Factors associated with anaemia in HIV-infected individuals in southern India

Prediction of the risk of cytopenia in hospitalized HIV/AIDS patients using machine learning methods based on electronic medical records

Background

Cytopenia is a frequent complication among HIV-infected patients who require hospitalization. It can have a negative impact on the treatment outcomes for these patients. However, by leveraging machine learning techniques and electronic medical records, a predictive model can be developed to evaluate the risk of cytopenia during hospitalization in HIV patients. Such a model is crucial for designing a more individualized and evidence-based treatment strategy for HIV patients.

Method

The present study was conducted on HIV patients who were admitted to Guangxi Chest Hospital between June 2016 and October 2021. We extracted a total of 66 clinical features from the electronic medical records and employed them to train five machine learning prediction models (artificial neural network [ANN], adaptive boosting [AdaBoost], k-nearest neighbour [KNN] and support vector machine [SVM], decision tree [DT]). The models were tested using 20% of the data. The performance of the models was evaluated using indicators such as the area under the receiver operating characteristic curve (AUC). The best predictive models were interpreted using the shapley additive explanation (SHAP).

Result

The ANN models have better predictive power. According to the SHAP interpretation of the ANN model, hypoproteinemia and cancer were the most important predictive features of cytopenia in HIV hospitalized patients. Meanwhile, the lower hemoglobin-to-RDW ratio (HGB/RDW), low-density lipoprotein cholesterol (LDL-C) levels, CD4+ T cell counts, and creatinine clearance (Ccr) levels increase the risk of cytopenia in HIV hospitalized patients.

Conclusion

The present study constructed a risk prediction model for cytopenia in HIV patients during hospitalization with machine learning and electronic medical record information. The prediction model is important for the rational management of HIV hospitalized patients and the personalized treatment plan setting.

Anemia and opportunistic infections in hospitalized people living with HIV: a retrospective study

BACKGROUND

There is a high prevalence of anemia among people living with HIV in Guangxi, China. Therefore, we investigated anemia and opportunistic infections in hospitalized people living with HIV and explored the risk factors related to anemia in people living with HIV to actively prevent anemia in people living with HIV.

METHODS

We retrospectively studied people living with HIV admitted to Guangxi Chest Hospital from June 2016 to October 2021. Detailed information on the sociodemographic and clinical features of the participants was collected. The X² test was used to compare the prevalence between the anemic and non-anemic groups. The logistic regression analysis was applied to exclude confounding factors and identify factors related to anemia.

RESULTS

Among 5645 patients with HIV, 1525 (27.02%) had anemia. The overall prevalence of mild, moderate, and severe anemia was 4.66%, 14.08%, and 8.27%, respectively. The factors significantly related to increased risk of anemia were CD4 count < 50 cells/µl (aOR = 2.221, 95% CI = [1.775, 2.779]), CD4 count 50-199 cells/µl (aOR = 1.659, 95% CI = [1.327, 2. 073]), female (aOR = 1.644, 95% CI = [1.436, 1.881]) co-infected with HCV (aOR = 1.465, 95% CI = [1.071, 2.002]), PM (aOR = 2.356, 95% CI = [1.950, 2.849]), or TB (aOR = 1.198, 95% CI = [1.053, 1.365]).

CONCLUSIONS

Within Guangxi of China, 27.02% of hospitalized people living with HIV presented with anemia. Most patients with anemia were in the mild to moderate stage. The low CD4 count, female gender, and concomitant infection with Penicillium marneffei, Hepatitis C virus, or Tuberculosis were independent correlates of anemia. Thus, these findings would be helpful to clinicians in preventing and intervening in anemia in people living with HIV.

Clinical Update

Parvovirus B19 is notoriously a cause of normocytic anaemia in patients in an immunocompromised state, more so than in patients without prior disease. It is increasingly prevalent in children and adults in an HIV-induced immunocompromised state, and its presentation may be varied. Red-cell aplasia and normocytic anaemia are common presenting derangements found. Here, we note the typical presentation of red-cell aplasia re-entering healthcare, with a dire effect on the quality of life of this patient.

Prevalence of anaemia and the associated factors among hospitalised people living with HIV receiving antiretroviral therapy in Southwest China: a cross-sectional study

OBJECTIVES

To estimate anaemia prevalence and the associated factors among hospitalised people living with HIV (PLHIV) receiving antiretroviral therapy (ART).

DESIGN

A cross-sectional study.

SETTING

PLHIV receiving ART and hospitalised in a specialised hospital for infectious disease in Guizhou Province, Southwest China, between 1 January 2018 and 31 March 2021.

PARTICIPANTS

A total of 6959 hospitalised PLHIV aged ≥18 years and receiving ART were included in this study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Anaemia was diagnosed as a haemoglobin concentration <120 g/L for non-pregnant females and <130 g/L for males. Mild, moderate and severe anaemia were diagnosed as below the gender-specific lower limit of normal but ≥110 g/L, 80-110 g/L and <80 g/L, respectively.

RESULTS

The prevalence of anaemia was 27.5%, and that of mild, moderate and severe anaemia was 9.2%, 12.2% and 6.1%, respectively. Results from multivariate logistic regression showed that females had increased odds of anaemia (adjusted OR (aOR)=1.60, 95% CI: 1.42 to 1.81) compared with males. Widowed or divorced inpatients (anaemia: aOR=1.26, 95% CI: 1.08 to 1.47; severe anaemia: aOR=1.52, 95% CI: 1.16 to 1.97) and thrombocytopenia inpatients (anaemia: aOR=4.25, 95% CI: 3.54 to 5.10; severe anaemia: aOR=4.16, 95% CI: 3.24 to 5.35) had increased odds of anaemia and severe anaemia compared with their counterparts. Hepatitis C was associated with increased odds of severe anaemia (aOR=1.80, 95% CI: 1.11 to 2.92).

CONCLUSIONS

Anaemia was prevalent among hospitalised PLHIV. Female sex, those widowed or divorced, and thrombocytopenia were associated with increased odds of anaemia, and those widowed or divorced, thrombocytopenia and hepatitis C were associated with increased odds of severe anaemia. Determination of anaemia predictors, early detection and timely management of anaemia are crucial to prevent anaemia progression.

Prevalence and Predictors of Cytopenias in HIV-Infected Adults at Initiation of Antiretroviral Therapy in Mehal Meda Hospital, Central Ethiopia

Background

Hematologic abnormalities are common complications of patients infected with HIV associated with accelerated deterioration in CD4+ cell counts, disease progression, poor quality of life and death. Few studies have evaluated the magnitude of cytopenias at the initiation of antiretroviral therapy (ART) in sub-Saharan Africa. The aim of this study was to determine the prevalence and predictors of cytopenias among HIV-infected adults at initiation of ART in a resource-limited setting in Ethiopia.

Methods

A cross-sectional study was conducted among HIV-infected adults initiating ART at the HIV care and treatment clinic of Mehal Meda Hospital between September 2008 and June 2019. Demographic, clinical and laboratory data of patients were collected from medical records. Anemia was defined according to WHO guidelines as hemoglobin concentration <12 g/dl for non-pregnant females and <13 g/dl for males. Leucopenia was defined as total white blood cell count <4.0 × 10³ cells/μL and thrombocytopenia as platelet count <150 × 10³ cells/μL. Logistic regression analysis was used to determine factors associated with the presence of cytopenias.

