Hematologic changes associated with Zidovudine following single-drug substitution from stavudine in a home-based AIDS care program in rural Uganda

Magnitude and associated factors of anemia among AZT based HAART experienced adult HIV patients at University of Gondar Comprehensive Specialized Referral Hospital, Northwest, Ethiopia, 2019: a retrospective cohort study

Background

Anemia is the most common hematologic abnormalities in AIDS patients usually associated with disease progression and poor clinical outcomes. Zidovudine (AZT), which is one of the nucleoside reverse transcriptase inhibitor drug families of the first line antiretroviral therapy regimen for HIV/AIDS patients, causes anemia due to early long-term of higher-dose therapy. This study was aimed to assess the magnitude and associated factors of anemia among AZT containing HAART experienced adult HIV/ADIS patients at University of Gondar Comprehensive Specialized Referral Hospital, northwest, Ethiopia, 2019.

Methods

A retrospective cohort study was conducted among a total of 320 adult AZT based HAART experienced HIV/AIDS patients from January 2016 to December 2018. Systematic random sampling technique was used to select the patients’ charts. All required data for this study were extracted from patients’ medical charts. Data were coded, cleared and entered into Epi Info version 3.5.3, and transformed to SPSS version 20 for analysis. Descriptive statistics, bivariable and multivariable logistic regression models were fitted to identify associated factors of anemia and P-value < 0.05 was considered as statistically significance.

Results

A total of 320 adult AZT based HAART experienced HIV/AIDS patients’ charts were assessed. Of the total patients, 198 (61.9%) were females and 133 (41.6%) were within the age range of 35–45 years. More than half, 237(76.9%) of the patients were from the urban area and 186 (58.1%) were on WHO clinical stage III at the baseline. The prevalence of anemia was 50% (95% CI 44.7–55.0%), 44.1% (95% CI 38.4–50.0%), 35.6% (95% CI 30.3–40.6%), 40% (95% CI 34.4–45.6%), 40.6% (95% CI 35.0–46.3) and 39.1% (95% CI 33.4–44.1%) at baseline, 6 months, 12 months, 18 months, 24 months and 30 months of follow-up period, respectively. The overall prevalence of anemia was 41.6%. Anemia had significant association with WHO clinical stage and base line Hgb values.

Conclusions

A significant number of participants were anemic in this study. WHO clinical stage and baseline Hgb value were the contributing factors for anemia among these patients. Therefore, anemia needs an immediate intervention on associated factor to improve the anemic status and living condition of HIV patient.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06712-5.

Prevalence of Leucopenia and Associated Factors before and after Initiation of ART among HIV-Infected Patients, North East Ethiopia: Cross-Sectional Study

Background

Leucopenia is the commonest hematological abnormaly that occurs in patients with human immune deficiency virus (HIV) infection. The magnitude and related factors of leucopenia during the time of ART are not characterized in Ethiopia. This study aimed to assess the prevalence of leucopenia before and after the initiation of ART among HIV patients attending Debre Berhan Referral Hospital (DBRH), North East Ethiopia.

Methods

A cross-sectional study was conducted from September to December 2020 in DBRH, North-East Ethiopia. A total of 272 patients on ART were selected by simple random sampling techniques. Socio-demographic and clinical characteristics of the study participants were collected by standard questionnaires. Measurements of leucocyte count and CD4 counts were made by Sysmex XT 2000i hematology analyzer and BD FACS count CD4 analyzer, respectively. Statistical analysis of data was done by SPSS version 23. Logistic regression was done and a P-value<0.05 was taken as statistically significant.

Results

The prevalence of leucopenia, neutropenia, and lymphopenia were 20.9%, 7.0%, and 6.6% before initiation of ART and 15.4%, 1.1, and 4.4% after initiation of ART, respectively. There was a significant difference in total white blood cell count, absolute neutrophil count, and total lymphocyte count between patients on ART and ART naïve patients. HIV patients whose cluster of differentiation (CD4) counts were <200 cells/µL and patients on a zidovudine (AZT)-based regimen were more likely to have leucopenia than HIV patients whose CD4 counts were ≥ 200 cells/µL and on a tenofovir (TDF)-based regimen.

