Iron status is an important cause of anemia in HIV-infected Tanzanian women but is not related to accelerated HIV disease progression

Dietary Iron Intake and HIV-Related Outcomes Among Adults Initiating Antiretroviral Therapy in Tanzania

OBJECTIVE

Anemia is highly prevalent among people living with HIV (PLWHIV) and is often due to iron deficiency. This study evaluated the relationship of dietary iron intake levels and sources with mortality and clinical outcomes among adults initiating HAART.

DESIGN

We conducted a secondary analysis of a multivitamin supplementation trial among 2293 PLWHIV initiating HAART in Dar es Salaam, Tanzania.

METHODS

Dietary iron intake was assessed with a food frequency questionnaire at HAART initiation, and participants followed until death or censoring. Total, animal-, and plant-sourced iron were categorized into quartiles. Intake of food groups was categorized into 0-1, 2-3, and ≥4 servings/wk. Cox proportional hazards models estimated hazard ratios for mortality and incident clinical outcomes.

RESULTS

There were 175 deaths (8%). Red meat intake was associated with a lower risk of all-cause mortality (HR: 0.54; 95% CI: 0.35 to 0.83), AIDS-related mortality (HR: 0.49; 95% CI: 0.28 to 0.85), and severe anemia (HR: 0.57; 95% CI: 0.35 to 0.91), when intake ≥4 servings/wk, compared with 0-1 servings/wk. Legume intake was a lower risk of associated with all-cause mortality (HR: 0.49; 95% CI: 0.31 to 0.77) and AIDS-related mortality (HR: 0.37; 95% CI: 0.23 to 0.61), when intake ≥4 servings/wk, compared with 0-1 servings/wk. Although total dietary iron and overall plant-sourced iron intake were not associated with the risk of mortality or HIV-related outcomes, the highest quartile of animal-sourced iron intake was associated with a lower risk of all-cause mortality (HR: 0.56; 95% CI: 0.35 to 0.90) and a lower risk of AIDS-related mortality (HR: 0.50; 95% CI: 0.30 to 0.90), compared with the lowest quartile.

CONCLUSION

Intake of iron-rich food groups may be associated with a lower risk of mortality and critical HIV-related outcomes among adults initiating HAART.

TRIAL REGISTRATION

The parent trial was registered at Clinicaltrials.gov . Identifier: NCT00383669.

Maternal anemia and preterm birth among women living with HIV in the United States

BACKGROUND

Women living with HIV (WLHIV) have a higher prevalence of anemia than women without HIV, possibly related to the effects of HIV and antiretroviral medications.

OBJECTIVES

To estimate the prevalence of anemia in the third trimester of pregnancy and the effect of anemia on preterm births in WLHIV in the longitudinal, US-based Pediatric HIV/AIDS Cohort Study (PHACS).

METHODS

During the third trimester, we obtained up to three 24-hour dietary recalls to estimate daily intakes of nutrients and measured serum concentrations of iron, vitamin B6, vitamin B12, zinc, folate, ferritin, total iron-binding capacity (TIBC), and high sensitivity C-reactive protein. Third trimester anemia was defined as hemoglobin < 11 g/d and iron-deficiency anemia (IDA) was defined as low ferritin, high TIBC, and low transferrin saturation. A preterm birth was defined as birth at < 37 completed weeks of gestation, regardless of etiology. We fit separate modified Poisson regression models for each outcome (anemia, preterm birth) and each main exposure, adjusted for confounders, and report adjusted prevalence ratios (aPR) and 95% CIs.

RESULTS

Of the 267 WLHIV, 50% were anemic in the third trimester, of whom 43.5% (n = 57/131) had IDA. On average, women with anemia were younger, were more likely to be black, started antiretroviral medications in the second trimester, had a low CD4 count (<200 cells/mm3) early in pregnancy, and were less likely to meet recommended intakes for iron, B6, and folate. The prevalence of anemia was greater in WLHIV with a low CD4 count (aPR = 1.65; 95% CI: 1.20-2.27) and high HIV viral load (>10,000 copies/mL; aPR = 1.38; 95% CI: 1.02-1.87). In total, 16% of women delivered preterm. Anemia was associated with a 2-fold (aPR = 2.04; 95% CI: 1.12-3.71) higher prevalence of preterm births.

