High Blood Pressure and Multiple Risk Behaviors among Individuals at High Risk of HIV/STIs

Purpose:

Cardiovascular disease (CVD) is the number one cause of death in the United States and worldwide. Hypertension, along with tobacco use, obesity, and other lifestyle behaviors, is one of the major risk factors for CVD. Despite significant efforts in the treatment of hypertension, severe complications of hypertension—ischemic heart disease, heart failure, and end stage renal disease—continue to increase, particularly among certain ethnic minorities and disadvantaged populations.

Numerous studies have shown that individuals at high risk of human immunodeficiency virus/sexually transmitted infections (HIV/STIs) often have problems in substance use and risky sexual behaviors, and suffer from psychological distress such as symptoms of depression. Depression is associated with risky sexual behaviors, smoking, alcohol abuse and unhealthy eating behaviors, which may influence the risk of CVD. The health problems that individuals at high risk of HIV/STIs have are compounded by limited access to health care as a result of high levels of unemployment and low socioeconomic and educational levels. Nevertheless, little attention has been paid to CVD in one of the most disadvantaged populations, individuals with high risk of HIV/STIs. Limited data available on effects of substance use, psychological, or other CVD risk factors on blood pressure (BP) among individuals with high risk of HIV/STIs. Therefore, the purpose of the study was two-fold: (1) to describe BP among individuals at high risk of HIV/STIs; and (2) to examine the relationships of substance use, psychological, CVD risk factors (e.g., diabetes, body mass index [BMI]), and BP.

Methods:

This current study is a sub-study of a larger randomized clinical trial: CHAT = Choose the right time, Hear what the person is saying, Ask questions, and Talk with respect−the four communication tools provided in the intervention. CHAT is a social network-based HIV/STI prevention study conducted in Baltimore, Maryland, U.S.A. (Clinical Trial #NCT00183456). The CHAT intervention was provided by peer mentors and consisted of 5 group-based sessions and one individual session. Peer mentors talked to their social network members about HIV and STI risk reduction, which was hypothesized to lead to safer behaviors among network members and peer mentors. There was no intervention regarding CVD risk reduction such as BP control, physical activity, or healthy eating. Participants were randomized into a standard of care comparison condition or the peer mentor condition. All participants participated in the baseline and 6, 12, and 18 months follow-up assessment. Eligibility criteria for primary participants included the following: (1) women 18–55 years of age, (2) had sex with a man in the past 6 months, (3) had not injected drugs in the past 6 months and had one of the following risk behaviors: (a) more than 1 sex partner in the past 6 months, (b) had a partner who engages in risky behaviors such as injecting in the past 90 days,  (c) smoked crack in past the 90 days, (d) is a man who had sex with other men, (e) had sex with a prostitute, or (f) snorted/sniffed or smoked heroin or cocaine. The primary participants were also asked to invite their network members such as friends or partners to enroll in the study. The eligibility criteria for the network members were as follows: (1) men or women 18 years of age or older and one of the following: (a) injected drugs in the past 6 months; (b) had sex with a primary participant in the past 90 days; (c) felt comfortable talking to network members about HIV and STI and (3) interacted with network members at least a few times a month. We focused on findings from the 18 month follow up where BP data were collected. After five minutes rest, BP was measured by an automated cuff twice, with 1 minute between readings. The average of the two readings were recorded. Other assessments included sociodemographic characteristics, insurance status, medical history, depression and CVD variables (i.e., diabetes, dyslipidemia, BMI), and drug and alcohol consumption behaviors by participants’ self-report. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to examine depression.

Descriptive statistics were used to examine the distribution of the variables and to summarize sample characteristics. We conducted Pearson’s correlation coefficients (r) and Spearman’s correlation (ρ) to examine the correlation between average systolic/diastolic BP (SBP/DBP) (continuous variables) and other variables.

General Estimating Equations (GEE) modeling was used to examine the relationship among BP, sociodemographics, CVD risk factors, depression, and other risk behaviors (cigarette smoking, alcohol and drug use), because some of the risk behaviors among the primary and network member participants may have been shared behaviors, not have been independent observations required for conventional logistic regressions. The outcome variables, SBP and DBP were dichotomized to normal or prehypertension to stage 2 hypertension.

Results:

A total of 672 primary and network members participated in the study. The majority of participants were women (75.3%), single (91.4%), unemployed (71%) and African American (96.9%), with a mean age of 44 years (SD: ± 8.56). More than half of the participants had health insurance (65.6%). Most of the participants were smokers (80.2 %) and reported that their general health was fair to excellent (93.8%) and no use of injected drug during the past 6 month (92.9%).Thirty-one percent of participants were previously diagnosed with hypertension. Approximately 60% of the participants whose BP was measured at least twice had prehypertension to stage 2 hypertension (by SBP: normal- 39.4 %; prehypertension- 32.6%; stage 1-15.7%; stage 2-7.9%) (by DBP: normal- 40 %; prehypertension- 24.2%; stage 1-17.5%; stage 2- 18.2%) as defined by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure criteria. Among those with hypertension diagnosis, only 2.2% reported that they had cut alcohol consumption, 9% reported that they engage in physical activity, 48.9% reported lowering salt intake, 7.3% reported controlling body weight, and 69% reported taking medications to lower their BP. A higher SBP was associated with older age (r=.365, p<.01), a higher number of drinks on a typical day (ρ=.191, p<.01), poorer self-reported general health (ρ=-.132, p<.01), and higher frequency of alcohol drinking (ρ=.170, p<.01). Similarly, variables significantly associated with  higher DBP were as follows: older age (r=.245, p<.01), higher number of drinks on a typical day (ρ=.184, p<.01), higher frequency of binge drinking (6 or more drinks on one occasion) (ρ=.121, p<.05), higher frequency of alcohol drinking (ρ=.178, p<.01), lower income (ρ=-.115, p<.05), HIV positive (ρ=-.276, p<.05), poorer self-reported general health (ρ= -.134, p<.01), and higher BMI (r=.097, p<.05). Clinical depression by CES-D (≥16) was not associated with high BP in our study sample but was significantly correlated with alcohol use, smoking and injected drug use. In the general estimating equation logistic models—adjusting for sociodemographics, CVD variables, and substance use—age (AOR=1.085, 95% CI, 1.051-1.121) and injected drug use (AOR=.255, 95% CI, .107-.606) were significant factors of high systolic BP. Age (AOR=1.077, 95% CI, 1.038-1.118), body mass index (AOR=1.085, 95% CI, 1.042-1.130), injected drug use (AOR=.356, 95% CI, .130-.976), and daily consumption of six or more alcoholic drinks (AOR=2.812, 95% CI, 1.005-7.869) were significant factors of high diastolic BP.

Conclusion:

This study highlighted several correlates of high BP that are modifiable. Future CVD program should be multi-faceted interventions by addressing mental health, multiple risk behaviors—including moderate alcohol consumption, avoidance of substance use, and weight control—to improve BP among individuals at high HIV/STI. Approaching this population in a more systematic way to develop integrated health care services by addressing multiple risk behaviors as well as multiple barriers to appropriate health care are needed. Future research should continue to target this high-risk group to improve cardiovascular health along with HIV/STI risk reduction. More importantly, health care professionals should understand the multiple risk factors among this population and expand their efforts to eliminate barriers to provide needed health care.