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August 30, 2022; 99 (9) Research Articles

Prevalence and Characteristics of HIV-Associated Stroke in a Tertiary Hospital Setting in South Africa

Craig Corbett, Naeem Brey, Richard D. Pitcher, Suzanne O'Hagan, Tonya M. Esterhuizen, Felicia C. Chow, Eric H. Decloedt
First published June 3, 2022, DOI: https://doi.org/10.1212/WNL.0000000000200780
Craig Corbett
From the Divisions of Clinical Pharmacology (C.C., E.H.D., F.C.C.) and Neurology (N.B.), Department of Medicine, Division of Radiodiagnosis (R.D.P., S.O.H.), Department of Medical Imaging and Clinical Oncology, and Biostatistics Unit (T.M.E.), Division of Epidemiology and Biostatistics, Stellenbosch University, Cape Town Western Cape, South Africa; and Departments of Neurology and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco.
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Naeem Brey
From the Divisions of Clinical Pharmacology (C.C., E.H.D., F.C.C.) and Neurology (N.B.), Department of Medicine, Division of Radiodiagnosis (R.D.P., S.O.H.), Department of Medical Imaging and Clinical Oncology, and Biostatistics Unit (T.M.E.), Division of Epidemiology and Biostatistics, Stellenbosch University, Cape Town Western Cape, South Africa; and Departments of Neurology and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco.
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Richard D. Pitcher
From the Divisions of Clinical Pharmacology (C.C., E.H.D., F.C.C.) and Neurology (N.B.), Department of Medicine, Division of Radiodiagnosis (R.D.P., S.O.H.), Department of Medical Imaging and Clinical Oncology, and Biostatistics Unit (T.M.E.), Division of Epidemiology and Biostatistics, Stellenbosch University, Cape Town Western Cape, South Africa; and Departments of Neurology and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco.
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Suzanne O'Hagan
From the Divisions of Clinical Pharmacology (C.C., E.H.D., F.C.C.) and Neurology (N.B.), Department of Medicine, Division of Radiodiagnosis (R.D.P., S.O.H.), Department of Medical Imaging and Clinical Oncology, and Biostatistics Unit (T.M.E.), Division of Epidemiology and Biostatistics, Stellenbosch University, Cape Town Western Cape, South Africa; and Departments of Neurology and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco.
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Tonya M. Esterhuizen
From the Divisions of Clinical Pharmacology (C.C., E.H.D., F.C.C.) and Neurology (N.B.), Department of Medicine, Division of Radiodiagnosis (R.D.P., S.O.H.), Department of Medical Imaging and Clinical Oncology, and Biostatistics Unit (T.M.E.), Division of Epidemiology and Biostatistics, Stellenbosch University, Cape Town Western Cape, South Africa; and Departments of Neurology and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco.
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Felicia C. Chow
From the Divisions of Clinical Pharmacology (C.C., E.H.D., F.C.C.) and Neurology (N.B.), Department of Medicine, Division of Radiodiagnosis (R.D.P., S.O.H.), Department of Medical Imaging and Clinical Oncology, and Biostatistics Unit (T.M.E.), Division of Epidemiology and Biostatistics, Stellenbosch University, Cape Town Western Cape, South Africa; and Departments of Neurology and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco.
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Eric H. Decloedt
From the Divisions of Clinical Pharmacology (C.C., E.H.D., F.C.C.) and Neurology (N.B.), Department of Medicine, Division of Radiodiagnosis (R.D.P., S.O.H.), Department of Medical Imaging and Clinical Oncology, and Biostatistics Unit (T.M.E.), Division of Epidemiology and Biostatistics, Stellenbosch University, Cape Town Western Cape, South Africa; and Departments of Neurology and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco.
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Prevalence and Characteristics of HIV-Associated Stroke in a Tertiary Hospital Setting in South Africa
Craig Corbett, Naeem Brey, Richard D. Pitcher, Suzanne O'Hagan, Tonya M. Esterhuizen, Felicia C. Chow, Eric H. Decloedt
Neurology Aug 2022, 99 (9) e904-e915; DOI: 10.1212/WNL.0000000000200780

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Abstract

Background and Objectives Antiretroviral treatment (ART) era HIV-associated stroke data from sub-Saharan Africa are limited. We determined the prevalence of HIV in patients presenting with acute symptomatic stroke and compared risk factors, clinical characteristics, and brain imaging with age-matched stroke patients without HIV.

Methods We conducted a retrospective study of adults presenting with any type of stroke to Tygerberg Hospital in a 12-month period. Patients living with HIV (PLWH) and HIV-uninfected (HIV−) patients were matched based on age group (1:2 ratio). Patients were identified by keyword search, while HIV status was ascertained from laboratory data. Clinical and imaging data were extracted from medical records.

Results Among 884 patients presenting with acute strokes, the minimum prevalence of HIV infection was 9.3% (95% CI: 7.4%–11.2%), with 496 patients (56.1%) with negative HIV status and 306 patients with unknown HIV status (34.6%). The mean age at presentation in PLWH was 46 (±11) years compared with 55 (±14) years in HIV− patients (p < 0.001). Smoking was less prevalent in PLWH with an adjusted relative risk ratio of RR = 0.58 (95% CI: 0.39–0.86). Concurrent infection was more prevalent in PLWH (25.6% vs 4.9%, p ≤ 0.001) with an adjusted relative risk ratio of RR = 2.07 (95% CI: 1.49–2.84), largely in patients with a CD4 count <200 cells/μL. PLWH with higher CD4 counts (≥200 cells/μL, 51.3%) had more traditional risk factors and less concurrent infection. Among PLWH, 68.3% were on ART, and 39.3% of them had been started or restarted on ART within the past 6 months. Basal ganglia infarcts (35.6% vs 18.3%, p = 0.014) and multiple vascular territory involvement (25.4% vs 7.7%, p = 0.002) were more common in PLWH. Clinical presentation, ischemic stroke type, and in-hospital outcomes did not differ between the groups.

Discussion Stroke patients with HIV were younger, had less traditional cardiovascular risk factors, and more concurrent infections than patients without HIV, especially those with a lower CD4 count. Recent ART initiation or reinitiation rates were high. Significant differences in CT brain imaging findings were seen. Understanding the multifactorial mechanisms underlying increased stroke risk, including associated infections and potential ART-associated immune reconstitution, is crucial and needs further study.

Glossary

ART=
antiretroviral treatment;
BP=
blood pressure;
CKD=
chronic kidney disease;
DM=
diabetes mellitus;
HIC=
high-income country;
LMIC=
lower-income and middle-income country;
PACS=
Picture Archiving and Communication System;
PLWH=
patients living with HIV;
SSA=
sub-Saharan Africa

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Editorial, page 366

  • Received October 4, 2021.
  • Accepted in final form April 11, 2022.
  • © 2022 American Academy of Neurology
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