HIV Patients in South Africa Fall Through the Cracks of Hypertension Care, Landmark Study Finds

Hypertension has quietly become one of the most formidable health threats in South Africa, a country already carrying one of the world’s heaviest HIV burdens. Now, a large clinic-based study has revealed a troubling pattern: people living with HIV are not only more likely to have their high blood pressure missed by the health system, but once diagnosed and treated, they are also more likely to slip backwards, losing control of their blood pressure or abandoning treatment altogether. The findings, published in PLOS Medicine, come from one of the most detailed longitudinal examinations of the hypertension care cascade ever conducted in a high-HIV-prevalence setting, and they carry stark implications for how chronic disease care is organized across sub-Saharan Africa.

The research, led by Siphamandla Bonga Gumede of the University of the Witwatersrand together with colleagues including Jennifer Manne-Goehler and Samanta Tresha Lalla-Edward, drew on data from the iHEART-SA trial, an implementation study spanning nine public primary healthcare clinics in Johannesburg. Between August 2022 and May 2024, the team enrolled adults aged eighteen and older who were already receiving chronic care at these facilities, requiring a known HIV status and a completed review of medical files. Follow-up continued through May 2025, allowing the investigators to track not just a single snapshot of care but the dynamic movement of patients up and down the cascade of hypertension services, from screening and diagnosis through treatment initiation and, ultimately, sustained blood pressure control.

The scale of the dataset lends the findings unusual weight. In total, 23,855 participants were included in the analysis, and 78.5 percent of them were living with HIV. The cohort had a median age of 42 years, with an interquartile range of 36 to 49, and 69 percent were female, reflecting the demographic profile of patients engaged in long-term chronic care in urban South African clinics. The median systolic blood pressure across the cohort stood at 132 mmHg, with an interquartile range of 120 to 145 mmHg, meaning that a substantial share of participants entered the study with blood pressure levels already at or above the thresholds at which cardiovascular risk rises sharply.

To understand how patients fared, the researchers modeled progression and regression across the hypertension care cascade, adjusting for potential confounders and comparing people living with HIV against those without the virus. The results were unambiguous. People living with HIV were substantially more likely to remain undiagnosed despite having elevated blood pressure, with an adjusted relative risk of 3.40 compared with their HIV-negative counterparts, a difference that was highly statistically significant. In other words, even within the same clinics, attending the same health system, patients engaged in HIV care were more than three times as likely to have their hypertension escape detection.

This diagnostic gap is particularly striking because people living with HIV are, in many respects, among the best-connected patients in the South African health system. Antiretroviral therapy programs have, over two decades, built some of the most robust retention and follow-up infrastructure anywhere on the continent, with routine viral load monitoring, scheduled clinic visits, and detailed patient records. Yet the new analysis suggests that this very success may have created a form of tunnel vision: clinical attention concentrates on HIV-related indicators, while cardiovascular risk factors accumulate in the background. Hypertension, which typically produces no symptoms until complications such as stroke, heart failure, or kidney disease emerge, is precisely the kind of condition that thrives in the blind spots of a disease-specific care model.

The story did not end at diagnosis, however. Among participants who had been prescribed antihypertensive medication, those living with HIV were less likely to achieve blood pressure control, with an adjusted relative risk of 0.85, a modest but statistically significant shortfall. More alarming still were the longitudinal findings on regression, the phenomenon of patients moving backwards down the cascade they had already climbed. During follow-up, 22 percent of people living with HIV who had been on treatment regressed to untreated hypertension, compared with 11 percent of those without HIV, an adjusted relative risk of 1.51. Patients living with HIV were also more likely to move from controlled to uncontrolled blood pressure, with an adjusted relative risk of 1.10.

These regression figures expose a vulnerability that single cross-sectional surveys cannot capture. A patient may appear well managed at one clinic visit, only to discontinue medication, miss follow-up appointments, or experience worsening control months later. By tracking the same individuals over time, the study demonstrates that hypertension care in this setting is not merely incomplete at the point of entry but fragile along its entire length. Treatment discontinuation and loss of control were not rare exceptions; they affected a meaningful fraction of patients, and they affected people living with HIV disproportionately. For a condition whose harm accumulates over years of sustained exposure to elevated pressure, every period of uncontrolled hypertension erodes the protective value of earlier treatment.

The clinical and programmatic implications are considerable. South Africa’s health system, like many across the region, was architecturally shaped by the HIV epidemic, with vertical programs delivering highly effective, disease-specific services. As antiretroviral therapy extends life expectancy, the population living with HIV is aging into the age range where noncommunicable diseases dominate, and hypertension is the most common of them. The study’s authors argue that their findings underscore persistent gaps in longitudinal hypertension management within HIV programs and point to the need for integrated, targeted chronic care models that ensure treatment continuity and sustained control. Integration, in this vision, means more than co-locating services in the same building; it means embedding blood pressure checks, medication refills, and adherence support into the routine architecture of HIV care visits, so that a patient’s cardiovascular status is reviewed with the same regularity as their viral load.

Why might people living with HIV fare worse on blood pressure control even after treatment begins? The study, which relied on routinely collected clinical data, cannot fully disentangle the mechanisms, and the authors are careful about the limits of their evidence. Variable follow-up duration, treatment ascertainment based on documented medication use rather than direct confirmation, and the inherent messiness of real-world records all constrain interpretation. Possible contributors include pill burden, since patients on antiretroviral therapy may face added complexity when antihypertensives are layered on; competing clinical priorities during busy consultations; drug interactions between antiretrovirals and some antihypertensive agents; and social factors such as stigma or economic precarity that shape whether patients can sustain multiple medication regimens. Distinguishing among these explanations will require targeted follow-up research, but the pattern itself is now firmly established at scale.

What makes the findings resonate beyond Johannesburg is their timing. Cardiovascular disease is rising rapidly across low- and middle-income countries, and health systems there are being asked to manage chronic, asymptomatic conditions with infrastructure built for acute and episodic care. The hypertension care cascade, analogous to the HIV care cascade that transformed global AIDS monitoring, offers a framework for measuring exactly where patients are lost, and this study shows that in a high-HIV-burden setting, the losses concentrate at diagnosis and in the fragile months and years after treatment begins. If the millions of South Africans living with HIV are to reap the full longevity dividend of antiretroviral therapy, the health system must learn to guard not only their viral suppression but their blood pressure, visit after visit, year after year. The alternative is a future in which successfully treated HIV patients survive the virus only to be felled by a silent, treatable, and entirely preventable cardiovascular disease.

Subject of Research: Longitudinal hypertension care cascade outcomes among people with and without HIV in South African primary healthcare clinics

Article Title: The longitudinal care cascade for hypertension in people with and without HIV in South Africa: A clinic-based observational study

Article References: Gumede, S. B., Manne-Goehler, J., Kelechi Oladimeji, E., Bulled, N., Brennan, A. T., & Lalla-Edward, S. T. (2026). The longitudinal care cascade for hypertension in people with and without HIV in South Africa: A clinic-based observational study. PLOS Medicine, 23(9), e1004957. https://doi.org/10.1371/journal.pmed.1004957

Image Credits: AI Generated

DOI: 10.1371/journal.pmed.1004957

Keywords: hypertension, HIV, South Africa, care cascade, blood pressure control, primary healthcare, chronic disease management, Johannesburg, antiretroviral therapy, cardiovascular risk, health systems, PLOS Medicine