Prevalence, clinical characteristics and severity of pulmonary hypertension among HIV-infected adults at Moi Teaching and Referral Hospital, Eldoret, Kenya.

Abstract

Background: Pulmonary Hypertension (PH) is a progressive and fatal disease, associated with high morbidity and mortality worldwide. Data shows that its prevalence is higher among HIV-infected patients than general population. HIV is thought to contribute to the development of PH via direct viral cytotoxic effect, resultant chronic immune response and increased oxidative stress. Despite the high burden of HIV in Sub-Saharan Africa, local data on pulmonary hypertension in HIV infected-patients is lacking. Therefore, this study contributes data from the region. Objective: To determine the prevalence, clinical characteristics and severity of PH among HIV infected adults at Moi Teaching and Referral Hospital (MTRH). Methods: This was an observational cross-section study carried out in the HIV clinic at MTRH from November 2020 to March 2021. The study employed a systematic sampling technique to recruit participants aged 18 years and above, on care in the HIV clinic at MTRH. Transient patients and those with chest deformities were excluded, and thus a total of 350 participants were enrolled for the study. A structured questionnaire was used to collect data on demographic and clinical characteristics. Echocardiography was performed on all participants by a trained Sonographer in echocardiography and reviewed by a cardiologist to reduce variability and for result confirmation. Pulmonary hypertension was defined as elevated right ventricular systolic pressure > 40 mmHg by Echocardiography (which corresponds to tricuspid regurgitation (TR) jet maximum velocity > 2.8 m2/s). Data analysis was done using STRATA version 15 and prevalence of PH was determined and reported alongside the corresponding 95 % confidence interval limits. Association between PH and the clinical characteristics was assessed using Fisher‟s exact test. Results: The mean age of the participants was 44.6 years (SD=10.5), 263 (75 %) were females and 141 (40%) had body mass index above 25. History of smoking was present in 49 (14%), 36 (10%) reported to have had prior treatment for tuberculosis, 151 (43%) for pneumonia and 50 (14%) for both tuberculosis and pneumonia. The median duration time since HIV diagnosis was 9.99 years (IQR=8.58), 344 (98%) were on anti-retroviral (ART) and 286 (82%) were on integrase-based regimen. Among those on ART, 298 (85%) had their viral load suppressed (< 40). Pulmonary hypertension was significant in 9 participants (3% 95% CI:1.2%, 4.8%). The proportion of HIV infected patients with PH (n=9) was higher in those aged 40-59 years, female gender, prior history of indoor air pollution, lung infections and those with detectable VL. Sub-analysis among HIV infected patients with PH showed that the prevalence of PH tended to increase with age, female gender, prior history of indoor air pollution and respiratory infections and those with un-detectable VL. Among those with PH n=9, 5 had mild to moderate disease, defined as RVSP > 40 to 65 mmHg. Overall, all patients with PH were symptomatic. Cough was present in all the patients (100%), 67% had dyspnea, and 44 % wheezing. Conclusion: Prevalence of PH among HIV infected patients at MTRH was low, and was associated with respiratory symptoms of cough, Dyspnea and wheezing. The low prevalence of PH in this study was postulated to be due to the fact that a high proportion of the patients were on a more potent ART regimen (integrase-based) and were virally suppressed. In addition, the high cut-off-point to define PH may have contributed to the low prevalence in this study compared to previous studies. Recommendation: We recommend a symptom driven evaluation for PH in HIV infected patients, and further studies to characterize PH and look at associated risk factors in this population.