Conclusion

In this study, the prevalence of leucopenia, neutropenia, and lymphopenia has shown a significant decrement after the initiation of ART. HIV patients with low CD4 count and on an AZT-based regimen are more likely to have leucopenia, neutropenia, and lymphopenia. Based on our findings, we recommend that the health care professional routinely investigate and should treat leucopenia.

Imbalance of antioxidant enzymes activities and trace elements levels in Ghanaian HIV-infected patients

Human immunodeficiency virus (HIV) infection and antiretroviral therapy (ART) have been associated with high oxidative stress in HIV patients. The disparity in antioxidant-oxidant levels in HIV patients favours viral replication and disease progression. This study aimed at determining the effect of ART on antioxidant enzymes activities and trace elements levels in Ghanaian HIV patients. A total of 242 participants; comprising of 105 HIV-infected patients on ART, 77 HIV-infected ART-naïve, and 60 HIV seronegative controls were recruited for the study. Whole blood was collected and used for haematological profiling, and the determination of CD4⁺ counts, superoxide dismutase (SOD) activity and trace element levels. Serum was used for liver function tests and the determination of glutathione reductase (GR) activity, and plasma was used to estimate reduced glutathione (GSH) levels. Low levels of haemoglobin (HB), hematocrit, mean cell volume (MCV) and mean cell hemoglobin (MCH), and trace elements were found in ART-naïve patients compared to those on ART and the seronegative controls. In the ART-naïve patients, glutathione reductase (GR) activity and reduced glutathione (GSH) level were significantly low compared to patients on ART and seronegative controls. Activity of SOD was significantly reduced in ART-naïve patients compared to those on ART and the control group, and manganese is the only trace element that showed a strong negative correlation with SOD activity and a positive and significant correlation with CD4⁺ count, and therefore needs to be investigated further. The study suggests that assessing antioxidant levels or enzymes activities of patients infected with HIV should be considered during therapy.

Predictors of Persistent Anaemia in the First Year of Antiretroviral Therapy: A Retrospective Cohort Study from Goma, the Democratic Republic of Congo

Background

Anaemia is associated with adverse outcomes including early death in the first year of antiretroviral therapy (ART). This study reports on the factors associated with persistent anaemia among HIV-infected patients initiating ART in the Democratic Republic of Congo (DR Congo).

Methods

We conducted a retrospective cohort study and analyzed data from patients receiving HIV care between January 2004 and December 2012 at two major hospitals in Goma, DR Congo. Haemoglobin concentrations of all patients on ART regimen were obtained prior to and within one year of ART initiation. A logistic regression model was used to identify the predictors of persistent anaemia after 12 months of ART.

Results

Of 756 patients, 69% of patients were anaemic (IC95%: 65.7–72.3) at baseline. After 12 months of follow up, there was a 1.2 g/dl average increase of haemoglobin concentration (P < 0.001) with differences depending on the therapeutic regimen. Patients who received zidovudine (AZT) gained less than those who did not receive AZT (0.99 g/dl vs 1.33 g/dl; p< 0.001). Among 445 patient who had anaemia at the beginning, 33% (147/445) had the condition resolved. Among patients with anaemia at ART initiation, those who did not receive cotrimoxazole prophylaxis before starting ART(AOR 3.89; 95% CI 2.09–7.25; P < 0.001) and a AZT initial regimen (AOR 2.19; 95% CI 1.36–3.52; P < 0.001) were significantly at risk of persistent anaemia.