CONCLUSIONS

Anemia is common in pregnant WLHIV, highlighting the need to address the underlying factors and clinical outcomes of anemia in this population.

Anemia, Iron Status, and HIV: A Systematic Review of the Evidence

People living with HIV (PLWHIV) are at high risk of anemia due to inadequate iron intake, HIV and opportunistic infections, and inflammation, and as a side effect of antiretroviral therapy. Though iron supplementation can reduce iron deficiency anemia (IDA) in the general population, its role in anemia and in the health of PLWHIV is unclear due to concerns that iron supplementation may increase HIV replication and risk of opportunistic infections. We systematically reviewed the evidence on indicators of iron status, iron intake, and clinical outcomes among adults and children with HIV. The evidence suggests that anemia is associated with an increased risk of all-cause mortality and incident tuberculosis among HIV-infected individuals, regardless of anemia type, and the magnitude of the risk is greater with more severe anemia. High serum ferritin is associated with adverse clinical outcomes, although it is unclear if this is due to high iron or inflammation from disease progression. One large observational study found an increased risk of all-cause mortality among HIV-infected adults if they received iron supplementation. Published randomized controlled trials of iron supplementation among PLWHIV tend to have small sample sizes and have been inconclusive in terms of effectiveness and safety. Large randomized trials exploring approaches to safely and effectively provide iron supplementation to PLWHIV are warranted.

Transferrin receptor 1 levels at the cell surface influence the susceptibility of newborn piglets to PEDV infection

Porcine epidemic diarrhea virus (PEDV) mainly infects the intestinal epithelial cells of newborn piglets causing acute, severe atrophic enteritis. The underlying mechanisms of PEDV infection and the reasons why newborn piglets are more susceptible than older pigs remain incompletely understood. Iron deficiency is common in newborn piglets. Here we found that high levels of transferrin receptor 1 (TfR1) distributed in the apical tissue of the intestinal villi of newborns, and intracellular iron levels influence the susceptibility of newborn piglets to PEDV. We show that iron deficiency induced by deferoxamine (DFO, an iron chelating agent) promotes PEDV infection while iron accumulation induced by ferric ammonium citrate (FAC, an iron supplement) impairs PEDV infection in vitro and in vivo. Besides, PEDV infection was inhibited by occluding TfR1 with antibodies or decreasing TfR1 expression. Additionally, PEDV infection was increased in PEDV-resistant Caco-2 and HEK 293T cells over-expressed porcine TfR1. Mechanistically, the PEDV S1 protein interacts with the extracellular region of TfR1 during PEDV entry, promotes TfR1 re-localization and clustering, then activates TfR1 tyrosine phosphorylation mediated by Src kinase, and heightens the internalization of TfR1, thereby promoting PEDV entry. Taken together, these data suggest that the higher expression of TfR1 in the apical tissue of the intestinal villi caused by iron deficiency, accounts for newborn piglets being acutely susceptible to PEDV.

Newborn piglets are particularly susceptible to infection by PEDV, with 80–100% dying within days of infection. The reasons for newborns’ acute susceptibility to PEDV infection have not been elucidated clearly. The primarily target of PEDV is the porcine intestinal epithelial cells. Here, we show that the high expression of TfR1 in the apical tissue of intestinal villi in newborn piglets with iron deficiency is a reason for their susceptibility to PEDV. Further, we demonstrate that iron supplementation reduces PEDV infection. This study reveals that iron plays an important role in the susceptibility of newborn piglets to PEDV and provides insights into therapies for the prevention and treatment of PEDV infections.

Impaired Hematological Status Increases the Risk of Mortality among HIV-Infected Adults Initiating Antiretroviral Therapy in Tanzania

BACKGROUND

Hematological status may predict HIV disease progression and mortality among adults initiating highly active antiretroviral therapy (HAART).

OBJECTIVES

We aimed to examine the relation of anemia and iron status at HAART initiation with survival and morbidity outcomes.

METHODS

We conducted a case-cohort study of 570 HIV-infected adults initiating HAART who were enrolled in a trial of multivitamins in Tanzania. Hemoglobin, serum ferritin, and hepcidin concentrations were assessed at HAART initiation and participants were followed up monthly. We adjusted serum ferritin for inflammation using a regression correction method to characterize hematological status. Cox proportional hazards models were used to estimate HRs for mortality and incident clinical outcomes.

