension to all-cause mortality among adults aged 40 years and older. We combine descriptive decremental life-table analysis with discrete-time logistic regression, applying both lagged and exponentially weighted moving-average (EWMA) exposure models to capture cumulative risk. The analytic baseline sample included 1,169 unique participants (Kenya = 698, Tanzania = 256, Uganda = 215), who expanded to 1,360 individuals across all biannual follow-up waves over ten years, contributing a total of 12,462 person-period observations to the final adjusted models. Participants were 51% male, with a mean age of 48 years, and 60% were from Kenya. The cumulative prevalence of hypertension during follow-up was 60%, with 10% mortality among hypertensive participants. The greatest disadvantage occurred in the 50–59 age group, where hypertension-attributable excess mortality accumulated steadily over time, rising to nearly 4% by year nine with modestly higher odds of death. In Model 6 (aOR: 1.13, 95% CI: 0.57–2.23, p < 0.05), while participants aged 60 years and above experienced substantially elevated mortality (aOR: 2.32, 95% CI: 0.89–6.01, p < 0.05). Subgroup analyses revealed sharper effects in men, underweight individuals, and those with unsuppressed viral load. Hypertension was an independent predictor of death (aOR = 3.25; 95 % CI 1.26–8.40). High viral load also remained a strong independent risk factor, doubling the odds of death (aOR 2.4; 95 % CI 1.3–4.5). These findings highlight a demographic transformation of the HIV epidemic in East Africa, where mortality among PLHIV increasingly reflects a growing influence of chronic diseases in addition to infection control. Hypertension has become a key driver of excess mortality and a demographic indicator of the region’s compressed health transition.