Dietary and lifestyle behaviours and health advice by hypertension status among people living with HIV in South Africa

South Africa has faced a dual burden of both HIV and hypertension. Improved survival and increased life expectancy among people living with HIV (PLWH) have made the prevention and management of hypertension an integral part of HIV care. However, evidence on hypertension awareness and differences in dietary and lifestyle behaviours by hypertension status among PLWH remains limited. This study described dietary and lifestyle behaviours and health advice received by hypertension status among South African adults living with HIV. Cross-sectional data were collected from participants receiving HIV care at primary health facilities in the Western Cape Province. Hypertension status was classified as ‘no-hypertension’ (no history and blood pressure (BP) < 140/90 mmHg), ‘newly-diagnosed hypertension’ (no history but systolic and/or diastolic BP ≥ 140/90 mmHg), and ‘known-hypertension’ (self-reported previous diagnosis). Lifestyle behaviour and dietary habits were assessed using the WHO STEPwise approach questionnaire. Adjusted logistic regression explored associations between lifestyle/dietary habits and hypertension status. Among 742 adults (mean age 38 years, 79.2% female, 93% on anti-retroviral treatment), 62% had no-hypertension, 19% newly-diagnosed hypertension, and 19% known-hypertension. Approximately two-thirds reported eating fruit and/or vegetables ≥ 4 days per week, but few consumed ≥ 5 servings of fruits and vegetables daily. Among known-hypertension participants, > 90% recognised that ‘eating too much salt could cause serious health problems’, yet 22% ‘added salt to their food before every or most meals’. Compared with participants without hypertension, those with known-hypertension were less likely to eat ≥ 5 servings of fruits and vegetables daily (OR: 0.01, 95%CI: 0.00-0.01, p < 0.001), while newly-diagnosed hypertension participants were more likely to report current alcohol use (OR: 2.35, 95%CI: 1.53–3.60, p < 0.001) and heavy-alcohol use (OR: 2.65, 95%CI: 1.40–5.20, p = 0.002). Known-hypertension was associated with receiving greater general and dietary advice, but not with healthier lifestyle and dietary practices. Dietary and lifestyle practices among people living with HIV were generally suboptimal, regardless of hypertension status. Greater receipt of advice among those with known-hypertension was not reflected in healthier practices, highlighting the need for tailored counselling, addressing barriers to healthy dietary practices, and routine hypertension screening within HIV care.