Results

Out of the total 566 patients included, 36.6% (95% CI 32.7–40.6%) had anemia, 17.1% (95% CI 14.2–20.4%) had leucopenia and 14.5% (95% CI 11.8–17.6%) had thrombocytopenia. A total of 53.2% (95% CI 49.1–57.3%) of patients had at least one form of cytopenia, 14.1% (95% CI 11.4–17.2%) had bicytopenia, and only 0.5% had pancytopenia. Factors associated with the presence of any cytopenia in multivariable analysis were male sex, advanced clinical disease stage, low CD4+ cell count, low BMI, and decreased renal function.

Conclusion

A substantial burden of cytopenias was detected among HIV-infected adults enrolled for care and treatment services in our setting. Patients with HIV infection should be screened for hematological abnormalities at initiation of ART because of its potential for morbidity and mortality during ART.

Prevalence of anemia among people living with HIV: A systematic review and meta-analysis

BACKGROUND

Anemia is the most frequent hematologic abnormality among people living with human immunodeficiency virus (HIV) (PLWHIV) and is associated with HIV disease progression and higher risk of mortality of the patients. However, there is a wide variation of the prevalence of anemia among PLWHIV in different clinical settings. We aimed to obtain more precise estimates of prevalence of anemia and severity of anemia among PLWHIV, which may be important for patients, caregivers, researchers and health policy-makers.

METHODS

We systematically searched PubMed, EMBASE, Web of Science, and Cochrane Library for original articles reporting the prevalence of anemia defined using age and sex-specific hemoglobin levels according to World Health Organization criteria among PLWHIV from inception to August 31, 2021. We used DerSimonian-Laird random-effects meta-analyses to obtain pooled prevalence and 95% confidence intervals (CIs) of anemia and severity of anemia among PLWHIV. A univariable meta-regression has been conducted to assess the association between anemia prevalence and study characteristics, including study design, median year of sampling, geographical region, World Bank Income level, and proportion of antiretroviral therapy (ART).

FINDINGS

We included 63 observational studies covering 110,113 PLWHIV. The pooled prevalence of anemia was 39.7% (95% CI: 31.4%-48.0%) for children living with HIV aged <15 years, 46.6% (95% CI: 41.9%-51.4%) for adults (men and non-pregnant women) living with HIV aged ≥15 years, and 48.6% (95% CI: 41.6%-55.6%) for pregnant women living with HIV. Among adults living with HIV, the pooled prevalence of severity of anemia was 21.6% (95% CI: 19.9%-23.3%), 22.6% (95% CI: 14.8%-30.4%), and 6.2% (95% CI: 4.4%-8.1%) for mild, moderate and severe anemia, respectively. Compared with East Africa, anemia prevalence among adults living with HIV was higher in Southern Africa (p = 0.033).

INTERPRETATION

Anemia is prevalent among PLWHIV. Thus, policies, strategies, and programs should be considered to identify the predictors of anemia among PLWHIV to reduce the burden of anemia among patients in the ART era.

The Impact of Syndromic Management of Vaginal Discharge Syndrome on Adverse Birth Outcomes in Botswana

Background

Vaginal discharge syndrome (VDS) is a common clinical diagnosis during pregnancy in Botswana; it is treated with broad-spectrum antibiotics using a syndromic approach. We evaluated associations between the syndromic management of VDS and adverse birth outcomes.

Methods

The Tsepamo Study performs birth outcomes surveillance at government hospitals throughout Botswana. Obstetric record data collected from August 2014 to March 2019 were analyzed. Chi-square tests were conducted to compare proportions of maternal characteristics and infant outcomes. To avoid immortal time bias, all analyses were conducted among women who presented to care before 24 weeks gestation, with VDS categorized as present or absent by 24 weeks gestation. Log-binomial regression models were generated to determine associations between treated VDS and infant outcomes.

Results

VDS was diagnosed in 36 731 (30.7%) pregnant women, of whom 33 328 (90.7%) received antibiotics. Adjusted analyses yielded a harmful association between treated VDS and very preterm delivery (adjusted risk ratio, 1.11; 95% CI, 1.02-1.21). This association remained when restricting to women with VDS who received the recommended antibiotic treatment regimen. Sensitivity analyses produced nonsignificant associations when women with treated VDS were compared with women without VDS who received antibiotics for other indications.

Conclusions

A clinical diagnosis of VDS is common among pregnant women in Botswana, and the majority receive antibiotics in pregnancy. Although analyses of VDS occurring later in pregnancy are precluded by immortal time bias, a modest association between treated VDS and very preterm delivery was observed among women diagnosed with VDS by 24 weeks gestation.

The hematologic profile of Filipino HIV-infected individuals and its association with CD4 counts

Introduction

Hematologic abnormalities are common in HIV and involve all blood cell lineages. A study on cytopenias, as correlated with disease progression, can be valuable in resource-limited settings. This study aimed to determine the hematologic profile of HIV patients and its association with CD4 count and antiretroviral (ARV) treatment.

Methods

This is a retrospective cohort study involving adult Filipino HIV patients with complete blood count (CBC) and CD4 count determinations prior to the initiation of ARV treatment and after ≥6 months of ARV treatment. Logistic regression was performed to determine the association between cytopenias and a CD4 count <200 cells/µL.

Results

The study included 302 patients. Anemia was the most common cytopenia. Anemia and leukopenia were associated with an increased likelihood of having a CD4 count <200 cells/µL in ARV-naïve patients. In ARV-treated patients, leukopenia was associated with an increased probability of having a CD4 count <200 cells/µL. An increase in hemoglobin, white blood cell (WBC) and platelet counts was observed after ≥6 months of ARV treatment.

Conclusion

Anemia and leukopenia can be used as markers of immune status in HIV-infected individuals and improvement in the CBC parameters can be used to assess response to ARV treatment. Routine monitoring of hematologic parameters is recommended.

Magnitude of Anemia and Associated Factors among HIV-Infected Children Receiving Antiretroviral Therapy in Pastoral Community, Ethiopia: A Retrospective Cross-Sectional Study

Background

The two major comrbidities (anemia and poor nutrition) are common manifestations of HIV-infected children, which threaten their lives. In Ethiopia, there is limited information on the magnitude and factors associated with anemia among HIV-infected children. Thus, this study was aimed to determine the magnitude and factors associated with anemia among HIV-infected children receiving antiretroviral therapy in the Afar region, Ethiopia.

Methods

A cross-sectional retrospective record review was conducted on a sample size of 102 HIV-infected children aged 6 months to < 15 years in selected ART sites of the Afar region from May 1 to 25, 2018. Patient cards from 2009 to 2017 with the required information were considered. A paired sample t-test was used to assess whether there is a significant difference in the hemoglobin level before and after the HAART regimen. Multivariable logistic regression was used to determine predictors of anemia. Statistical significance was determined atp value < 0.05.