RESULTS

We found an 83% prevalence of anemia, 15% prevalence of iron deficiency anemia, and 66% prevalence of anemia of chronic diseases (ACD). The prevalence of elevated iron was 33% and 19% had iron deficiency (ID). After multivariate adjustment, severe anemia (HR: 2.57; 95% CI: 1.49, 4.45) and ACD (HR: 4.71; 95% CI: 2.91, 7.62) were associated with increased risk of mortality as compared with nonanemic participants. In addition, both ID (HR: 2.65; 95% CI: 1.08, 7.78) and elevated iron (HR: 2.83; 95% CI: 2.10, 3.82) were associated with increased risk of mortality as compared with normal iron concentrations. Severe anemia and elevated iron concentrations were associated with incident wasting and >10% weight loss (P values <0.05).

CONCLUSIONS

Anemia and both ID and elevated iron were associated with increased mortality among HIV-infected adults initiating HAART. Safety and efficacy studies including anemia etiology, timing of HAART initiation, and dose of iron supplementation among HIV patients appear warranted.This trial was registered at clinicaltrials.gov as NCT00383669.

Multiple Concurrent Illnesses Associated with Anemia in HIV-Infected and HIV-Exposed Uninfected Children Aged 6-59 Months, Hospitalized in Mozambique

Anemia is an increasingly recognized problem in sub-Saharan Africa. To determine the magnitude, severity, and associated factors of anemia among hospitalized children aged 6–59 months, HIV-infected and HIV-exposed uninfected children (a child born to a known HIV-infected mother) with a documented fever or history of fever within the prior 24 hours of hospital admission (N = 413) were included in this analysis. Of 413 children enrolled, 364 (88%) were anemic, with 53% classified as mild anemia (hemoglobin [Hb] 7–9.9 g/dL). The most common diagnoses associated with hospital admission included acute respiratory illness (51%), malnutrition (47%), gastroenteritis/diarrhea (25%), malaria (17%), and bacteremia (13%). A diagnosis of malaria was associated with a decrease in Hb by 1.54 g/dL (P < 0.001). In HIV-infected patients, malaria was associated with a similar decrease in Hb (1.47 g/dL), whereas a dual diagnosis of bacteremia and malaria was associated with a decrease in Hb of 4.12 g/dL (P < 0.001). No difference was seen in Hb for patients on antiretroviral therapy versus those who were not. A diagnosis of bacteremia had a roughly 4-fold increased relative odds of death during hospitalization (adjusted odds ratio = 3.97; 95% CI: 1.61, 9.78; P = 0.003). The etiology of anemia in high-burden malaria, HIV, tuberculosis, and poor nutrition countries is multifactorial, and multiple etiologies may be contributing to one’s anemia at any given time. Algorithms used by physician and nonphysician clinicians in Mozambique should incorporate integrated and non–disease specific approaches to pediatric anemia management and should include improved access to blood culture.

Severe anaemia complicating HIV in Malawi; Multiple co-existing aetiologies are associated with high mortality

BACKGROUND

Severe anaemia is a major cause of morbidity and mortality in HIV-infected adults living in resource-limited countries. Comprehensive data on the aetiology are lacking but are needed to improve outcomes.

METHODS

HIV-infected adults with severe (haemoglobin ≤70g/l) or very severe anaemia (haemoglobin ≤ 50 g/l) were recruited at Queen Elizabeth Central Hospital, Blantyre, Malawi. Fifteen potential causes and associations with anaemia severity and mortality were explored.

RESULTS

199 patients were enrolled: 42.2% had very severe anaemia and 45.7% were on ART. More than two potential causes for anaemia were present in 94% of the patients including iron deficiency (55.3%), underweight (BMI<20: 49.7%), TB infection (41.2%) and unsuppressed HIV infection (viral load >1000 copies/ml) (73.9%). EBV/CMV co-infection (16.5%) was associated with very severe anaemia (OR 2.8 95% CI 1.1-6.9). Overall mortality was high (53%; 100/199) with a median time to death of 17.5 days (IQR 6-55) days. Death was associated with folate deficiency (HR 2.2; 95% CI 1.2-3.8) and end stage renal disease (HR 3.2; 95% CI 1.6-6.2).