Conclusions

More than two thirds of patients had anaemia at baseline. The AZT-containing regimen and absence of cotrimoxazole prophylaxis before starting ART were associated with persistent anaemia 12 months, after initiation of treatment. Considering the large proportion of patients with persistence of anaemia at 12 months, we suggest that it is necessary to conduct a large study to assess anaemia among HIV-infected patients in Goma.

Prevalence and correlates of anemia among HIV infected patients on highly active anti-retroviral therapy at Zewditu Memorial Hospital, Ethiopia

Background

Ethiopia is one of the most seriously HIV affected countries in Sub-Saharan Africa. Anemia is a known predictor of disease progression and death among HIV infected patients. In this study, we investigated the magnitude and correlates of anemia among HIV infected patients receiving HAART at a referral hospital in Ethiopia.

Methods

A retrospective cohort study was conducted from November 2011 to February 2012 in Zewditu Memorial Hospital, Addis Ababa, Ethiopia. Records of 1061 patients on HAART were selected using simple random sampling technique. Socio-demographic and clinical characteristics of the study patients were collected using standardized data extraction instrument. Data were analyzed using STATA version 11.0. Odds ratios with 95% confidence intervals were used to quantify the strength of association between anemia and its potential predictors.

Results

The prevalence of anemia at baseline was 42.9%. However, the prevalence significantly decreased to 20.9% at 6 months (p < 0.001) and to 14.3% at 12 months (p = 0.001) after HAART initiation. At baseline, male sex (AOR = 1.55; 95% CI: 1.18-2.03), clinical stage III/IV (AOR = 2.03; 95% CI: 1.45-2.83) and TB co-infection (AOR = 1.52; 95% CI: 1.08-2.13) were independently associated with the odds of being anemic. After 6 months of HAART, male sex (AOR = 1.59; 95% CI: 1.13-2.23), baseline anemia (AOR = 2.38; 95% CI: 1.71-3.33) and TDF-based HAART (AOR = 2.87; 95% CI: 1.80-4.60) were independently associated with the odds of being anemic. Besides, anemia was independently associated with older age at 6 months. After 12 months of HAART, baseline anemia (AOR = 2.01; 95% CI: 1.36-2.97), age group 25–34 years (AOR = 5.92; 95% CI: 1.39-25.15), age group 45–54 years (AOR = 4.78; 95% CI: 1.07-21.36), CD4 count below 200 cells/mm³ (AOR = 2.15; 95% CI: 1.21-3.82) and 200–350 cells/mm³ (AOR = 1.91; 95% CI: 1.13-3.25) were independently associated with the odds of being anemic.

Conclusions

Although a remarkable reduction in the prevalence of anemia was observed following initiation of HAART, a significant proportion of HIV patients remained anemic after 12 months of HAART suggesting the need for routine screening and proper treatment of anemia to mitigate its adverse effects.

Resolution of anaemia in a cohort of HIV-infected patients with a high prevalence and incidence of tuberculosis receiving antiretroviral therapy in South Africa

BACKGROUND

Anaemia is frequently associated with both HIV-infection and HIV-related tuberculosis (TB) in antiretroviral therapy (ART)-naïve patients in sub-Saharan Africa and is strongly associated with poor prognosis. However, the effect of ART on the resolution of anaemia in patient cohorts with a high prevalence and incidence of tuberculosis is incompletely defined and the impact of TB episodes on haemoglobin recovery has not previously been reported. We therefore examined these issues using data from a well-characterised cohort of patients initiating ART in South Africa.

METHODS

Prospectively collected clinical and haematological data were retrospectively analysed from patients receiving ART in a South African township ART service. TB diagnoses and time-updated haemoglobin concentrations, CD4 counts and HIV viral loads were recorded. Anaemia severity was classified according to WHO criteria. Multivariable logistic regression analysis was used to determine factors independently associated with anaemia after 12 months of ART.

