HIVMED Southern African Journal of HIV Medicine 1608-9693 2078-6751 AOSIS HIVMED-26-1769 10.4102/sajhivmed.v26i1.1769 Conference Abstracts Association between antiretroviral therapy initiation or reinitiation timing and neuroimaging-confirmed stroke in people with HIV https://orcid.org/0000-0002-6464-4257 van Rensburg Roland 1 https://orcid.org/0009-0005-4641-377X Smuts Alexander 1 https://orcid.org/0000-0002-7845-4219 Pennefather Camilla 1 https://orcid.org/0000-0003-4749-2404 Jennings Lauren 2 https://orcid.org/0009-0007-9456-3996 Schreuder Chantel 2 https://orcid.org/0000-0003-3021-5101 van Zyl Gert 3 https://orcid.org/0000-0002-8368-393X Brey Naeem 4 https://orcid.org/0000-0002-9297-0244 Saylor Deanna 5 https://orcid.org/0000-0003-0155-485X O’Hagan Suzanne 6 https://orcid.org/0000-0003-1542-4976 Kellermann Tracy 1 https://orcid.org/0000-0003-1134-7475 Orrell Catherine 2 https://orcid.org/0000-0003-1815-5150 Decloedt Eric 1 Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Desmond Tutu Health Foundation, Cape Town, South Africa Division of Medical Virology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Division of Neurology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Department of Neurology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, United States Division of Radiodiagnosis, Department of Radiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Corresponding author: Roland van Rensburg, rvr@sun.ac.za 25112025 2025 26 1 1769 05092025 17092025 © 2025. The Authors 2025 Licensee: AOSIS. This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license.

Stroke among people with HIV (PWH) has been linked to initiating or reinitiating antiretroviral therapy (ART) within six months.1,2,3 We examined this association in a large prospective cohort. We conducted a descriptive interim analysis of data from the ongoing AVALON study investigating stroke in PWH (NIH-1R21TW012384-01A1). Over 12 months (September 2024–August 2025), we included all PWH presenting with neuroimaging-confirmed acute/subacute stroke (imaging within three weeks of symptom onset) to Western Cape public sector hospitals with brain imaging facilities (n = 10). We identified 605 PWH with stroke. Median age was 44 years (interquartile range [IQR] 36–54), with 51% female at birth (Table 1). Ischaemic stroke comprised 85% of cases, mostly involving the middle cerebral artery territory (63%). Previous stroke (> 4 weeks before current) was evident in 17%. At presentation, 76% were on ART for a median 8.2 years (IQR 3.8–11.9), most commonly tenofovir/lamivudine/dolutegravir (73%). ART was initiated/reinitiated within six months prior to stroke in 24.4%, with a median of 68 days (IQR 26–119) from initiation/reinitiation to stroke. ART adherence derived from pharmacy refills was 57% in the preceding six months. The most recent median viral load was < 50 copies/mL (IQR < 20–6777), measured a median of 85 days (IQR 4–420) before stroke. We report the largest South African cohort of PWH with stroke to date. Participants were young, on currently recommended ART, and 28% had no comorbidities. A quarter initiated/reinitiated ART within six months of stroke, supporting previous reports suggesting a potential immune reconstitution-like syndrome.

 stroke HIV antiretroviral therapy adherence neuroimaging Funding information Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health under award number R21TW012384-01A1. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Comorbidities and co-infections (N = 605).

Variable Category n %
Comorbidities† 435‡ 72
Hypertension 211 35
Dyslipidaemia 60 9.9
Diabetes 50 8.3
Chronic kidney disease 47 7.8
Heart failure 23 3.8
Arrhythmia 9 1.5
Heart valve disorder 7 1.2
Previous myocardial infarction 7 1.2
On treatment for comorbidities
Yes 227 38
Co-infections§ 210 35
Tuberculosis 127 21
Pulmonary 58 46
Meningitis 48 38
Disseminated 21 16
Syphilis 59 9.8
Cryptococcus spp. 24 4.0
Cryptococcal meningitis 19 79
On treatment for co-infections
Yes 79 13

, The top 8 comorbidities are shown;

, 92 had more than one comorbidity;

, The top 3 co-infections are shown;

, 9 had multi-site tuberculosis.

 Acknowledgements

This abstract is based on research previously presented in abstract oral form at the 7th Southern African HIV Clinicians Society Conference, held in Cape Town from 20 August 2025 to 22 August 2025. The abstract has since been developed into a written abstract for journal publication. This republication is done with permission from the conference organisers.

Competing interests

The authors of this publication received research support from Fogarty International Center with an equipment loan from the National Institutes of Health under award number R21TW012384-01A1. The terms of this arrangement have been reviewed and approved by the National Institutes of Health in accordance with its policy on objectivity in research.

 Authors’ contributions

R.v.R. and E.D. conceptualised the study and methodology. R.v.R., E.D., and C.O. secured funding. R.v.R., A.S., C.P., C.O., L.J., and C.S. provided study coordination and data management. R.v.R., A.S., C.P., L.J., and C.S. performed the data collection. G.v.Z., N.B., D.S., S.O., and T.K. provided expert and material input on the data and data interpretation. R.v.R., A.S., C.P., L.J., and C.S. directly accessed and verified the underlying data reported in the abstract. R.v.R. and A.S. wrote the original draft of the abstract. All authors reviewed the abstract, provided scientific input to the abstract, and agreed with the final version of the abstract

 Ethical considerations

An application for full ethical approval was made to the Health Research Ethics Committee of Stellenbosch University and ethics consent was received on 03 May 2024. The ethics approval number is N23/11/140.

 Data availability

Study data will not be publicly available. Data can be made available to interested researchers after submission of a clear proposal to the corresponding author, R.v.R.

 Disclaimer

The views and opinions expressed in this abstract are those of the authors and are the product of professional research. The abstract does not necessarily reflect the official policy or position of any affiliated institution, funder, agency, or that of the publisher. The authors are responsible for this abstract’s results, findings, and content.

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How to cite this article: Van Rensburg R, Smuts, A, Pennefather, C, et al. Association between antiretroviral therapy initiation or reinitiation timing and neuroimaging-confirmed stroke in people with HIV. S Afr J HIV Med. 2025;26(1), a1769. https://doi.org/10.4102/sajhivmed.v26i1.1769