Result

At baseline, 53.9% of study participants were anemic, from which 8.7%, 36.3%, and 9.8% were mild, moderate, and severe, respectively. There was a statistically significant improvement of hemoglobin level following the one-year course of ART treatment from 10.67 ± 1.82 to 11.5 ± 1.5 (p value ≤ 0.001): an improvement of 0.83 ± 1.74. Children who were moderately and severely stunted were more than five (AOR = 5.16, 95% CI (1.71, 15.56)) and more than twelve (AOR = 12.45, 95% CI (2.62, 59.21)) times more likely to be anemic than children who were not stunted, respectively. Children whose mothers had not attended ANC follow-up were more than three (AOR = 3.68, 95% CI (1.38, 9.81)) times more likely to be anemic than children whose mothers attended ANC. Children who were in clinical stages 3 and 4 were more than five (AOR = 5.07, 95% CI (1.79, 14.37)) times more likely to be anemic than children who were in clinical stage 1 and 2.

Conclusion

The magnitude of anemia among HIV-infected children was found to be high, which is 53.9%. Nutritional status (stunting), WHO clinical stage, and history of ANC follow-up were the predictors significantly associated with childhood anemia. Thus, interventions for HIV-infected children should consider those factors.

Prevalence and risk factors of anaemia in hospitalised HIV-infected patients in southeast China: a retrospective study

The association between opportunistic infection (OI) and anaemia among HIV-infected patients remains to be studied. We investigated the prevalence and risk factors of anaemia in hospitalised HIV-infected patients to reveal the association between OI and anaemia. We conducted a retrospective study of HIV-positive hospitalised patients from June 2016 to December 2017 in Mengchao Hepatobiliary Hospital of Fujian Medical University. Patients’ information on socio-demographic and clinical characteristics were carefully collected. The comparison of anaemia prevalence between groups was conducted with χ² test. A logistic regression model was carried out to analyse the predictors of anaemia. The total prevalence of anaemia in hospitalised HIV-infected patients was 55.15%. The prevalence of mild, moderate and severe anaemia was 41.42%, 11.08% and 2.64%, respectively. Predictors independently associated with anaemia were: CD4 counts <50 cells/μl (odds ratio (OR): 6.376, 95% confidence interval (CI) = 1.916–21.215, P = 0.003), CD4 counts 50–199 cells/μl (OR: 6.303, 95% CI = 1.874–21.203, P = 0.003), co-infection with tuberculosis (TB) (OR: 2.703, 95% CI = 1.349–5.414, P = 0.005) or Penicillium marneffei (PM) (OR: 7.162, 95% CI = 3.147–15.299, P < 0.001). In Fujian, China, more than half inpatients with HIV were anaemic, but severe anaemia is infrequent. Lower CD4 counts, co-infection with TB or PM were independent risk factors for anaemia. Chinese HIV patients especially with TB, PM infection and low CD4 level should be routinely detected for anaemia to improve therapy.

Time to Development of Anemia and Predictors among HIV-Infected Patients Initiating ART at Felege Hiwot Referral Hospital, Northwest Ethiopia: A Retrospective Follow-Up Study

Methods

A retrospective follow-up study was conducted among clients on ART from 2012 to 2017. Data were collected using checklists. The Kaplan-Meier curve was employed to compare survival rates. The Cox proportional hazard model was applied to identify predictors of time to development of anemia.

Results

A total of 490 ART patients were followed. The overall incidence of anemia was 27/100 person-years. The incidence was highest in the second year (18.7/100 PY) of starting ART when compared with the first year (13.8/100 PY) and third year (18.1/100 PY) of ART initiation. The independent predictors show an association for time to development of anemia and were as follows: being female (AHR = 2.94, 95%CI = 2.15–4.0), pulmonary tuberculosis positive (AHR = 2.98, 95%CI = 1.62–5.51), baseline weight < 60 kg (AHR = 1.51, 95%CI = 1.19-1.92), and severe acute malnutrition (AHR = 2.0, 95%CI = 1.39-2.89).

Conclusion

Most of the anemia cases occurred after the first year of ART initiation. Pulmonary tuberculosis, baseline weight, nutritional status, and sex were predictors for anemia. Clients with low baseline weight and abnormal nutritional status need to get close follow-up to prevent the risk of early development of anemia.

Determinants of Anemia among HIV-Positive Children on Highly Active Antiretroviral Therapy Attending Hospitals of North Wollo Zone, Amhara Region, Ethiopia, 2019: A Case-Control Study

Introduction. Anemia is one of the most commonly observed hematological abnormalities and an independent poor prognostic marker of HIV disease. The rate of progression and mortality in this subgroup of patients is high compared to nonanemic patients. WHO estimates that over two billion people are anemic worldwide and young children bear the world's highest prevalence rate of anemia. In Ethiopia, there is limited information about the determinant factors associated with anemia among HIV positive children. Thus, this study aimed to determine the determinant factors of anemia among HIV-infected children on HAART.

Seroprevalence of HIV-2 and dual infection among HIV-infected individuals with clinical and laboratory features at a Tertiary Care Teaching Hospital, Mangalore: The present scenario

Introduction:

Human immunodeficiency virus (HIV) belongs to the Genus Lentiviruses and is made up of two main types HIV-1 and HIV-2 which are the causative agents of acquired immune deficiency syndrome (AIDS). It is well documented that HIV-1 infection is predominantly found, but HIV-2 infection has also been detected occasionally now and then.

Objective:

The objective of this study is to determine the seroprevalence of HIV-2 and dual infection in HIV-infected individuals along with the clinical presentation, co-infections, laboratory profile, and outcome of these patients.

Materials and Methods:

This descriptive cross-sectional study was carried out at a Tertiary Care Teaching Hospital for 2 years from August 2013 to July 2015, after obtaining approval from the Institutional Ethics Committee. Patients confirmed having HIV infection, as per the National AIDS Control Organization guidelines were included in the study. The sociodemographic pattern along with clinico-laboratory details and outcome were noted.

Results and Discussion:

In the present study, out of a total of 214 confirmed HIV-infected individuals, 2.8% (n = 6) were HIV-2 and 1.4% (n = 3) were dual infected where 40–50 years age group were most commonly affected. Males were more commonly affected than females in a ratio of 8:1. The most common presentation was fever (n = 5) followed by gastrointestinal (n = 5) symptoms. The most common opportunistic infection (OI) was tuberculosis (TB) (n = 4) followed by oral candidiasis (n = 2). Majority had anemia (n = 5) with raised erythrocyte sedimentation rate. Furthermore, majority (n = 7) showed improvement on discharge, whereas two (n = 2) left against medical advice and outcome is unknown.

Conclusion:

We conclude that the incidence of HIV-2 and dual infection does occur in our setup with males of older age group being more commonly affected where TB is the most common OI. Hence, clinicians should keep in mind that HIV-2 infection does occur and differentiating as HIV-1, HIV-2, or dual infection is important, to provide appropriate treatment which will result in decreased morbidity and mortality rates.

Factors Associated with Anemia among People Living with HIV/AIDS Taking ART in Ethiopia

Background

Globally, anemia, among people living with HIV/AIDS, is a major public health problem. It has a significant effect on the progression of HIV/AIDS to advanced stages and there are a number of factors that often affect anemia. However, there is little insight regarding factors affecting anemia among HIV/AIDS patients in developing countries, including Ethiopia.

Objective

This study aimed at investigating factors affecting anemia among people living with HIV/AIDS taking ART drug at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

Methods

A hospital based cross-sectional study design was used to assess factors affecting anemia among people living with HIV/AIDS. Structured checklist was used to gather information from charts of patients selected by simple random sampling method. We analyzed the data to identify factors associated with anemia among people with HIV/AIDS using logistic regression models.