CONCLUSION

Mortality among severely anaemic HIV-infected adults is strikingly high. Clinicians should be aware of the urgent need for a multifactorial approach including starting or optimising HIV treatment, considering TB treatment, nutritional support and optimising renal management.

Anemia, Iron Deficiency, and Iron Supplementation in Relation to Mortality among HIV-Infected Patients Receiving Highly Active Antiretroviral Therapy in Tanzania

Anemia in HIV-infected patients improves with highly active antiretroviral therapy (HAART); however, it may still be associated with mortality among patients receiving treatment. We examined the associations of anemia severity and iron deficiency anemia (IDA) at HAART initiation and during monthly prospective follow-up with mortality among 40,657 adult HIV-infected patients receiving HAART in Dar es Salaam, Tanzania. Proportional hazards models were used to examine the associations of anemia severity and IDA at HAART initiation and during follow-up with mortality. A total of 6,261 deaths were reported. Anemia severity at HAART initiation and during follow-up was associated with an increasing risk of mortality (trend tests P < 0.001). There was significantly higher mortality risk associated with IDA at HAART initiation and during follow-up versus no anemia or iron deficiency (both P < 0.001). These associations differed significantly by gender, body mass index, and iron supplement use (all interaction test P < 0.001). The magnitude of association was stronger among men. Mortality risk with severe anemia was 13 times greater versus no anemia among obese patients, whereas it was only two times greater among underweight patients. Higher mortality risk was observed among iron supplement users, irrespective of anemia severity. Anemia and IDA were significantly associated with a higher mortality risk in patients receiving HAART. Iron supplementation indicated an increased mortality risk, and its role in HIV infections should be examined in future studies. Given the low cost of assessing anemia, it can be used frequently to identify high-risk patients in resource-limited settings.

Crossing the Iron Gate: Why and How Transferrin Receptors Mediate Viral Entry

Because both the host and pathogen require iron, the innate immune response carefully orchestrates control over iron metabolism to limit its availability during times of infection. Nutritional iron deficiency can impair host immunity, while iron overload can cause oxidative stress to propagate harmful viral mutations. An emerging enigma is that many viruses use the primary gatekeeper of iron metabolism, the transferrin receptor, as a means to enter cells. Why and how this iron gate is a viral target for infection are the focus of this review.

Effect of baseline micronutrient and inflammation status on CD4 recovery post-cART initiation in the multinational PEARLS trial

BACKGROUND & AIMS

Nutritional deficiency and inflammation may impact CD4+ T cell recovery during combination antiretroviral therapy (cART), particularly in resource-limited settings where malnutrition is prevalent. The aim of this study was to investigate the relationship of micronutrient and inflammation biomarkers to CD4 recovery after cART initiation.

METHODS

We conducted a secondary analysis of a random sub-cohort sample (n = 270) from a multinational randomized trial of cART regimen efficacy among 1571 cART-naïve adults. We measured pre-cART serum levels of micronutrients (Vitamin A, B₆, B₁₂, D, total carotenoids, selenium, and iron) and inflammation (C-reactive protein, soluble CD14 (sCD14), IFNγ, TNFα, Interleukin-6, and C-X-C motif chemokine 10 (CXCL10/IP10), EndoCab (IgM)) biomarkers. Biomarker status (i.e. micronutrient deficiency vs. sufficiency and elevated vs. low inflammation) was defined using established cutoffs or quartiles. Mixed-effects linear regression models were used to determine the association of baseline (pre-cART) concentrations of individual biomarkers with CD4 recovery through 96 weeks post-cART initiation.

RESULTS

In models adjusting for time-dependent viral load and baseline CD4 count, age, sex, body mass index, country, treatment regimen, anemia and hypoalbuminemia status, pre-cART vitamin D deficiency was associated with lower CD4 recovery (-14.9 cells/mm³, 95% CI: -27.9, -1.8) compared to sufficiency. In contrast, baseline selenium deficiency (20.8 cells/mm³, 95% CI: 3.3, 38.3), vitamin A deficiency (35.9 cells/mm³, 95% CI: 17.6, 54.3) and high sCD14 (23.4 cells/mm³, 95% CI: 8.9, 37.8) were associated with higher CD4 recovery compared to sufficient/low inflammation status.

