First-line Antiretroviral Regimens and Risk of Incident Hypertension in People With HIV: a 15-year Cohort Study
José I Bernardino, C Busca, L Serrano, A de Gea-Grela, M M Arcos-Rueda, L Martin-Carbonero, M L Montes, R Montejano, J Llenas-García, R Mican, R de Miguel, J González-García, A Borobia, José R ArribasAbstract
Background
People with HIV (PWH) face a growing burden of cardiovascular disease. Integrase strand transfer inhibitors (INSTI) have been linked to weight gain and possibly hypertension, but head-to-head data among contemporary regimens are scarce, and few studies analyze older and modern regimens together. We evaluated the incidence of hypertension in antiretroviral therapy (ART)-naïve PWH initiating Spanish guidelines-recommended first-line regimens since 2009.
Methods
Retrospective cohort of ART-naïve adults initiating first-line regimens from 2009 to 2024, grouped into NNRTI, INSTI, and boosted PI-based classes. Incident hypertension was defined by a composite of clinical diagnosis, antihypertensive initiation, or two consecutive measurements ≥ 140/90 mmHg. Time to hypertension was analysed using Kaplan-Meir methods and Cox regression, with a pre-specified INSTI subanalysis.
Results
Among 1,134 participants (median age 34.1years; 89.8% male), 205 (18.1%) developed hypertension over a median of 135.9 weeks (incidence 4.9/100 person-years). Hypertension free survival differed by class (log-rank p = 0.005); INSTI-based ART was independently associated with higher risk than NNRTIs (adjusted HR 1.61; 95% CI 1.20-2.17). Within the INSTI subgroup (n = 437; incidence 7/100 person-years), 5-year cumulative hypertension ranged from 9% (EVG/c/FTC/TAF) to 37% (dolutegravir-based); dolutegravir-based regimens carried a > 2-fold adjusted hazard versus EVG/c/FTC/TAF. Higher BMI was independently predictive but did not abolish this signal.
Conclusions
In ART-naïve PWH, INSTI-based regimens were associated with a higher incidence of hypertension than NNRTI-based regimens, whereas the comparison with PI-based regimens were not statistically significant. Dolutegravir-containing regimens were independently associated with incident hypertension supporting systematic blood pressure surveillance and further comparative studies.