Results

A total of 301 selected charts were reviewed. The median age was 38 ± 10.38. The majority (62.5%) of the patients were taking ZDV-containing ART drug (ZDV/3TC/NVP). The overall anemia prevalence was 34.6%, while about 5%, 15.6%, and 14% of the patients had severe, moderate, and mild prevalence of anemia, respectively. Factors that were found to affect anemia among these patients include gender (OR = 2.26 [95% CI: 1.22, 4.16]), occupation (OR: 0.57 [95%CI: 0.35, 0.92]), WBC count (OR = 2.30 [95% CI: 1.29, 4.09]), platelet count (OR = 2.89 [95% CI: 0.99, 8.41]), nutritional status (OR = 2.05 [95% CI: 0.69, 6.02]), and WHO clinical stage of HIV/AIDS (OR = 3.69 [95% CI: 1.86, 7.31]).

Conclusions

About one in three patients was found to be anemic. Intervention aimed at diagnosing and treating anemia among people living with HIV/AIDS should be considered.

BURDEN OF CYTOPAENIAS AMONG HIV POSITIVE PREGNANT WOMEN AT THE UNIVERSITY COLLEGE HOSPITAL, IBADAN

INTRODUCTION

Few studies have examined cytopaenia among HIV positive pregnant women.

OBJECTIVES

To assess burden of cytopaenia among HIV positive pregnant women.

METHODOLOGY

This cross-sectional study of women on HAART ≤6months, defined anemia as hematocrit <33%, leucopenia as total white blood cell count <3,000 cells/mm3 and thrombocytopenia as absolute platelet count <100,000 cells/mm3. Univariate and bivariate analyses were performed.

RESULTS

Over 8 years, of 1,197 women, the mean age was 29.02(±5.4) years and mean gestational age 25.9(±8.1) weeks. Prevalence of anaemia was 76.8%, leucopaenia 6.9% and thrombocytopenia 4.7%. The mean haematocrit was 28.5%(±4.5); median white blood count 5,500/mm3 ; median platelet count 200,000/mm3 and median CD4 323 cells/mm3. Mean haematocrit was highest (29.7%±5.3) in women in the first trimester but lowest (28.4% ±4.6) in women in second trimester (p=0.04). Compared with earlier trimesters, women in the third trimester had higher median white blood count (5,600 cells/mm3), higher neutrophil (61.0% ±11.2) but lower lymphocytes (28.3%± 9.2) (p=0.18; 0.00, 0.00). Median absolute platelet count was highest (206,000 cells/mm3) in the first trimester but lowest (195,000 cells/mm3) in third trimester (0.04). Women with lower CD4 had higher prevalence of cytopaenias.

CONCLUSION

Cytopaenias are not uncommon in this population especially with lower CD4.

Prognostic markers in HIV mono-and co-infected individuals: A study from Karachi-Pakistan

BACKGROUND

Multiple infections are the most common problem among HIV infected individuals. The prognostic impact of these co infections in HIV-population in resource-limited countries like Pakistan has not been fully elucidated. The aim of this study was to assess CD4 and hemoglobin (Hb) levels in patients with HIV mono infection and HIV co-infection with Hepatitis C (HCV), Hepatitis B (HBV) and Mycobacterium tuberculosis (MTB).

METHODS

A total of 207 HIV positive patients were assessed for CD4 cells count and hemoglobin levels after confirmation of HIV by rapid tests as well as PCR. CD4 counts were performed via flow cytometry whereas hemoglobin levels were performed by Sysmex K-4500 auto-analyzer.

RESULTS

Out of 207 patients, 22 patients were found to be HIV mono-infected, while 185 patients were HIV positive along with co-infections of MTB or HCV or HBV. We found significant positive correlation between HB levels and CD4 count across the studied group (r=0.30 in HIV mono-infected group, r=0.23 in HIV co-infected group, p<0.05) at baseline. However, majority of the low hemoglobin levels (<8g/dl) and low CD4 count (<200cells/ul) cases were observed particularly in HIV/TB co-infections.

CONCLUSION

This study documents the prognostic value of hemoglobin assessment in HIV patients. The results indicate that decreasing Hb levels correlate with decreasing CD4 counts. It is emphasizing that Hb measurement may be used as an inexpensive surrogate marker as compared to CD4 analysis for disease progression in HIV patients. In addition, low Hb levels may also indicate presence of under lying co-infections, particularly, with M. tuberculosis (MTB).

Prevalence of anaemia among HIV patients in rural China during the HAART era

The prevalence of anaemia among HIV patients receiving highly active antiretroviral therapy (HAART) in China has not been extensively studied. The purpose of this study was to estimate the prevalence of anaemia among HIV patients receiving HAART in China. This cross-sectional study was conducted based on data in routine record registers. Factors associated with anaemia were evaluated by logistic regression model. Among the 8632 HIV patients in this analysis, the overall prevalence of anaemia was 39.2%, and the prevalence of mild, moderate, and severe anaemia were 27.2%, 10.8%, and 1.2%, respectively. Anaemia was more prevalence among male, older, little time taken HAART and lower CD4 cell count. Patients taken TCM had lower prevalence of anaemia. The prevalence of anaemia among the HIV patients receiving HAART was high in this study. HIV patients with anaemia who are older and have CD4 cells count lower than 200 cells/mL require more attention. Traditional Chinese medicine may be a potential method to lower the frequency of anaemia.

Haematological manifestations of human immune deficiency virus infection

Early in the human immunodeficiency virus (HIV) epidemic, infected patients presented to medical attention with striking abnormalities in each of the major blood cell lineages. The reasons for these derangements remain complex and multifactorial. HIV infects multipotent haematopoietic progenitor cells and establish latent cellular reservoirs, disturbs the bone marrow microenvironment and also causes immune dysregulation. These events lead to cytokine imbalances and disruption of other factors required for normal haematopoiesis. Activation of the reticulo-endothelial system can also result in increased blood cell destruction. The deleterious effects of medications, including first and second generation anti-retroviral agents, on haematopoiesis were well documented in the early years of HIV care; in the current era of HIV-care, the advent of newer and less toxic anti-retroviral drugs have had a more beneficial impact on haematopoiesis. Due to impaired regulation of the immune system and potential side effects of one or more anti-retroviral agents, there is also an increase in coagulation abnormalities such as thromboembolism, and less frequently, acquired disorders of coagulation including thrombotic thrombocytopenic purpura, immune thrombocytopenic purpura and acquired inhibitors of coagulation. In this article we review the epidemiology and aetiology of select non-oncological haematological disorders commonly seen in people living with HIV-acquired immune deficiency syndrome.

Concurrent Anemia and Elevated C-Reactive Protein Predicts HIV Clinical Treatment Failure, Including Tuberculosis, After Antiretroviral Therapy Initiation

BACKGROUND

Anemia is a known risk factor for clinical failure following antiretroviral therapy (ART). Notably, anemia and inflammation are interrelated, and recent studies have associated elevated C-reactive protein (CRP), an inflammation marker, with adverse human immunodeficiency virus (HIV) treatment outcomes, yet their joint effect is not known. The objective of this study was to assess prevalence and risk factors of anemia in HIV infection and to determine whether anemia and elevated CRP jointly predict clinical failure post-ART.

