Management of anemia of chronic disease in patients with the human immunodeficiency virus

Weight changes among antiretroviral therapy-naïve people living with human immunodeficiency virus in Lagos, Nigeria

Introduction

The advent of antiretroviral therapy (ART) has converted HIV from a death sentence to a chronic disease. Subsequently, weight changes, including the development of overweight/obesity have been observed following ART initiation. Our study aimed to assess weight changes and the associated factors among ART-naïve people living with HIV (PLWH) following enrollment in an ART clinic in Lagos, Nigeria.

Methodology

Data were collected among adult ART-naïve PLWH enrolled at a large ART clinic over 10 consecutive years. Weight changes within the first 6 months of enrolment were determined by actual and relative weight differences expressed in kilogram (kg) and percentages (%) respectively. Weight changes were classified as neutral weight change, weight gain and weight loss. Logistic regressions were applied to identify variables associated with weight changes with statistical significance set at p < 0.05.

Results

A total of 6,737 study participants had their weights available at both visits. Most study participants were females (67.2%), employed (83.3%), married (57.1%), and had normal range body mass index (53.5%). Almost half (49.5%) of the study participants gained weight, while 25.5% recorded weight loss. Baseline variables, including viral load ≥ 100,000 copies/ml, CD4 counts ≤ 200 cells/μL, WHO clinical stages 3 and 4, male gender, presence of anaemia and tuberculosis were associated with weight gain after ART initiation.

Conclusion

Considering the high proportion of participants that gained weight, this study highlights the importance of monitoring weight changes following ART initiation. This will facilitate the identification of PLWH at greater risk for cardiometabolic diseases and other weight-related health outcomes.

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.

Risk factors for HIV-associated neurocognitive disorders (HAND) in sub-Saharan Africa: the case of Yaoundé-Cameroon

BACKGROUND

The prevalence of HIV-associated neurocognitive disorders (HAND), especially HIV-associated dementia (HAD) is influenced by several risk factors. The prevalence as well as risk factors for HAD are not well known in sub-Saharan Africa (SSA). We have shown that the International HIV Dementia Scale (IHDS) is a useful screening tool for HAND in Yaoundé [Njamnshi AK, Djientcheu VdP, Fonsah JY, Yepnjio FN, Njamnshi DM, Muna WFT. The IHDS is a useful screening tool for HAD/Cognitive Impairment in HIV-infected adults in Yaoundé-Cameroon. Journal of Acquired Immune Deficiency Syndromes 2008;49(4):393-397], but no study in Cameroon has yet investigated the risk factors for HAND or HAD.

PATIENTS AND METHODS

A cross-sectional study was conducted in Yaoundé, the capital of Cameroon from September to December 2006. One hundred and eighty-five HIV-positive subjects were included. Diagnosis of HAND was done using the IHDS with a score < or = 10 considered as abnormal. Age, sex, level of education, IV drug use, body mass index (BMI), CDC clinical stage, CD4 counts, hemoglobin levels, administration of highly active antiretroviral therapy (HAART) and type of regimen used, were considered in univariate analysis, with level of significance set at P < or = 0.05. A binary logistic regression was used to determine independent risk factors.

RESULTS

The following factors were independent predictors of HAND: advanced clinical stage (OR=7.43, P=0.001), low CD4 count especially CD4 < or = 200 cells/microL (OR=4.88, P=0.045) and low hemoglobin concentration (OR=1.16, P=0.048).

CONCLUSION

This first study of the risk factors for HAND in Yaoundé-Cameroon shows findings similar to those described in other studies. These results call for rapid action by policy makers to include HAND prevention strategies such as providing early universal access to HAART based on these risk factors, in the management of HIV patients at risk of HAND in resource-limited settings of SSA like ours.

Newer strategies for anemia prevention in hemodialysis

Anemia prevention for hemodialysis relies primarily on supplemental erythropoietin (EPO) and intravenous iron (IV-iron). The doses of EPO utilized are somewhat higher than normal endogenous rates of EPO production in healthy subjects, and the amount of IV-iron used to boost red blood cell (RBC) production may be greater than the amounts used for erythropoiesis. EPO and IV-iron might be used more efficiently if two fundamental problems were solved in the management of dialysis patients: better vitamin C status, and avoidance of chronic inflammation. The low levels of plasma vitamin C commonly observed in dialysis patients restrict mobilization of stored iron from the reticuloendothelial system (RES), and inflammation has a very similar effect. The impact of low vitamin C levels and concurrent inflammation causes a large amount of iron to be stored, with relatively inefficient utilization for erythropoiesis. Vitamin C intake for dialysis patients is often restricted because of avoidance of vitamin C-rich foods, and because of concerns about oxalosis. Inflammation is a chronic feature of renal disease, which is compounded by infections from use of catheters. Research strategies to improve vitamin C status and to decrease inflammation would lead to better utilization of iron and EPO, and could have parallel benefits for the long-term health of patients on hemodialysis.

Treatment for anemia in people with AIDS

BACKGROUND

Anemia is a common clinical disease 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 3, 2005), MEDLINE (1980-July 2005), EMBASE (1980-July 2005), LlLACS (1982 to July 2005), reference lists of relevant articles and contact with authors. See Cochrane HIV/AIDS Group search strategy.

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

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

MAIN RESULTS

We included four trials, but focused on the results based on three trials with acceptable attrition rate. None of the trials reported data on death. The two trials that compared recombinant human erythropoietin (rHuEPO) to placebo did not show any benefit on hematological values response, number of patients transfused, or number of packed red cell transfused. One trial compared the effects of two rHuEPO dosing regimens on hemoglobin value and quality of life, but the effects are unclear.

AUTHORS' CONCLUSIONS

There is a lack of reliable evidence on interventions for treating anemia in patients with HIV infection. This Cochrane review has found some evidence that rHuEPO reduces transfusion requirements, increases hemoglobin levels, and improves quality of life in HIV-infected patients with anemia. However, this is based on evidence from randomized trials with weak or poor methodological quality. There is a need for randomized trials of high methodological quality to evaluate the effect of interventions on anemia in persons infected with human immunodeficiency virus.

Enrichment of activated monocytes in cerebrospinal fluid during antiretroviral therapy

OBJECTIVES

In HIV infection, activated monocytes are enriched in blood and in the perivascular area of the brain, especially in patients with HIV-associated dementia. Although clinical brain disease is uncommon during combination antiretroviral therapy (ART), autopsy series indicate that HIV-infected brain tissue can contain high numbers of monocytes/macrophages despite ART.

DESIGN

We assessed activated monocytes in blood and cerebrospinal fluid (CSF) in 76 living patients on and off ART. Plasma lipids were measured because they have been associated with monocyte activation and ART.

METHODS

A novel quantitative six-color flow cytometric approach was used to identify monocytes in blood and CSF and to evaluate monocyte activation status.

RESULTS

The mean percentage and number of activated CD16 monocytes in CSF was highest in individuals on combination ART, especially in those receiving protease inhibitors (PI). CSF viral load was also associated with higher monocyte activation in CSF. The mean calculated low density lipoprotein (LDL)-, oxidized LDL- and total cholesterol in plasma were highest in patients receiving PI.

CONCLUSIONS

Activated monocytes are enriched in the CSF of persons living with HIV-1 and receiving ART. This finding is consistent with previously reported autopsy series. The mechanisms and long-term clinical consequences of persistent monocyte activation require further study.