RESULTS

Of 1,140 patients with baseline haemoglobin levels, 814 were alive in care and had repeat values available after 12 months of ART. The majority of patients were female (73%), the median CD4 count was 104 cells/uL and 30.5% had a TB diagnosis in the first year of ART. At baseline, anaemia (any severity) was present in 574 (70.5%) patients and was moderate/severe in 346 (42.5%). After 12 months of ART, 218 (26.8%) patients had anaemia of any severity and just 67 (8.2%) patients had moderate/severe anaemia. Independent predictors of anaemia after 12 months of ART included greater severity of anaemia at baseline, time-updated erythrocyte microcytosis and receipt of an AZT-containing regimen. In contrast, prevalent and/or incident TB, gender and baseline and time-updated CD4 cell count and viral load measurements were not independent predictors.

CONCLUSIONS

Although anaemia was very common among ART-naive patients, the anaemia resolved during the first year of ART in a large majority of patients regardless of TB status without routine use of additional interventions. However, approximately one-quarter of patients remained anaemic after one year of ART and may require additional investigations and/or interventions.

Development of Severe Anemia and Changes in Hemoglobin in a Cohort of HIV-Infected Ugandan Adults Receiving Zidovudine-, Stavudine-, and Tenofovir-Containing Antiretroviral Regimens

INTRODUCTION

Anemia is a common problem in HIV in sub-Saharan Africa. We describe the contribution of antiretroviral therapy (ART) regimen to the incidence of anemia and changes in hemoglobin (Hb) in HIV-infected patients in Uganda.

METHODS

This study was nested in a prevention of cryptococcal disease trial (CRYPTOPRO; ISCRTN7648152). Patients received 3 different backbones of nucleoside reverse transcriptase inhibitor in a nonrandomized manner.

RESULTS

Of the 852 patients (161 on zidovudine [ZDV], 628 on stavudine [d4T], and 63 on tenofovir [TDF]; all received lamuvidine), the risk of developing grade 4 anemia was higher (adjusted hazard ratio 2.7) for those receiving ZDV than those receiving d4T. Those receivingd4T had a higher average increase in Hb than those receiving ZDV (P = .024) or TDF (P = .014).

CONCLUSION

In this observational study, ZDV was associated with severe anemia compared to d4T or TDF; those receiving ZDV and TDF had smaller increases in Hb after ART initiation. We encourage publication of data on cohorts using TDF from Africa.

Incidence and predictors of recovery from anaemia within an HIV-infected South African Cohort, 2004-2010

Introduction

Anaemia is one of the most frequent haematological complications in HIV-infected persons. Understandingfactors associated with recovery from anaemia during ART is vital in improving clinical outcomes since anaemia is a strong predictor of mortality.

Methods

Cohort study of 12,441 HIV-infected adults initiating ART between 2004-2010 in Johannesburg, South Africa. A further 2,489 patients with prevalent anaemia at ART initiation were examined to determine the incidence and predictors of recovery from anaemia. Cox proportional hazards models were fitted to investigate predictors of recovery from anaemia.

Results

Of the 2,489 patients with prevalent anaemia, most patients (n = 2,225, 89.4%) recovered from anaemia. Median time to anaemia recoverywas 3.9 months (IQR: 3.22-6.20) and incidence rate was 180 per 100person years (95% CI: 172-187). In univariateanalysis, sex, CD4 count, BMI, WHO stage, employment status, smoking status and presence of tuberculosis at initiation ofART were significant predictors of recovery from anaemia. However in multivariateanalysis, predictors of recovery from anaemia were: male sex-HR: 1.43 (95% CI: 1.29-1.59) p< 0.001, advanced WHO stage III/IV - HR: 1.17 (95% CI: 1.07-1.29) p = 0.001). There was no significant association with CD4 count in multivariate analysis.

Conclusion

A large proportion of HIV infected patients with anaemia at baseline recover early during the course of ART. Females and those with less advanced WHO stage seem to be at higher risk of poor recovery from anaemia. Understanding the predictors for poor recovery from anaemia would allow closer follow-up and more targeted interventions thus reducing excess anaemia and mortality burden.

