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  1. Laura Benjamin1,2,3,4,
  2. Elizabeth Corbett1,5,
  3. Myles Connor6,
  4. Henry Mzinganjira4,
  5. Hedley Emsley2,8,
  6. Alan Bryer7,
  7. Brian Faragher9,
  8. Robert Heyderman1,4,9,
  9. Theresa Allain4,9,
  10. Tom Solomon2,3
  1. 1Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi
  2. 2University of Liverpool
  3. 3Walton Center for Neurology and Neurosurgery
  4. 4Department of Medicine, College of Medicine, University of Malawi
  5. 5London School of Hygiene and Tropical Medicine
  6. 6University of Edinburgh
  7. 7University of Cape Town
  8. 8Royal Preston Hospital
  9. 9Liverpool School of Tropical Medicine


Objective We investigated HIV, its treatment and other risk factors for stroke in Malawi.

Methods We performed a prospective case-control study of 222 adults with acute stroke, confirmed by MRI in 86%, and 503 population controls, frequency-matched for age, sex and place of residence. Multivariate logistic regression models were used for case–control comparisons.

Findings HIV infection (Population Attributable Fraction [PAF] 15%) and hypertension (PAF 46%) were strongly linked to stroke. HIV was the predominant risk factor for young stroke (≤45 years), with a prevalence of 67% and an adjusted odds ratio [aOR, 95% CI] of 5.57 [2.43, 12.8]; PAF 42%. There was an increased risk of a stroke in patients with untreated HIV infection (aOR 4.48 [2.44, 8.24]), but the highest risk was in the first 6 months after starting antiretrovirals (aOR 15.6 [4.21,46.6]). Stroke risk increased with declining CD4+ T-lymphocyte counts (p=0.008).

Interpretation HIV infection increases the risk of stroke especially ischaemic stroke in young people; this is largely driven by immunosuppression. However, there is a markedly increased stroke risk in the first 6 months of starting antiretrovirals. A better understanding of this risk is urgently needed in order to try and reduce it.


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