Physical activity and hypertension amongst HIV-positive and HIV-negative populations in rural South Africa

Hypertension Research https://doi.org/10.1038/s41440-026-02652-2 REVIEW ARTICLE Physical activity and hypertension amongst HIV-positive and HIVnegative populations in rural South Africa Benjamin Zebita Mayasi1 Peter Asaga Mac2 ● 1234567890();,: 1234567890();,: Received: 18 November 2025 / Revised: 7 February 2026 / Accepted: 26 March 2026 © The Author(s) 2026. This article is published with open access Abstract Hypertension represents a major public health challenge in sub-Saharan Africa, characterised by substantial underdiagnosis and inadequate management. This secondary analysis of cross-sectional survey data examined the association between physical activity patterns and hypertension prevalence amongst HIV-positive and HIV-negative populations in rural South African communities. Data were drawn from the ongoing Agincourt Health and Socio-Demographic Surveillance System Site (AHDSS), collected between August 2022 and May 2023, involving 4,436 participants aged ≥ 15 years. Physical activity was assessed using the Global Physical Activity Questionnaire (GPAQ) within the WHO STEPwise framework, and blood pressure was measured using an automated digital device (OMRON R6 wrist monitor). Statistical analyses employed chi-squared tests, two-sample t tests, and multivariable logistic regression models adjusting for demographic, anthropometric, metabolic, and behavioural confounders. Moderate physical activity was associated with lower odds of hypertension irrespective of HIV serostatus, supporting the integration of physical activity counselling into HIV care and primary healthcare services in resource-limited settings (adjusted OR = 0.74, 95% CI: 0.56–0.99, p = 0.043). Hypertension prevalence was 40.4% overall. HIV-positive males demonstrated higher prevalence (60.2%) compared with HIV-negative males (46.9%, p < 0.001). HIV-positive status was independently associated with increased odds of hypertension (adjusted OR = 1.45, 95% CI: 1.18–1.78). Age, male sex, obesity, elevated waist-hip ratio, and current alcohol consumption showed significant positive associations with hypertension. Moderate physical activity provides protective benefits against hypertension irrespective of HIV serostatus, supporting the integration of physical activity counselling into HIV care and primary healthcare services in resource-limited settings. Keywords HIV/AIDSHypertension Physical Activity South Africa Cardiovascular Disease Sub-Saharan Africa ● ● Introduction Hypertension, defined as persistently elevated arterial blood pressure, constitutes a leading modifiable risk factor for cardiovascular morbidity and mortality globally [1]. In sub-Saharan Africa, the burden of hypertension is Supplementary information The online version contains supplementary material available at https://doi.org/10.1038/s41440026-02652-2. * Peter Asaga Mac 1 School of Public Health, University of the Witwatersrand, Johannesburg, South Africa 2 Institute for Infection Prevention and Control, Medical Center, Faculty of Medicine, University of Freiburg, Breisacher Str. 115B, Freiburg 79106, Germany ● ● escalating rapidly owing to urbanisation, epidemiological transition, and lifestyle changes, with prevalence estimates ranging from 20 to 50% across populations [1, 2]. Within South Africa, hypertension is an established risk factor for myocardial infarction, cerebrovascular accidents, chronic kidney disease, and retinopathy, and remains inadequately diagnosed and treated across communities [2, 3]. Hypertension frequently coexists with additional risk factors for chronic diseases of lifestyle, including diabetes mellitus, obesity, and physical inactivity. These interrelationships between hypertension and other chronic disease risk factors, combined with the diverse organ systems affected by uncontrolled hypertension, generate a complex clinical picture with substantial population health implications [4–7]. Physical activity has demonstrated consistent protective effects against hypertension through multiple physiological mechanisms, including enhancement of endothelial function, reduction of systemic vascular resistance, attenuation B. Z. Mayasi, P. A. Mac Graphical Abstract Visual summary of key findings. Physical activity and hypertension amongst HIV-positive and HIV-negative populations in rural South Africa: moderate physical activity provides protective benefits against hypertension regardless of HIV status of sympathetic nervous system activity, and improvement of insulin sensitivity [3, 4, 8]. In the context of HIV infection, these mechanisms assume particular importance, as HIV-positive individuals experience chronic immune activation, systemic inflammation, and endothelial dysfunction that independently promote hypertension [9–11]. Furthermore, antiretroviral therapy (ART) may induce metabolic disturbances including lipodystrophy and insulin resistance, which further elevate cardiovascular risk [12, 13]. Physical activity may attenuate these pathological processes, though population-based evidence examining physical activity–hypertension associations stratified by HIV serostatus remains limited, particularly in rural African settings [5, 14, 15]. Whilst several large-scale studies have examined HIV–hypertension associations across sub-Saharan Africa, including the H3Africa AWI-Gen study [5], meta-analyses by Bigna et al. [16] and Davis et al. [17], and regional investigations in East and Southern Africa [18–24], few have incorporated domain-specific physical activity analysis using metabolic equivalent of task (MET)-based quantification. Understanding these associations in rural populations, where physical activity patterns differ substantially from urban settings, is essential for developing context-appropriate preventive strategies. We hypothesised that higher levels of physical activity would be inversely associated with hypertension prevalence, and that this protective association would persist regardless of HIV serostatus. This secondary analysis of cross-sectional survey data therefore examined physical activity patterns and their association with hypertension prevalence amongst HIV-positive and HIV-negative populations in rural South Africa, utilising data from the Agincourt Health and Socio-Demographic Surveillance System. Methods Ethical considerations The primary study received approval from the University of the Witwatersrand Human Research Ethics Committee Physical activity and hypertension amongst HIV-positive and HIV-negative populations in rural South. . . (HREC clearance certificate number M10458) and the Mpumalanga Provincial Research and Ethics Committee. This secondary analysis was approved by the University of the Witwatersrand Human Research Ethics Committee (clearance certificate number M140917). Permission to utilise the data was obtained from the Agincourt Health and Socio-Demographic Surveillance Site. Written informed consent was obtained from all participants aged ≥ 18 yea (...truncated)