Efficacy and safety of darunavir/ritonavir at 48 weeks in treatment-naïve, HIV-1-infected adolescents: results from a phase 2 open-label trial (DIONE)

BACKGROUND

Twice-daily darunavir/ritonavir is indicated in treatment-experienced children (≥3 years). This study assessed once-daily administration in treatment-naïve adolescents.

METHODS

Phase 2, 48-week, open-label, single-arm study evaluating pharmacokinetics, safety and efficacy of once-daily darunavir/ritonavir 800/100 mg in treatment-naïve, HIV-1-infected adolescents (≥12 to <18 years, ≥40 kg) with zidovudine/lamivudine or abacavir/lamivudine.

RESULTS

Twelve patients (67% female; median 14.4 years) were enrolled. After 24 and 48 weeks, respectively, 11 of 12 (92%) and 10 of 12 (83%) patients achieved viral load <50 copies/mL (intent-to-treat time-to-loss of virologic response); all had ≥1 log10 drop in viral load versus baseline. Median CD4 cell count increased by 175 and 221 cells/mm (intent-to-treat-noncompleter = failure) after 24 and 48 weeks, respectively. Eighty-three percent of patients were adherent to darunavir/ritonavir. One patient was never suppressed and 1 patient rebounded. No patients developed darunavir resistance-associated mutations or lost phenotypic susceptibility to any commercially available protease inhibitor or any background nucleoside reverse transcriptase inhibitor. Eleven patients (92%) reported ≥1 adverse event (AE), considered in 2 patients to be at least possibly related to darunavir (gastrointestinal-related events and dizziness). Four patients had ≥1 serious AE. Three patients reported ≥1 grade 3/4 AE; no serious or grade 3/4 AEs were considered darunavir related. No patients discontinued because of AEs.

CONCLUSIONS

Over 48 weeks, once-daily darunavir/ritonavir 800/100 mg plus NRTIs was effective and well-tolerated for treatment of HIV-1-infected, antiretroviral-naïve adolescents (≥12 to <18 years). These findings support use of once-daily darunavir/ritonavir 800/100 mg in this population.

A prospective study of haematological changes after switching from stavudine to zidovudine-based antiretroviral treatment in HIV-infected children

Long-term use of stavudine is associated with a high incidence of lipodystrophy, warranting its substitution with zidovudine in first-line antiretroviral therapy (ART) regimens. In a prospective observational study, we determined the spectrum and severity of haematological changes after switching from stavudine- to zidovudine-based ART in Indian children aged 2-18 years who had received a stavudine-based ART regimen for at least 48 weeks. They were followed for 48 weeks for changes in haematological parameters and CD4 cell counts after switching to zidovudine. Of the 60 children analysed, 45 (75%) showed a significant fall in Hb (>1 g/dl). A majority developed grade 1 anaemia (14 [31%]) while only three (6%) developed grade 4 anaemia. The lowest Hb was recorded between 12 and 16 weeks with spontaneous improvement noticed after 28 weeks. A significant drop in absolute neutrophil count (5067 cells/mm³ to 3625 cells/mm³; p = 0.004) was also observed but none developed severe neutropenia. No significant changes were observed in platelet and CD4 cell counts. Since the incidence of severe drug toxicity was low with zidovudine and the majority of children recovered without intervention, drug toxicity should not preclude its routine use in poor countries.

Anaemia and zidovudine-containing antiretroviral therapy in paediatric antiretroviral programmes in the IeDEA Paediatric West African Database to evaluate AIDS

INTRODUCTION

There is a risk of anaemia among HIV-infected children on antiretroviral therapy (ART) containing zidovudine (ZDV) recommended in first-line regimens in the WHO guidelines. We estimated the risk of severe anaemia after initiation of a ZDV-containing regimen in HIV-infected children included in the IeDEA West African database.