CONCLUSIONS

In summary, baseline vitamin D deficiency was associated with diminished CD4 recovery after cART initiation; impaired CD4 recovery may contribute to the poor clinical outcomes recently observed in individuals with vitamin D deficiency. Vitamin A, selenium and sCD14 were associated with CD4 recovery but future studies are needed to further explore these relationships.

Anemia in people on second line antiretroviral treatment in Lilongwe, Malawi: a cross-sectional study

Background

Anemia is common among people living with HIV infection and is frequently associated with poor quality of life and poor prognosis. It has been well described in antiretroviral naïve individuals and those on non-nucleoside reverse transcriptase inhibitor-based first line antiretroviral therapy (ART) regimens. However there is limited information on anemia for ART experienced individuals on protease inhibitor-based second line ART regimens in resource limited settings. Our objective was to describe the prevalence and risk factors of anemia in this ART experienced population in Malawi.

Methods

We conducted a cross-sectional study using routine facility data at two HIV clinics in Lilongwe, Malawi. The analysis included individuals receiving protease inhibitor-based second line ART. Clinical and laboratory data were collected at routine clinic visits. We used descriptive statistics, two-sample t-tests and multivariate logistic regression for data analysis.

Results

Three hundred seventy-seven records were included in this analysis (37% male, median age 41 years, median CD4 count 415 cells/μL). The prevalence of anemia was 125/377 (33.2%) − mild, moderate and severe anemia was 17.5%, 13.8%, and 1.9% respectively. Female participants had a higher prevalence than male participants (43.6% vs. 15.7%, p < 0.001). In multivariate logistic regression, female sex (adjusted odds ratio (aOR) 5.3; 95% CI 2.9–9.5) and a CD4 count <200 cell/ul (aOR 3.1; 95%CI 1.6–6.0) were associated with increased risk of having anemia while a BMI ≥30 kg/m2 (aOR 0.8; 95% CI 0.6–1.0) and being on ART for more than 10 years (aOR 0.4; 95% CI 0.2–0.9) were associated with reduced risk of anemia. Being on a zidovudine- containing ART regimen was not associated with anemia.

Conclusion

Anemia is common in people on second line ART in Lilongwe, Malawi. Screening for anemia in this population would be a useful strategy; especially for female patients, those who are underweight and have a low CD4 cell counts.

Prevalence and risk factors of micronutrient deficiencies pre- and post-antiretroviral therapy (ART) among a diverse multicountry cohort of HIV-infected adults

BACKGROUND & AIMS

HIV-infected adults have increased risk of several individual micronutrient deficiencies. However, the prevalence and risk factors of concurrent and multiple micronutrient deficiencies and whether micronutrient concentrations change after antiretroviral therapy (ART) initiation have not been well described. The objective of this study was to determine the prevalence and risk factors of individual, concurrent and multiple micronutrient deficiencies among ART-naïve HIV-infected adults from nine countries and assess change in micronutrient status 48 weeks post-ART initiation.

METHODS

A random sub-cohort (n = 270) stratified by country was selected from the multinational PEARLS clinical trial (n = 1571 ART-naïve, HIV-infected adults). We measured serum concentrations of vitamins A, D (25-hydroxyvitamin), E, carotenoids and selenium pre-ART and 48 weeks post-ART initiation, and measured vitamins B6, B12, ferritin and soluble transferrin receptor at baseline only. Prevalence of single micronutrient deficiencies, concurrent (2 coexisting) or conditional (a deficiency in one micronutrient given a deficiency in another) and multiple (≥3) were determined using defined serum concentration cutoffs. We assessed mean changes in micronutrient concentrations from pre-ART to week 48 post-ART initiation using multivariable random effects models.

RESULTS

Of 270 participants, 13.9%, 29.2%, 24.5% and 32.4% had 0, 1, 2 and multiple deficiencies, respectively. Pre-ART prevalence was the highest for single deficiencies of selenium (53.2%), vitamin D (42.4%), and B6 (37.3%) with 12.1% having concurrent deficiencies of all three micronutrients. Deficiency prevalence varied widely by country. 48 weeks post-ART initiation, mean vitamin A concentration increased (p < 0.001) corresponding to a 9% decrease in deficiency. Mean concentrations also increased for other micronutrients assessed 48 weeks post-ART (p < 0.001) but with minimal change in deficiency status.

