BackgroundAntiretroviral therapy scale-up in Sub-Saharan Africa has created a growing, aging HIV-positive population at risk for non-communicable diseases such as hypertension. However, the prevalence and risk factors for hypertension in this population remain incompletely understood.MethodsWe measured blood pressure and collected demographic data on over 65,000 adults attending multi-disease community health campaigns in 20 rural Ugandan communities (SEARCH Study: NCT01864603). Our objectives were to determine (i) whether HIV is an independent risk factor for hypertension, and (ii) awareness and control of hypertension in HIV-positive adults and the overall population.ResultsHypertension prevalence was 14% overall, and 11% among HIV-positive individuals. 79% of patients were previously undiagnosed, 85% were not taking medication, and 50% of patients on medication had uncontrolled blood pressure. Multivariate predictors of hypertension included older age, male gender, higher BMI, lack of education, alcohol use, and residence in Eastern Uganda. HIV-negative status was independently associated with higher odds of hypertension (OR 1.2, 95% CI: 1.1–1.4). Viral suppression of HIV did not significantly predict hypertension among HIV-positives.SignificanceThe burden of hypertension is substantial and inadequately controlled, both in HIV-positive persons and overall. Universal HIV screening programs could provide counseling, testing, and treatment for hypertension in Sub-Saharan Africa.

Background Statins are effective in primary prevention of atherosclerotic cardiovascular disease. The 2013 American College of Cardiology/American Heart Association (ACC-AHA) guideline expands recommended statin use, but its cost-effectiveness has not been compared with other guidelines. Methods We used the Cardiovascular Disease (CVD) Policy Model to estimate the cost-effectiveness of the ACC-AHA, relative to current use, Adult Treatment Panel III (ATP III) guidelines, and universal statin use in all men age 45-74 years and women age 55-74 years over a 10-year horizon from 2016 to 2025. Sensitivity analyses varied costs, risks, and benefits. Main outcomes were incremental cost-effectiveness ratios (ICER) and numbers needed to treat for ten years per quality-adjusted life-year gained (NNT/QALY). Results Each approach produces substantial benefits and net cost savings relative to the status quo. Full adherence to the ATP III guideline would result in 8.8 million more statin users than the status quo, at an NNT/QALY of 35. The ACC-AHA guideline would potentially result in up to 12.3 million more statin users than the ATP III guideline, with a marginal NNT/QALY of 68. Moderate-intensity statin use in all men 45-74 and women 55-74 would result in 28.9 million more statin users than the ACC-AHA guideline, with a marginal NNT/QALY of 108. In all cases, benefits would be greater in men than women. Results vary moderately with different risk thresholds for instituting statins and statin toxicity estimates, but greatly depend on the disutility caused by daily medication use (pill burden). Conclusions At a population level, the ACC-AHA guideline for expanded statin use for primary prevention is projected to treat more people, save more lives, and cost less compared with ATP III, in both men and women. Whether individuals benefit from long-term statin use for primary prevention depends more on the disutility associated with pill burden than their degree of cardiovascular risk.

BACKGROUND Over 40% of adults 75 and older are taking statins, yet there is little evidence to guide primary prevention in this population. OBJECTIVE To project the population impact and cost-effectiveness of statin therapy in adults aged 75 years and older. DESIGN Forecasting study using the Cardiovascular Disease Policy Model, a Markov model. DATA SOURCE Trial, cohort, and nationally-representative data sources. TARGET POPULATION U.S. adults aged 75–94 years. TIME HORIZON 10 years. PERSPECTIVE Health care system. INTERVENTION Statins for primary prevention based on: 1) Low density lipoprotein cholesterol ≥4.91 mmol/L (190 mg/dL), 2) ≥4.14 mmol/L (160 mg/dL), 3) ≥3.36 mmol/L (130 mg/dL), 4) diabetes, 5) 10-year risk score ≥7.5% (treat all). OUTCOME MEASURES Myocardial infarction (MI), coronary heart disease (CHD) death, disability adjusted life years, costs RESULT OF BASE-CASE ANALYSIS All adults aged 75 and older in NHANES have a 10-year risk score >7.5%. If statins have no effect on functional limitation or cognitive impairment, all primary prevention strategies would prevent MIs and CHD deaths and be cost effective. The broadest strategy, treatment of all adults aged 75–94 years would result in 8 million additional users, and prevent 105,000 (4.3%) incident MIs and 68,000 (2.3%) CHD deaths at an incremental cost per disability adjusted life year of $25,200. RESULT OF SENSITIVITY ANALYSIS An increased relative risk of functional limitation or mild cognitive impairment in the range of 1.10 to 1.30 could offset the cardiovascular benefits. LIMITATIONS Limited trial evidence targeting primary prevention in adults 75 and older. CONCLUSIONS At effectiveness similar to trial findings, statins are projected to be cost-effective for primary prevention in adults age 75–94 years; however, even a small increase in geriatric specific side effects could offset the cardiovascular benefit. Improved data on the potential benefits and harms of statins are needed to inform decision-making.