METHODS

A case-cohort study (N = 470 [236 cases, 234 controls]) was nested within a multinational randomized trial of ART efficacy (Prospective Evaluation of Antiretrovirals in Resource Limited Settings [PEARLS]). Cases were incident World Health Organization stage 3, 4, or death by 96 weeks of ART treatment (clinical failure). Multivariable logistic regression was used to determine risk factors for pre-ART (baseline) anemia (females: hemoglobin <12.0 g/dL; males: hemoglobin <13.0 g/dL). Association of anemia as well as concurrent baseline anemia and inflammation (CRP ≥ 10 mg/L) with clinical failure were assessed using multivariable Cox models.

RESULTS

Baseline anemia prevalence was 51% with 15% prevalence of concurrent anemia and inflammation. In analysis of clinical failure, multivariate-adjusted hazard ratios were 6.41 (95% confidence interval [CI], 2.82-14.57) for concurrent anemia and inflammation, 0.77 (95% CI, .37-1.58) for anemia without inflammation, and 0.45 (95% CI, .11-1.80) for inflammation without anemia compared to those without anemia and inflammation.

CONCLUSIONS

ART-naive, HIV-infected individuals with concurrent anemia and inflammation are at particularly high risk of failing treatment, and understanding the pathogenesis could lead to new interventions. Reducing inflammation and anemia will likely improve HIV disease outcomes. Alternatively, concurrent anemia and inflammation could represent individuals with occult opportunistic infections in need of additional screening.

HIV symptom burden and anemia among HIV-positive individuals: cross-sectional results of a community-based positive living with HIV (POLH) study in Nepal

Background

Previous research has reported high rates of anemia in people living with HIV/AIDS (PLWHA) in hospital or tertiary care settings. The objective of this community-based study was to measure the prevalence of anemia and describe the risk factors, with a specific emphasis on HIV symptom burden, in PLWHA in the Kathmandu Valley, Nepal.

Methods

We conducted a cross-sectional survey of 319 PLWHA residing in the Kathmandu Valley, Nepal. We recruited participants from five non-governmental organizations in the Kathmandu Valley. Descriptive statistics and multivariable logistic regression analyses were used.

Results

Our study found a 55.8% prevalence of anemia in PLWHA in the Kathmandu Valley. The prevalence of anemia among the participants with first, second, third, and fourth quartiles of HIV symptom burden was 44.8%, 49.3%, 60.3%, and 69.6%, respectively. Compared to the participants with lowest level of HIV symptom burden, the participants with highest level of HIV symptom burden were more likely to have anemia (adjusted odds ratio = 2.14; 95% confidence interval = 1.07 to 4.30).

Conclusion

Due to a high prevalence of anemia in a community-based sample of PLWHA, HIV patients should be counseled on their risk of developing anemia and encouraged to seek timely care for HIV symptoms.

Prevalence and correlates of cytopenias in HIV-infected adults initiating highly active antiretroviral therapy in Uganda

Background

Cytopenias are the most common HIV-associated hematological abnormality. Cytopenias have been associated with several factors including sex, race/ethnicity, geographical location and comorbidities such as tuberculosis, hepatitis B infection, fever and oral candidiasis. Cytopenias become more prevalent as HIV progresses and are often fatal. Data from resource-limited settings about the prevalence and correlates of cytopenia are limited. Therefore we conducted this cross-sectional study to assess the prevalence and correlates of cytopenia among adult AIDS patients at initiation of HAART in Uganda.

Methods

400 HIV-infected subjects who were HAART-naïve or on HAART for ≤ 6 months were enrolled into the Multivitamins, HAART and HIV/AIDS Trial. Anemia was defined according to WHO guidelines as any hemoglobin concentration < 12 g/dl for non-pregnant females and < 13 g/dl for males. Leucopenia and thrombocytopenia were defined using study site laboratory reference ranges for lack of generally accepted definitions for these 2 cell lines as leucopenia if white blood cell count < 2.75 × 10⁹ cells/litre and thrombocytopenia if platelets < 125 × 10⁹ cells/litre for females and < 156 × 10⁹ cells/litre for males. Univariate and bivariate analyses were done to describe the patient population and log-binomial regression was used to quantify the correlates of cytopenia.

Results

Sixty five percent of the 400 subjects had at least one form of cytopenia. Anemia occurred in 47.8%, leucopenia in 24.3%, thrombocytopenia in 8.3%, bicytopenia in 21.9% and only 2 had a pancytopenia. Cytopenia was more prevalent in females (prevalence ratio [PR]:1.33, 95% confidence interval [CI]:1.12-1.59); CD4 count category 50 to <200 (PR: 0.75, 95% CI: 0.64 -0.88) and CD4 count category 200 to <350 (PR: 0.74, 95% CI: 0.59 - 0.92) compared to CD4 count category <50; normal BMI (PR: 0.82, 95% CI:0.68-1.00) and overweight BMI (PR: 0.64, 95% CI:0.50- 0.82) compared to underweight BMI and those with a history or presence of oral candidiasis.

Conclusions

Cytopenias are a frequent complication in HIV-infected adults at initiation of HAART in Uganda. The presence of any cytopenia was associated with female sex, decreasing CD4 count and decreasing body mass index. Prospective studies in resource-limited settings on the trend in HIV-related cytopenias are needed.

Anemia in a cohort of HIV-infected Hispanics: prevalence, associated factors and impact on one-year mortality

BACKGROUND

Anemia occurs frequently in HIV-infected patients and has been associated with an increased risk of death in this population. For Hispanic subjects, information describing this blood disorder during HIV is scarce. Therefore, the present study examined data from a cohort of HIV-positive Hispanics to determine the prevalence of anemia, identify its associated factors, and evaluate its relationship with one-year mortality.

METHODS

This study included 1,486 patients who enrolled between January, 2000 and December, 2010 in an HIV-cohort in Bayamón, Puerto Rico. Data were collected through personal interviews and medical record abstractions. To determine the factors independently associated with anemia, a multivariable logistic regression model was used. Kaplan-Meier and Cox proportional hazards models were also performed to estimate survival time and to predict death risk.

RESULTS

The prevalence of anemia at enrollment was 41.5%. Factors independently associated with increased odds of anemia were: unemployment (OR = 2.02; 95% CI 1.45-2.79), CD4 count <200 cells/μL (OR = 2.66; 95% CI 1.94-3.66), HIV viral load ≥100,000 copies/mL (OR = 1.94; 95% CI 1.36-2.78), white blood cell count <4,000 cells/μL (OR = 2.42; 95% CI 1.78-3.28) and having clinical AIDS (OR = 2.39; 95% CI 1.39-4.09). Overweight (OR = 0.43; 95% CI 0.32-0.59) and obese (OR = 0.44; 95% CI 0.29-0.67) BMI's were independently associated with reduced odds of anemia. Survival differed significantly by anemia status (log-rank test: p < 0.001). One-year mortality estimates were: 30.8%, 23.3%, 8.4% and 2.5%, for patients with severe, moderate, mild and no anemia, respectively. Having anemia at baseline was independently associated with an increased one-year mortality risk (severe anemia: HR = 9.06; 95% CI: 4.16-19.72; moderate anemia: HR = 6.51; 95% CI: 3.25-13.06; mild anemia: HR = 2.53; 95% CI: 1.35-4.74).