METHODS

Standardized collection of data from HIV-infected children (positive PCR<18 months or positive serology ≥ 18 months) followed up in HIV programmes was included in the regional IeDEA West Africa collaboration. Ten clinical centres from seven countries contributed (Benin, Burkina Faso, Côte d'Ivoire, Gambia, Ghana, Mali and Senegal) to this collection. Inclusion criteria were age <16 years and starting ART. We explored the data quality of haemoglobin documentation over time and the incidence and predictors of severe anaemia (Hb<7 g/dL) per 100 child-years of follow-up over the duration of first-line antiretroviral therapy.

RESULTS

As of December 2009, among the 2933 children included in the collaboration, 45% were girls, median age was five years; median CD4 cell percentage was 13%; median weight-for-age z-score was-2.7; and 1772 (60.4%) had a first-line ZDV-containing regimen. At baseline, 70% of the children with a first-line ZDV-containing regimen had a haemoglobin measure available versus 76% in those not on ZDV (p ≤ 0.01): the prevalence of severe anaemia was 3.0% (n=38) in the ZDV group versus 10.2% (n=89) in those without (p<0. 01). Over the first-line follow-up, 58.9% of the children had ≥ 1 measure of haemoglobin available in those exposed to ZDV versus 60.4% of those not (p=0.45). Severe anaemia occurred in 92 children with an incidence of 2.47 per 100 child-years of follow-up in those on a ZDV-containing regimen versus 4.25 in those not (p ≤ 0.01). Adjusted for age at ART initiation and first-line regimen, a weight-for-age z-score ≤-3 was a strong predictor associated with a 5.59 times risk of severe anaemia (p<0.01).

CONCLUSIONS

Severe anaemia is frequent at baseline and guides the first-line ART prescription, but its incidence seems rare among children on ART. Severe malnutrition at baseline is a strong predictor for development of severe anaemia, and interventions to address this should form an integral component of clinical care.

Antiretroviral treatment reverses HIV-associated anemia in rural Tanzania

Background

HIV-associated anemia is common and associated with poor prognosis. However, its response to antiretroviral treatment (ART) in rural Africa is poorly understood.

Methods

HIV-infected adults (≥15 years) who enrolled in HIV care at Haydom Lutheran Hospital in northern Tanzania were included in the study. The effect of ART (zidovudine/stavudine + lamivudine + efavirenz/nevirapine) on HIV-associated anemia was studied in a subset of patients who were anemic at the time they started ART and had a follow-up hemoglobin measurement 12 months later. Pregnant women were excluded from the study, as were women who had given birth within the past 6 weeks. Anemia was defined as hemoglobin <12 g/dL in women and <13 g/dL in men. We applied paired sample T-tests to compare hemoglobin levels before and one year after ART initiation, and logistic regression models to identify predictors of persistent anemia.

Results

At enrollment, mean hemoglobin was 10.3 g/dL, and 649 of 838 patients (77.4%) were anemic. Of the anemic patients, 254 (39.1%) had microcytosis and hypochromia. Among 102 patients who were anemic at ART initiation and had a follow-up hemoglobin measurement after 12 months, the mean hemoglobin increased by 2.5 g/dL (P < 0.001); however, 39 patients (38.2%) were still anemic after 12 months of ART. Independent predictors of persistent anemia were mean cell volume in the lower quartile (<76.0 fL; Odds Ratio [OR] 4.34; 95% confidence interval [CI] 1.22-15.5) and a zidovudine-containing initial regimen (OR 2.91; 95% CI 1.03-8.19).

Conclusions

Most patients had anemia at enrollment, of whom nearly 40% had microcytosis and hypochromia suggestive of iron deficiency. The mean hemoglobin increased significantly in patients who received ART, but one third were still anemic 12 months after ART initiation indicating that additional interventions to treat HIV-associated anemia in rural Africa might be warranted, particularly in patients with microcytosis and those treated with zidovudine.