Experts have found that people living with HIV tend to experience stroke at younger ages, with ischemic stroke and HIV-related blood vessel abnormalities prominent among reported cases, according to a systematic review of studies across sub-Saharan Africa.
Published in The Egyptian Journal of Neurology, Psychiatry and Neurosurgery, the review examined 21 studies conducted between 2000 and 2023, covering 5,693 stroke patients in studies that assessed HIV status.
The findings highlight a growing public health concern in a region heavily affected by HIV, where improved survival through antiretroviral therapy (ART) has increased the need to address long-term conditions, including cardiovascular and cerebrovascular diseases.
The researchers, including Nicholas Aderinto, Bonaventure Michael Ukoaka, and Mohamed Mustaf Ahmed, identified immune suppression, chronic inflammation, blood-clotting abnormalities, and HIV-associated vasculopathy as potential contributors to stroke risk.
They called for closer integration of HIV and stroke services, alongside more geographically representative research across Africa.
According to the review, the average age of HIV-positive stroke patients ranged from 32.1 to 49 years, compared with approximately 54.9 to 61 years among HIV-negative patients in some study groups.
The researchers said this age difference raises concerns about premature disability among working-age adults, with potentially serious consequences for families, employment, and healthcare systems.
They explained that chronic immune activation and inflammation associated with HIV may accelerate vascular ageing, increasing vulnerability to stroke even when conventional risk factors are less prominent.
Among general stroke cohorts in which HIV status was systematically assessed, the reported prevalence of HIV ranged from 4.8 per cent to 34 per cent.
A study in Malawi reported a prevalence of 34 per cent, while research in Benin found 26.1 per cent. A South African study reported 23 per cent, compared with 4.8 per cent among young stroke patients in a Nigerian study.
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South Africa accounted for eight of the 21 studies reviewed. Nigeria and Malawi contributed three studies each, while Uganda contributed two. The remaining studies were conducted in other African countries, including Benin, Ghana, Kenya, and Sierra Leone, alongside a multicountry study in Central Africa.
Ischemic stroke accounted for approximately 69.4 to 96 per cent of cases among HIV-positive patients in studies reporting stroke subtypes, while hemorrhagic stroke was less common.
The review identified several potential mechanisms underlying this pattern, including HIV-associated vasculopathy, immune suppression, chronic inflammation, and abnormalities in blood coagulation.
The findings suggest that stroke assessment in people living with HIV should consider immune status and HIV-related complications alongside conventional risk factors such as hypertension, diabetes, and smoking.
The review also identified evidence linking stroke to the first six months after ART initiation. However, the researchers stressed that the relationship between ART and stroke is complex and that the findings do not establish that treatment directly causes all early cerebrovascular events.
They suggested that immune reconstitution inflammatory syndrome (IRIS), which can occur when the immune system begins recovering after treatment starts, may contribute to some of these events.
The researchers emphasised that the findings do not justify delaying or discontinuing HIV treatment. Instead, they underscore the importance of appropriate clinical monitoring, prompt management of infections, and adherence to established treatment guidelines.
They called for closer integration of HIV services and stroke care, with vascular risk assessment incorporated into long-term HIV management and HIV-related factors considered during stroke evaluation.
They also stressed that stroke prevention should not focus exclusively on older adults, given the younger age of onset observed among people living with HIV.
Alongside blood pressure control, diabetes management, and smoking cessation, clinicians should consider CD4 counts, viral suppression, and opportunistic infections when assessing individual patients.
The authors called for prospective studies involving more African countries, with improved reporting of ART exposure, stroke subtypes, sex differences, neuroimaging findings, and cognitive outcomes.
The review highlights the need to address stroke as part of the long-term care of people living with HIV, even as the researchers concluded that integrated prevention, timely diagnosis, appropriate treatment, and access to rehabilitation could help reduce the consequences of stroke in settings with a high HIV burden.
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