CONCLUSIONS

Single and multiple micronutrient deficiencies are common among HIV-infected adults pre-ART initiation but vary between countries. Importantly, despite increases in micronutrient concentrations, prevalence of individual deficiencies remains largely unchanged after 48 weeks on ART. Our results suggest that ART alone is not sufficient to improve micronutrient deficiency.

Anaemia in HIV-infected pregnant women receiving triple antiretroviral combination therapy for prevention of mother-to-child transmission: a secondary analysis of the Kisumu breastfeeding study (KiBS)

OBJECTIVE

The prevalence of anaemia during pregnancy is estimated to be 35-75% in sub-Saharan Africa and is associated with an increased risk of maternal mortality. We evaluated the frequency and factors associated with anaemia in HIV-infected women undergoing antiretroviral (ARV) therapy for prevention of mother-to-child transmission (PMTCT) enrolled in The Kisumu Breastfeeding Study 2003-2009.

METHODS

Maternal haematological parameters were monitored from 32 to 34 weeks of gestation to 2 years post-delivery among 522 enrolled women. Clinical and laboratory assessments for causes of anaemia were performed, and appropriate management was initiated. Anaemia was graded using the National Institutes of Health Division of AIDS 1994 Adult Toxicity Tables. Data were analysed using SAS software, v 9.2. The Wilcoxon two-sample rank test was used to compare groups. A logistic regression model was fitted to describe the trend in anaemia over time.

RESULTS

At enrolment, the prevalence of any grade anaemia (Hb < 9.4 g/dl) was 61.8%, but fell during ARV therapy, reaching a nadir (7.4%) by 6 months post-partum. A total of 41 women (8%) developed severe anaemia (Hb < 7 g/dl) during follow-up; 2 (4.9%) were hospitalised for blood transfusion, whereas 3 (7.3%) were transfused while hospitalised (for delivery). The greatest proportion of severe anaemia events occurred around delivery (48.8%; n = 20). Anaemia (Hb ≥ 7 and < 9.4 g/dl) at enrolment was associated with severe anaemia at delivery (OR 5.87; 95% CI: 4.48, 7.68, P < 0.01). Few cases of severe anaemia coincided with clinical malaria (24.4%; n = 10) and helminth (7.3%; n = 3) infections.

CONCLUSION

Resolution of anaemia among most participants during study follow-up was likely related to receipt of ARV therapy. Efforts should be geared towards addressing common causes of anaemia in HIV-infected pregnant women, prioritising initiation of ARV therapy and management of peripartum blood loss.

Practical Management of HIV-Associated Anemia in Resource-Limited Settings: Prospective Observational Evaluation of a New Mozambican Guideline

Mozambique's updated guideline for management of HIV-associated anemia prompts clinicians to consider opportunistic conditions, adverse drug reactions, and untreated immunosuppression in addition to iron deficiency, intestinal helminthes, and malaria. We prospectively evaluated this guideline in rural Zambézia Province. Likely cause(s) of anemia were determined through prespecified history, physical examination, and laboratory testing. Diagnoses were "etiologic" if laboratory confirmed (sputum microscopy, blood culture, Plasmodium falciparum malaria rapid test) or "syndromic" if not. To assess hemoglobin response, we used serial point-of-care measurements. We studied 324 ambulatory, anemic (hemoglobin <10 g/dl) HIV-infected adults. Study clinicians treated nearly all [315 (97.2%)] for suspected iron deficiency and/or helminthes; 56 (17.3%) had laboratory-confirmed malaria. Other assigned diagnoses included tuberculosis [30 (9.3%)], adverse drug reactions [26 (8.0%)], and bacteremia [13 (4.1%)]. Etiologic diagnosis was achieved in 79 (24.4%). Of 169 (52.2%) subjects who improved (hemoglobin increase of ≥1 g/dl without indications for hospitalization), only 65 (38.5%) received conventional management (iron supplementation, deworming, and/or antimalarials) alone. Thirty (9.3%) died and/or were hospitalized, and 125 (38.6%) were lost to follow-up. Multivariable linear and logistic regression models described better hemoglobin responses and/or outcomes in subjects with higher CD4(+) T-lymphocyte counts, pre-enrollment antiretroviral therapy and/or co-trimoxazole prophylaxis, discontinuation of zidovudine for suspected adverse reaction, and smear-positive tuberculosis. Adverse outcomes were associated with fever, low body mass index, bacteremia, esophageal candidiasis, and low or missing CD4(+) T cell counts. In this severely resource-limited setting, successful anemia management often required interventions other than conventional presumptive treatment, thus supporting Mozambique's guideline revision.

