Africa Needs to Rethink How It Treats High Blood Pressure

In a lecture hall in Potchefstroom, South Africa, a physiologist stood in front of colleagues, students and health officials and made a claim that runs against decades of standard medical practice: the blood pressure guidelines that shape treatment for hundreds of millions of Africans were largely built without Africans in mind.

Hypertension, once considered a disease of aging, is now showing up earlier in life across the continent, raising the risk of kidney failure and heart disease in people still in their twenties and thirties. That was the central message delivered by Prof. Lebo Gafane-Matemane of the Faculty of Health Sciences during her inaugural lecture at North-West University (NWU) on June 30, and it lands at a moment when the numbers behind it have become difficult to ignore.

Up to 44 percent of adults aged 30 to 79 in the World Health Organization’s African Region now live with hypertension, according to the WHO Regional Office for Africa, which marked World Hypertension Day this year by warning that in most countries on the continent, fewer than half of those cases are diagnosed and fewer than one in five are under control. 

A pooled analysis of 52 community-based studies published this year put the sub-Saharan prevalence rate at 27.09 percent, with regional estimates ranging from roughly 22 percent in southern Africa to nearly 33 percent in central Africa. Older projections that once seemed alarmist, an increase from 74.7 million hypertensive adults in 2008 to 125.5 million by 2025, are now being revised upward again, with newer modeling suggesting the continent could reach 216.8 million cases by 2030.

What has changed is not just the scale of the disease but who it is showing up in. A large, multicountry analysis of 61 national surveys across 37 African countries between 2003 and 2022 found hypertension diagnosed in nearly 29 percent of women and 26 percent of men, but treatment rates lagging far behind: just 15 percent of women and 8.4 percent of men with the condition were actually receiving medication for it. In South Africa specifically, a national screening study found that among adults under 40, 15.6 percent already had hypertension, and of those, 76 percent had no idea they had it.

That silence is the crux of Prof. Gafane-Matemane’s argument. In her address, titled “When biology meets context: RAAS, hypertension and the future of cardiorenal health in Africa,” she drew on more than a decade of research to argue that Africa cannot rely solely on global models to address hypertension. She said the continent requires research and treatment strategies that reflect its own populations, disease patterns and healthcare realities.

Calling for greater investment in early screening, kidney health monitoring and precision medicine, she warned that the burden of hypertension extends beyond high blood pressure to include chronic kidney disease, cardiovascular disease and growing economic costs. 

The stakes of that shift are not abstract: a global analysis of chronic kidney disease attributable to hypertension found that the disability-adjusted life-years lost to the condition among adolescents and young adults have been climbing steadily worldwide, a trend researchers say is likely to compound in regions where diagnosis already lags years behind disease onset.

“The face of hypertension is changing rapidly, and we should worry about the consequences such as kidney disease,” Prof. Gafane-Matemane said.

Other clinicians treating the condition on the ground describe the same pattern in blunter terms. Nokuthula Padayachy, a hypertension specialist quoted in a recent account of South Africa’s screening gap, has called hypertension a “silent killer” precisely because patients can feel perfectly well for years while the disease quietly damages arteries and organs. 

“This lack of early warning signs often leads to delayed health-seeking behaviour,” she said, describing communities where routine screening remains out of reach. Public health advocates point to a related problem downstream of diagnosis: even patients who know their status often fail to stay on treatment, with limited access to healthcare facilities, medication shortages and inconsistent counseling from providers all cited as barriers to the kind of sustained care hypertension requires.

African forms of hypertension respond differently

Prof. Gafane-Matemane’s own research sits inside a specific and, until recently, under-studied corner of that puzzle: the renin-angiotensin-aldosterone system, or RAAS, a hormone system that regulates blood pressure, fluid balance and kidney function. It is the system most global antihypertensive drugs are designed to target, and it is also, her research suggests, the system that behaves differently in many African patients than it does in the European and North American populations on which those drugs were originally tested.

Through studies conducted in South Africa, including the SABPA, PURE and African-PREDICT cohort studies run by North-West University’s Hypertension in Africa Research Team, her work has shown that many Africans present with low-renin forms of hypertension, a phenotype that responds differently to standard first-line treatments than other forms of the disease. 

