Key result
First-line INSTI-based ART is linked to ~61% higher risk of incident hypertension versus NNRTIs.
Why the study?
Integrase strand transfer inhibitors have been linked to weight gain and possibly hypertension in people with HIV, but head-to-head data among contemporary regimens are scarce and few studies analyze older and modern regimens together.
Does first-line INSTI-based antiretroviral therapy increase the risk of incident hypertension compared to NNRTI-based and boosted PI-based regimens in ART-naïve adults with HIV?
Cohort (n=1,134)
Does first-line INSTI-based antiretroviral therapy increase the risk of incident hypertension compared to NNRTI-based and boosted PI-based regimens in ART-naïve adults with HIV?
Hazard Ratio: 1.61 (95% CI 1.2–2.17)
p-value: p=0.005
In ART-naïve adults with HIV, initiating first-line INSTI-based regimens—especially those containing dolutegravir—is independently associated with a significantly higher risk of incident hypertension compared to NNRTI-based regimens, warranting systematic blood pressure monitoring.
Background People with HIV (PWH) face a growing burden of cardiovascular disease. Integrase strand transfer inhibitors (INSTI) have been linked to weight gain and possibly hypertension, but head-to-head data among contemporary regimens are scarce, and few studies analyze older and modern regimens together. We evaluated the incidence of hypertension in antiretroviral therapy (ART)-naïve PWH initiating Spanish guidelines-recommended first-line regimens since 2009. Methods Retrospective cohort of ART-naïve adults initiating first-line regimens from 2009 to 2024, grouped into NNRTI, INSTI, and boosted PI-based classes. Incident hypertension was defined by a composite of clinical diagnosis, antihypertensive initiation, or two consecutive measurements ≥ 140/90 mmHg. Time to hypertension was analysed using Kaplan-Meir methods and Cox regression, with a pre-specified INSTI subanalysis. Results Among 1,134 participants (median age 34.1years; 89.8% male), 205 (18.1%) developed hypertension over a median of 135.9 weeks (incidence 4.9/100 person-years). Hypertension free survival differed by class (log-rank p = 0.005); INSTI-based ART was independently associated with higher risk than NNRTIs (adjusted HR 1.61; 95% CI 1.20-2.17). Within the INSTI subgroup (n = 437; incidence 7/100 person-years), 5-year cumulative hypertension ranged from 9% (EVG/c/FTC/TAF) to 37% (dolutegravir-based); dolutegravir-based regimens carried a > 2-fold adjusted hazard versus EVG/c/FTC/TAF. Higher BMI was independently predictive but did not abolish this signal. Conclusions In ART-naïve PWH, INSTI-based regimens were associated with a higher incidence of hypertension than NNRTI-based regimens, whereas the comparison with PI-based regimens were not statistically significant. Dolutegravir-containing regimens were independently associated with incident hypertension supporting systematic blood pressure surveillance and further comparative studies.
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Bernardino et al. (2026) conducted a cohort in HIV (antiretroviral therapy-naïve) (n=1,134). Integrase strand transfer inhibitor (INSTI)-based first-line antiretroviral therapy vs. Non-nucleoside reverse transcriptase inhibitor (NNRTI)-based or boosted protease inhibitor (PI)-based regimens was evaluated on Incident hypertension (composite of clinical diagnosis, antihypertensive initiation, or two consecutive measurements ≥ 140/90 mmHg) (adjusted HR 1.61, 95% CI 1.20-2.17, p=0.005). INSTI-based first-line ART was independently associated with a higher risk of incident hypertension than NNRTI-based regimens in ART-naïve adults with HIV (adjusted HR 1.61; 95% CI 1.20-2.17).
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