CONCLUSIONS

A high prevalence of anemia at enrollment was observed in this cohort of HIV-infected Hispanics. Unemployment and several adverse prognostic features of HIV infection were independently associated with this blood disorder. Anemia resulted to be the strongest predictor of one-year mortality, evidencing a dose-response effect. Further investigations are needed to evaluate whether recovering from anemia is associated with longer survival, and to identify the types of anemia affecting this particular group of HIV patients.

Predictive value of anemia for tuberculosis in HIV-infected patients in Sub-Saharan Africa: an indication for routine microbiological investigation using new rapid assays

BACKGROUND

The relationship between anemia and undiagnosed tuberculosis (TB) in patients living with HIV in sub-Saharan Africa is incompletely defined. We assessed the prevalence of TB among those with HIV-related anemia and evaluated new means of rapid TB diagnosis.

METHODS

Blood hemoglobin levels were measured in unselected antiretroviral treatment-naive patients in Cape Town, South Africa, and anemia was classified according to World Health Organization criteria. All patients were screened for TB by testing paired sputum samples using liquid culture (reference standard), fluorescence microscopy, and Xpert MTB/RIF. Urine samples were tested for lipoarabinomannan (LAM) using the Determine TB-LAM diagnostic assay.

RESULTS

Of 602 adults screened, 485 had complete results. Normal hemoglobin levels were found in 44.5% (n = 216) of patients, and mild, moderate, or severe anemia were present in 24.9% (n = 121), 25.4% (n = 123) and 5.2% (n = 25) of patients, respectively. Culture-confirmed pulmonary TB was diagnosed in 8.8% (19/216) of those without anemia compared with 16.5% (20/121), 26.0% (32/123), and 40.0% (10/25) among those with mild, moderate, or severe anemia, respectively (P < 0.001). Anemia was a strong independent predictor of TB. The sensitivities of diagnostic assays were much higher among those with moderate/severe anemia compared with those with no/mild anemia using sputum microscopy (42.9% vs 15.4%), urine LAM (54.8% vs 0%), sputum microscopy plus urine LAM (71.4% vs 15.4%), and sputum Xpert (73.8% vs 41.0%) (P < 0.01 for all).

CONCLUSIONS

A very high prevalence of undiagnosed TB was found in patients with moderate or severe anemia. Such patients should be prioritized for routine microbiological investigation using rapid diagnostic assays.

Prevalence and predictors of anaemia in patients with HIV infection at the initiation of combined antiretroviral therapy in Xinjiang, China

Summary

We retrospectively analysed routinely collected baseline data of 2252 patients with HIV infection registered in the National Free Antiretroviral Treatment Program in Xinjiang province, China, from 2006 to 2011 to estimate the prevalence and predictors of anaemia at the initiation of combined antiretroviral therapy. Anaemia was diagnosed using the criteria set forth by the World Health Organisation, and univariate and multivariate logistic regression analyses were performed to determine its predictors. The prevalences of mild, moderate, and severe anaemia at the initiation of combined antiretroviral therapy were 19.2%, 17.1%, and 2.6%, respectively. Overall, 38.9% of the patients were anaemic at the initiation of combined antiretroviral therapy. The multivariate logistic regression analysis indicated that Uyghur ethnicity, female gender, lower CD4 count, lower body mass index value, self-reported tuberculosis infection, and oral candidiasis were associated with a higher prevalence of anaemia, whereas higher serum alanine aminotransferase level was associated with a lower prevalence of anaemia. The results suggest that the overall prevalence of anaemia at the initiation of combined antiretroviral therapy in patients with HIV infection is high in Xinjiang, China, but severe anaemia is uncommon. Patients in China should be routinely checked for anaemia prior to combined antiretroviral therapy initiation, and healthcare providers should carefully select the appropriate first-line combined antiretroviral therapy regimens for anaemic patients.

Determination of hematological and immunological parameters among HIV positive patients taking highly active antiretroviral treatment and treatment naïve in the antiretroviral therapy clinic of Gondar University Hospital, Gondar, Northwest Ethiopia: a comparative cross-sectional study

Background

Anemia, leucopenia and thrombocytopenia are the commonest hematological abnormalities resulting from human immunodeficiency virus infection. The use of antiretroviral drugs could positively or negatively affect these disorders. Thus a specific diagnosis and a determination of hematological and immunological parameters are required for initiating and monitoring early treatment to avert disease progression. Therefore, this study aimed to compare hematological and immunological parameters in HIV positive patients taking antiretroviral therapy and those treatment naïve patients in Gondar University Hospital.

Methods

A comparative cross-sectional study was conducted on a total of 290 HIV patients from February to May 2012 in Gondar University Hospital. Study subjects were divided in to two groups: 145 HIV positive treatment naïve and 145 on HAART. Data of socio demographic characteristics and clinical conditions of the study subjects was collected using structured pretested questionnaire at their follow up date. Hematological and immunological parameters were collected and processed by cell Dyne 1800 and BD FACS count respectively. The variables compared here were Hematological parameters (Total and differential WBC, RBC, Hgb, HCT, MCV, MCH, MCHC, RDW, PLT, and MPV) and CD4 count. In order to compare means independent sample T-test was conducted using SPSS version 20 statistical software. P- Value < 0.05 was considered as significant.

Result

Prevalence of anemia, leucopenia, thrombocytopenia, neutropenia and lymphopenia were 11.7%, 35.9%, 4.1%, 28.3% and 2.1% in patients on HAART and 29.7%, 16.6%, 9%, 14.5% and 2.1% in HAART naïve patients respectively. There was a significant difference in total WBC, RBC, Hgb, MCV, MCH, MCHC, MPV and CD4 counts between patients on HAART and HAART naïve patients.

Conclusion

Prevalence of anemia was high in HAART naïve patients while leucopenia and neutropenia prevalence was higher in patients on HAART and their prevalence increased as the CD4 count decreased. HIV Patients should be investigated for hematological and immunological changes following with appropriate therapeutic interventions.

Prevalence of anemia among adults with newly diagnosed HIV/AIDS in China

BACKGROUND

The prevalence of anemia among antiretroviral-naïve HIV-infected patients in China has not been well characterized. We conducted a cross-sectional study to estimate the prevalence of anemia among Chinese adults with newly diagnosed HIV/AIDS.

METHODS

One thousand nine hundred and forty-eight newly diagnosed HIV-infected patients in China were selected during 2009 and 2010. Serum samples obtained from each individual were collected to measure hemoglobin levels. Demographics and medical histories were recorded. Factors associated with the presence of anemia were analysed by logistic regression.

RESULTS

Among the 1948 patients, 75.8% were male. Median age was 40 years (range: 18-80 years). The overall prevalence of anemia among HIV-infected patients was 51.9% (51.5% among men, 53.2% among women). The prevalences of mild anemia, of moderate anemia, of severe anemia were 32.4%, 17.0%, and 2.5%, respectively. The prevalence of anemia was higher among ethnic minority patients than among the Han patients (70.9% versus 45.9%). The prevalence of anemia increased with increasing age (49.6%, 53.5% and 60.1% among patients who were 18-39, 40-59, and ≥ 60 years of age respectively) and with decreasing CD4 count (14.0%, 22.4%, 50.7%, and 74.6% among patients with CD4 count of ≥ 350, 200-349, 50-199, and <50 cells/mm(3) respectively). The logistic regression analysis showed that older age, lower CD4 count and minority ethnicity were significantly associated with an increased risk of anemia.