That finding is not new to her lecture; it traces back to her own doctoral research on the low-renin phenotype in African populations, but her address positioned it as unfinished business rather than settled science, a foundation still waiting for the clinical infrastructure to act on it.

Understanding these biological differences can improve patient care by allowing healthcare professionals to select treatments based on individual hormonal profiles rather than relying on a single approach for everyone, an idea that echoes what cardiologists elsewhere on the continent have been arguing for years through bodies like the Pan-African Society of Cardiology, which has spent more than four decades pushing back against the once-common assumption in African ministries of health that the continent’s populations carried some inherent protection against cardiovascular disease.

Questions that need to be answered are “What does the RAAS mean for hypertension care in Africa?” and “What are the implications for cardiovascular disease and chronic kidney disease?” These questions will shape the future direction of her research, Prof. Gafane-Matemane said.

Beyond the laboratory

Beyond laboratory research, her address highlighted the importance of translating scientific knowledge into community action. She said research should not end with scientific publications but should lead to better healthcare, increased public awareness and earlier diagnosis, a gap that public health researchers elsewhere have described as one of the most persistent failures in the region’s response to non-communicable disease: high-quality science that never reaches a clinic waiting room.

“It is necessary to link knowledge generation with application,” she said while presenting plans for the Cardio-Renal Health Research Initiative, which seeks to strengthen screening, prevention and collaborative research across Africa.

The initiative’s ambitions track closely with targets the Pan-African Society of Cardiology set for itself a decade ago, when it committed the continent’s cardiology community to a roadmap aimed at bringing hypertension under control in a quarter of affected patients by 2025, a target that, judging by the WHO’s most recent regional figures showing barely one in five patients with controlled blood pressure, remains largely unmet.

Prof. Gafane-Matemane called for hypertension screening to begin earlier in life, including among children and young adults, with routine checks for early kidney damage alongside blood pressure monitoring. She also encouraged multidisciplinary collaboration, investment in biomarker research and partnerships across countries to improve cardiovascular and kidney health.

That call for earlier screening is not simply precautionary. Researchers who surveyed thousands of Zimbabwean youth between 18 and 24 found meaningful rates of both hypertension and high-normal blood pressure already present in a population most health systems would not think to screen, evidence that treats the disease’s early onset less as an outlier finding and more as a pattern researchers are now documenting across multiple African countries.

For health systems already stretched thin by infectious disease burdens and constrained budgets, the economic argument may prove as persuasive as the clinical one. Researchers tracking the broader non-communicable disease burden estimate that cardiovascular disease alone cost low- and middle-income countries more than $3.7 trillion between 2011 and 2015, a figure that helps explain why health economists increasingly frame earlier detection not as an added cost but as a way of avoiding far larger ones down the line. The same analysis projects that non-communicable diseases broadly, hypertension chief among them, will drain low- and middle-income economies of roughly $500 billion a year, or about 4 percent of GDP, through the 2020s, a cost that falls disproportionately on health systems already absorbing the continent’s HIV and tuberculosis caseloads.

The WHO’s regional office has tried to translate that arithmetic into a concrete policy target, calling on member states to expand access to a package of low-cost primary care interventions for cardiovascular disease and to align national screening programs with a global goal of cutting uncontrolled hypertension by 25 percent. 

Whether that target is reachable depends less on the existence of effective, inexpensive treatments, which are well established, than on whether primary health clinics from Potchefstroom to Lusaka to Kampala have the staff, the supply chains and the diagnostic tools to use them consistently. 

It is a gap Prof. Gafane-Matemane’s proposed initiative is explicitly designed to narrow, by pairing biological research with the unglamorous, harder-to-fund work of getting blood pressure cuffs, kidney function tests and follow-up care into the hands of primary care workers who see patients long before a specialist ever will.

Reflecting on her academic journey, Prof. Gafane-Matemane said meaningful research begins by asking how science can improve people’s lives.

“Focus on research that matters most not only to you but to those who would benefit from your work,” she told Impact Newswire, describing the principle that continues to guide her work.

It is a modest way of framing an argument with large implications: that a disease affecting nearly half of Africa’s adults, and increasingly its young people, cannot be managed with borrowed guidelines alone, and that closing the gap between what science already knows about African bodies and what African clinics are equipped to do about it may be the more urgent frontier.

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