Stroke in Human Immunodeficiency Virus-infected Individuals in Sub-Saharan Africa (SSA): A Systematic Review

Abstract

Background: Human immunodeficiency virus (HIV) infection is associated with worse outcomes after stroke, but this association is less well-described in sub-Saharan Africa (SSA). We reviewed literature on stroke among people living with HIV (PLWH) in SSA.

Methods: We systematically reviewed published literature for original clinical stroke studies conducted in SSA that included PLWH. We included studies that reported data on presenting characteristics, risk factors, and/or outcomes after stroke.

Results: Seventeen studies (N = 478) met inclusion criteria. At the time of stroke presentation, PLWH had a median age ranging from 32 to 43 years. Subjects had low CD4 counts (median CD4, 108-225 cells/µl), and most were antiretroviral therapy-naïve. Fever, seizures, and concurrent opportunistic infections were common at presentation. Ischemic stroke accounted for up to 96% of strokes, which were mostly located in the anterior circulation territory. In studies comparing PLWH with HIV-uninfected individuals, PLWH had more frequent coagulopathy, greater stroke severity, (72% versus 36% National Institutes of Health Stroke Scale >13, P = .02), longer hospital length of stay (30.5 versus <10 days), and a higher 30-day mortality rate (23% versus 10.5%, P = .007).

Conclusion: Stroke in PLWH in SSA occurs at a young age, in those with advanced disease, and is associated with worse outcomes than in HIV-uninfected comparators. Stroke in young individuals in the region should prompt HIV testing, and ongoing efforts to promote early antiretroviral therapy initiation might also help decrease stroke incidence, morbidity, and mortality in the region.

Keywords: HIV infection; Stroke; outcomes; risk factors; sub-Saharan Africa.

Figure 1.

Details of search and study inclusion from PubMed alone.

Figure 2:. A comparison of the prevalence of stroke risk factors in different populations with stroke.

The figure below shows a comparison of four different studies that have been conducted in different population groups. It gives a snapshot of the contrast in median age and prevalence of certain traditional cardiovascular risk factors as reported from different settings. We have reported findings from the following groups: (a) general stroke patients in Nigeria, (b) general black stroke population in USA (c) HIV infected stroke population in USA (d) HIV infected stroke population in South Africa .

Figure 3:. Stroke mortality rates in PLWH versus HIV-uninfected individuals from two studies from sub-Saharan Africa ^,.

This figure is a summary of findings from two cohort studies, which compared mortality outcomes in PLWH with stroke versus HIV uninfected stroke patients. The first study found a significant difference in 30-day mortality rates between PLWH and HIV uninfected patients (23% vs. 10.5%, p = 0.007) respectively. The second study had a much longer follow up period and found no difference in mortality rates at 6 month and 1 year between PLWH and HIV uninfected.