CONCLUSIONS

Anemia is highly prevalent among Chinese adults with newly diagnosed HIV/AIDS, but severe anemia is less prevalent in this population. Older age, lower CD4 count and minority ethnicity are associated with an increased risk of anemia.

Burden and Determinants of Severe Anemia among HIV-Infected Adults: Results from a Large Urban HIV Program in Tanzania, East Africa

BACKGROUND AND METHODS

This cross-sectional study aimed at determining the prevalence and risk factors for severe anemia, severe microcytic anemia, and severe normocytic anemia among HIV-infected individuals aged >15 years. Univariate and multivariate analyses were performed to identify the risk factors for anemia.

RESULTS

Data from 40 408 patients were analyzed, showing an overall prevalence of 22% for severe anemia. The risk of developing severe anemia increased by 49% among patients with a body mass index of <18.5 kg/m(2), by approximately 2-fold among patients with the World Health Organization (WHO) stage III, and by 3-fold among patients with WHO stage IV illness. Severe normocytic anemia was uniquely increased among patients aged ≥50 years, among those with chronic diarrhea and Kaposi's sarcoma, and those taking cotrimoxazole.

CONCLUSION

There was a high prevalence of severe anemia among adults infected with HIV. Focused identification of anemia should be based on the hemoglobin and mean corpuscular volume measurements.

The burden of anaemia and associated factors in HIV positive Nigerian women

BACKGROUND

Anaemia is the most common complication of pregnancy and a predictor of poor maternal and foetal outcomes. HIV infection is now recognized as one of the major contributors to anaemia in pregnancy. It is therefore important to determine the burden and risk factors of anaemia in maternal HIV infection in others to plan effective prevention strategies as well as optimize management outcomes.

OBJECTIVE

To determine the prevalence and risk factors of anaemia in pregnant HIV positive Nigerians.

METHODS

The prevalence and possible risk factors of anaemia were investigated in HIV positive pregnant Nigerian women at a large HIV treatment clinic in southwestern Nigeria using a cross-sectional design between January 2006 and December 2011.

RESULTS

Nine hundred and eighty-five (42.5 %) women of 2,318 HIV positive pregnant women seen during the period were anaemic by WHO standard defined by haemoglobin <11 g/dl. Majority were of mild to moderate severity (97.9 %). Short inter birth interval (p = 0.002), presence of opportunistic infections (OIs), (p = 0.001), use of zidovudine containing regimen (p = 0.0005) and CD4 cell count <200 cells/mm(3) (p = 0.001) were found to be independently associated with anaemia in HIV positive pregnant women after controlling for confounding variables.

CONCLUSION

Anaemia was found to be high at 42.5 % among the HIV positive women studied and was found to be independently associated with short inter birth interval, presence of OIs, advanced HIV disease and use of zidovudine containing HAART regimen.

Anemia and pregnancy: a link to maternal chronic diseases

Anemia is a global public health problem. It has serious short- and long-term consequences during pregnancy and beyond. The anemic condition is often worsened by the presence of other chronic diseases such as malaria, tuberculosis, HIV, and diabetes. Untreated anemia also leads to increased morbidity and mortality from these chronic conditions as well. It is surprising that despite these chronic conditions (such as malaria, tuberculosis, and HIV) often being preventable, they still pose a real threat to public health. This article aims to review the current understanding of the pathophysiology, risks, prevention, and treatment of anemia in the light of these chronic conditions.

Body mass index in individuals with HIV infection and factors associated with thinness and overweight/obesity

A cross-sectional study was conducted using body mass index (BMI) to estimate the prevalence of thinness and overweight/obesity and associated factors in 2,018 individuals with HIV/AIDS attending health services referral centers. The dependent variable was classified as thinness, overweight/obesity and eutrophy. Multinomial logistic regression analyses were performed considering eutrophy as the reference level. The prevalence of thinness was 8.8% and of overweight/obesity, 32.1%. The variables associated with thinness were anemia and CD4 cell count < 200mm³. The variables associated with risk of overweight/obesity were age > 40 years and diabetes, and the variables identified as decreasing likelihood of overweight/obesity were having no long-term partner, smoking, presence of an opportunistic disease, anemia, and albumin levels < 3.5mg/dL. The main nutritional problem observed in this population was overweight and obesity, which were much more prevalent than thinness. Older individuals with diabetes should be targeted for nutritional interventions and lifestyle changes.

Prevalence, severity, and related factors of anemia in HIV/AIDS patients

OBJECTIVE

The prevalence of anemia in HIV infected patients has not been well characterized in Iran. This study aimed to describe the prevalence of anemia and related factors in HIV positive patients.

MATERIALS AND METHODS

In a cross-sectional study, anemia prevalence and risk factors of 212 HIV positive patients were assessed, at the behavioral disease consulting center in Isfahan. The relationship between anemia, demographic variables, and clinical histories were analyzed. Mild to moderate anemia was defined as hemoglobin 8-13 g/dL for men and 8-12 g/dL for women. Severe anemia was defined as hemoglobin, 8 g/dL.

RESULTS

A total of 212 HIV positive patients with a mean±SD age of 36.1 ± 9.1 years were assessed. We found that hemoglobin levels were between 4.7 and 16.5 gr/dL. In this study, the overall prevalence of anemia was 71%, with the majority of patients having mild to moderate anemia. Mild to moderate anemia and severe anemia occurred in 67% and 4% of patients, respectively. The mean absolute CD4 count was 348 ± 267.8 cells/cubic mm. Sixty one of 212 patients were at late stage of HIV infection (males=51 and female=10). Of the 212 HIV positive patients enrolled, 17 (8%) had a positive history of tuberculosis. We found a strong association between anemia and death.

CONCLUSION

Normocytic anemia with decreased reticulocyte count was the most common type of anemia in overall. Prevalence of anemia in this study is relatively higher than other similar studies. Such a high prevalence of anemia needs close monitoring of patients on a zidovudine-based regimen. Better screening for anemia and infectious diseases, and modified harm reduction strategy (HRS) for injection drug users are primary needs in HIV seropositive patients.

Anemia in adults with tuberculosis is associated with HIV and anthropometric status in Dar es Salaam, Tanzania

SETTING

Tuberculosis (TB) infected adults attending out-patient TB clinics in Dar es Salaam, Tanzania.

OBJECTIVE

To examine the association of anemia with human immunodeficiency virus (HIV) co-infection, indicators of socio-economic status (SES) and anthropometric status in TB-infected adults.

DESIGN

Cross-sectional data collection during screening for a clinical trial.

RESULTS

Overall, 750 females and 1693 males participated in this study, of whom respectively 49% and 24% were co-infected with HIV-1. Hemoglobin levels were significantly lower in females than in males and in HIV-positive than in HIV-negative participants. HIV co-infection in this antiretroviral-naïve population was also associated with severe anemia (hemoglobin < 85 g/l) in both women (prevalence ratio [PR] = 2.07, 95%CI 1.65-2.59) and men (PR 3.45, 95%CI 2.66-4.47). Although severe anemia was negatively associated with indicators of SES, especially in males, adjustment for SES indicators only marginally changed its association with HIV co-infection. In both sexes, anemia was inversely associated with anthropometric status, independently of HIV infection and SES.

