A Notable Prevalence of HIV-Associated Stroke in an Endemic Region

Abstract

Low-and middle-income countries shoulder a disproportionate burden of HIV infection, which frequently intertwines with a high prevalence of noncommunicable diseases such as stroke. Sub-Saharan Africa, for example, has 12% of the world population but 71% of HIV infections worldwide, and the prevalence of patients with stroke and coexisting HIV infection has risen. 1 This is supported by data from the USA, which shows that admissions of patients with stroke and concurrent HIV infection have increased by 43% over 9 years. 2 Furthermore, people living with HIV (PLWH) are twice as likely to develop cardiovascular disease, and the global burden of HIV-associated cardiovascular disease has tripled over the past 2 decades. 3 HIV is now responsible for 2.6 million cardiovascular disease-associated disability-adjusted life years per year, with the greatest effect in sub-Saharan Africa. This increase has occurred despite good antiretroviral therapy (ART) uptake. Despite this compelling evidence, the national stroke guidance in the continent of Africa makes no mention of HIV. 4 Burden assessments, including incidence, prevalence, risk attribution, risk reduction, mortality, and disability rates of HIV-associated stroke in HIV endemic populations at a national, regional, and continental level, are lacking and would help drive the agenda forward. Although we have increasing certainty about the etiologic role of HIV infection in stroke and our knowledge about the multifactorial mechanisms is improving, disproportionately few research articles are emerging from the regions most affected by HIV infection, limiting progress.In this issue of Neurology ® , Corbett et al. 5 report a retrospective matched case-control study that gives important insight into the prevalence of HIV in patients with acute stroke. In addition, they describe the characteristics of HIV-associated stroke in a tertiary hospital setting in South Africa. They used electronic health records of adults presenting with any stroke to the Tygerberg Hospital over a 12-month period and matched them by age to a group of PLWH and HIV-uninfected patients with stroke [HIV(−)] in a 1:2 ratio. Among 884 patients presenting with an acute stroke, 82 (9.3%) were PLWH and 496 (56.1%) were HIV(−), and in 306 (34.6%) patients, their HIV status was unknown. The minimum HIV prevalence was 9.3% and the adjusted prevalence was 13.3%, when the HIV unknown group with stroke was assumed to have a similar distribution of HIV prevalence to the population in the Western Cape province.Compared with the HIV(−) group with stroke, PLWH and stroke were nearly a decade younger and had fewer traditional risk factors but more concurrent infections. This difference was more evident among those with CD4 counts of <200 cells/mcl who had more than double the risk of concurrent infection. Among PLWH, 68.3% were on ART and 39.3% had been started or restarted on ART within the past 6 months. Ischemic strokes in PLWH were more likely to involve multiple vascular territories and the basal ganglia regions in ...