Hypertension is a marker of the micro-epidemiologic transition in ageing HIV populations in Kenya, Uganda and Tanzania (AFRICOS, 2013–2023)

Background Although mortality among people living with HIV (PLHIV) in sub-Saharan Africa has decreased markedly with the scale-up of antiretroviral therapy (ART), the demographic consequences of this success remain underexamined. Methods Using ten years of longitudinal data from the African Cohort Study (AFRICOS; 2013–2023) in Kenya, Tanzania, and Uganda, we estimated the association of hypertension with all-cause mortality among adults aged 40 years and older. We combined descriptive decremental life-table analysis with discrete-time logistic regression, applying both lagged and exponentially weighted moving-average (EWMA) exposure models to capture cumulative risk. Results At baseline, 18.6% of participants were hypertensive; 60.1% experienced hypertension during follow-up, and all-cause mortality was 6.4%. Life-table estimates showed cumulative excess mortality (Δqₓ) among hypertensive participants increasing from 0.4% in the first interval to 4.4% by year nine. Excess mortality was larger among adults aged ≥ 50 years (Δqₓ ≈ 5.4% vs. 4.4% at ages 40–49), men (Δqₓ ≈ 8.0% vs. 2.8% in women), underweight participants (Δqₓ > 20% in early intervals), and those with high viral load (Δqₓ ≈ 7.0%). In adjusted discrete-time models controlling for age, sex, body mass index, viral load, and country, hypertension was associated with higher mortality under a standard lag specification (aOR = 2.04; 95% CI 1.10–3.80) and under EWMA exposure definitions (aOR = 3.25; 95% CI 1.26–8.40 at α = 0.3; aOR = 2.51; 95% CI 1.16–5.44 at α = 0.7). Mortality odds were higher among participants aged ≥ 60 years (aOR = 2.23–2.40; 95% CIs 0.85–6.16) and those with high viral load (aOR = 2.36–2.44; 95% CIs 1.28–4.51), while overweight and obese participants had substantially lower odds of death (aOR = 0.29; 95% CI 0.10–0.85 and aOR = 0.14; 95% CI 0.04–0.56). Conclusions These findings highlight a demographic transformation of the HIV epidemic in East Africa, where mortality among PLHIV increasingly reflects a growing influence of chronic diseases in addition to infection control. Hypertension has become a key driver of excess mortality and a demographic indicator of the region’s compressed health transition.