CONCLUSION

Among TB-infected adults, anemia is strongly associated with HIV co-infection and anthropometric status, independently of SES indicators. As anemia is a risk factor for morbidity and mortality in both infections, the management of anemia in TB-HIV co-infected patients warrants special attention.

Treatment for anemia in people with AIDS

BACKGROUND

Anemia is common in persons with HIV infection and is associated with poor prognosis. There is a need to assess the effects of anemia treatments, and to determine whether these interventions are beneficial.

OBJECTIVES

To determine the efficacy and safety of treatments for anemia in people with HIV infection and AIDS.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 10, 2010), MEDLINE (1980-November 25, 2010), EMBASE (1980-November 25, 2010), LlLACS (1982 to November 25, 2010), Africa Index Medicus (up to November 9, 2010), ISI Web of Knowledge (2005 to October 9, 2010), Scirus (October 9, 2010) reference lists of relevant articles. We asked the Cochrane HIV/AIDS and Pregnancy and Childbirth Groups to check their Specialised Registers. We also checked the reference lists of all trials identified by the above methods.

SELECTION CRITERIA

Randomized trials assessing the effects of treatments for anemia in people diagnosed with HIV infection. There were no age restrictions.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed relevant studies for inclusion. Data extraction and quality assessment of relevant studies was performed by two authors and checked by the other two authors.

MAIN RESULTS

Six trials with a high risk of bias, including 537 patients, met the inclusion criteria. These trials only covered recombinant Human erythropoietin alfa (rHuEPO). Two of them including adult and paediatric participants (84 participants and 4 events) comparing rHuEPO to placebo did not reduce the risk of mortality with a follow up to 12 weeks (pooled RR 0.56, 95% confidence interval (CI) 0.08 to 4.05, I(2) = 0%). Any trials that compared rHuEPO to placebo did not show any benefit on hematological values response, number of patients transfused, or number of packed red cell transfused. Two trial compared the effects of two rHuEPO dosing regimens on hemoglobin value and quality of life, but the effects are unclear. Three RCT reported high risk of attrition bias; therefore, were not included in a meta-analysis.

AUTHORS' CONCLUSIONS

This updated Cochrane review provides evidence that rHuEPO compared with placebo does not reduce mortality, does not reduce transfusion requirements, did not increase hemoglobin levels, and did not improve quality of life in HIV-infected patients with anemia. The results are based on six RCTs with high risk of bias. Therefore prescription of this intervention for treating anemia in patients with AIDS is not justified, unless new evidence from a large high quality trial alters this conclusion.

Haemoglobin and anaemia in the SMART study

BACKGROUND

Data from randomized trials on the development of anaemia after interruption of therapy are not well-described.

METHODS

A total of 2,248 patients from the SMART study were included. We used Cox proportional hazards models to investigate development of new (≤12 mg/dl for females and ≤14 mg/dl for males) or worsening (≤8 mg/dl if anaemic at randomization) anaemia and Poisson regression analyses to explore the relationship between anaemia and the development of AIDS, death or non-AIDS events.

RESULTS

Overall, 759 patients developed new or worsening anaemia: 420/1,106 (38.0%) in the drug conservation (DC) arm and 339/1127 (30.1%) in the viral suppression (VS) arm (P<0.0001). At 4 months after randomization, patients in the DC arm had a significantly increased risk of developing new or worsening anaemia (adjusted relative hazard 1.56, 95% CI 1.28-1.89). Currently anaemic patients had an increased incidence of AIDS (adjusted incidence rate ratio [IRR] 2.31, 95% CI 1.34-3.98), death (adjusted IRR 2.19, 95% CI 1.23-3.87) and non-AIDS events (adjusted IRR 2.98, 95% CI 2.01-4.40) compared to non-anaemic patients.

CONCLUSIONS

Patients who interrupted combination antiretroviral therapy had a higher risk of new or worsening anaemia. Anaemic patients had a higher incidence of AIDS, non-AIDS defining events or deaths, possibly due to deteriorating health and subclinical disease.

Anaemia in Ugandan preschool-aged children: the relative contribution of intestinal parasites and malaria

Anaemia is a severe public health issue among African preschool-aged children, yet little effective progress has been made towards its amelioration, in part due to difficulties in unravelling its complex, multifactorial aetiology. To determine the current anaemia situation and assess the relative contribution of malaria, intestinal schistosomiasis and infection with soil-transmitted helminths, two separate cross-sectional epidemiological surveys were carried out in Uganda including 573 and 455 preschool-aged children (≤6 years) living along the shores of Lake Albert and on the islands in Lake Victoria, respectively. Anaemia was found to be a severe public health problem in Lake Albert, affecting 68·9% of children (ninety-five percent confidence intervals (95% CI) 64·9-72·7%), a statistically significant higher prevalence relative to the 27·3% detected in Lake Victoria (95% CI: 23·3-31·7%). After multivariate analysis (controlling for sex and age of the child), the only factor found to be significantly associated with increased odds of anaemia in both lake systems was malaria (Lake Albert, odds ratio (OR)=2·1, 95% CI: 1·4-3·2; Lake Victoria, OR=1·9, 95% CI: 1·2-2·9). Thus intervention strategies primarily focusing on very young children and combating malaria appear to represent the most appropriate use of human and financial resources for the prevention of anaemia in this age group and area. Looking to the future, these activities could be further emphasised within the National Child Health Days(PLUS) agenda.

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.

Short communication: Severe symptomatic hyperlactatemia among HIV type 1-infected adults on antiretroviral therapy in Côte d'Ivoire

Stavudine is no longer recommended for use in first-line antiretroviral therapy (ART), but it remains in high demand worldwide because it is affordable. We report the clinical presentation and incidence of severe hyperlactatemia (SL) in HIV-infected adults who initiated ART between April 2005 and May 2009 in Côte d'Ivoire, West Africa. In a prospective cohort study at the HIV care center affiliated with the National Centre for Blood Transfusion, we used standardized forms to record baseline and follow-up data. We measured serum lactate levels for all adults on ART who showed signs of hyperlactatemia. SL was defined as serum lactate >2.5 mmol/liter. Overall, 806 adults initiated ART. Among the 591 patients (73%) on stavudine-containing regimens, 394 were women (67%); the median pre-ART CD4 count was 150/mm3 and the median body mass index was 20.9 kg/m2. These patients were followed for a median of 28 months. We detected SL only among patients taking stavudine. The incidence of SL was 0.55/100 person-years (PY) (95% CI 0.47-0.63) overall and 0.85/100 PY among women (95% CI 0.75-0.95). Among the eight patients with SL, 100% lost >9% of body weight before diagnosis, 100% had serum lactate >4 mmol/liter (range 4.2-12.1), 50% had pre-ART BMI >25 kg/m2, and three patients died (38%), accounting for 6.4% of deaths among patients taking stavudine. As long as HIV clinicians continue to use stavudine in sub-Saharan Africa, they should watch out for acute unexplained weight loss in patients taking ART, particularly among women and patients with high pre-ART BMI.