Determinants of Anemia Among Human Immunodeficiency Virus-Positive Adults at Care and Treatment Clinics in Dar es Salaam, Tanzania

Anemia is often a comorbidity of human immunodeficiency virus (HIV) infection. Many cross-sectional studies have been conducted on anemia and HIV, but few, if any, have addressed incidence of anemia prospectively. A longitudinal analysis was conducted in 48,068 nonpregnant HIV-infected adults in Dar es Salaam, Tanzania, seen at Management and Development for Health-U.S. President's Emergency Plan for AIDS Relief HIV care and treatment programs between 2004 and 2011. Almost 56% (N = 27,184) of study participants had anemia (hemoglobin < 11 g/dL) at the time of enrollment at the clinic. Female gender, low body mass index (BMI), low CD4 T-cell count, high levels of liver enzyme alanine aminotransferase, antiretroviral treatment (ART) regimens, and concurrent tuberculosis treatment were all independently significantly associated with an increased risk of anemia. Low BMI and low CD4 T-cell count were independently significantly associated with an increased risk for iron deficiency anemia (IDA). Higher BMI status and ART use were associated with recovery from anemia. Anemia, including IDA, is a comorbidity that is associated with other adverse consequences (e.g., low BMI and CD4 T-cell count) among individuals with HIV infection, including those on ART. Interventions to prevent anemia and its complications need to be examined in the context of future studies.

Plasma Micronutrient Concentrations Are Altered by Antiretroviral Therapy and Lipid-Based Nutrient Supplements in Lactating HIV-Infected Malawian Women

BACKGROUND

Little is known about the influence of antiretroviral therapy with or without micronutrient supplementation on the micronutrient concentrations of HIV-infected lactating women in resource-constrained settings.

OBJECTIVE

We examined associations of highly active antiretroviral therapy (HAART) and lipid-based nutrient supplements (LNS) with concentrations of selected micronutrients in HIV-infected Malawian women at 24 wk postpartum.

METHODS

Plasma micronutrient concentrations were measured in a subsample (n = 690) of Breastfeeding, Antiretrovirals, and Nutrition (BAN) study participants who were randomly assigned at delivery to receive HAART, LNS, HAART+LNS, or no HAART/no LNS (control). HAART consisted of protease inhibitor-based triple therapy. LNS (140 g/d) met energy and micronutrient requirements of lactation. Multivariable linear regression tested the association of HAART and LNS, plus their interaction, with micronutrient concentrations, controlling for season, baseline viral load, and baseline CD4 count.

RESULTS

We found significant HAART by LNS interactions for folate (P = 0.051), vitamin B-12 (P < 0.001), and transferrin receptors (TfRs) (P = 0.085). HAART was associated with lower folate (with LNS: -27%, P < 0.001; without LNS: -12%, P = 0.040) and higher TfR concentrations (with LNS: +14%, P = 0.004; without LNS: +28%, P < 0.001), indicating iron deficiency. LNS increased folate (with HAART: +17%, P = 0.037; without HAART: +39%, P < 0.001) and decreased TfR concentrations (with HAART only: -12%, P = 0.023). HAART was associated with lower vitamin B-12 concentrations only when LNS was present (-18%, P = 0.001), whereas LNS increased vitamin B-12 only when no HAART was present (+27%, P < 0.001). HAART, but not LNS, was associated with higher retinol-binding protein (RBP; +10%, P = 0.007). We detected no association of HAART or LNS with selenium, ferritin, or hemoglobin.

CONCLUSION

The association of HAART with lower folate, iron deficiency, and higher RBP plus the attenuation of LNS effects on folate and vitamin B-12 when combined with HAART has implications for the health of lactating HIV-infected women taking HAART in prevention of mother-to-child transmission programs. This trial was registered at clinicaltrials.gov as NCT00164736.

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-associated anemia after 96 weeks on therapy: determinants across age ranges in Uganda and Zimbabwe

Given the detrimental effects of HIV-associated anemia on morbidity, we determined factors associated with anemia after 96 weeks of antiretroviral therapy (ART) across age groups. An HIV-positive cohort (n=3,580) of children age 5-14, reproductive age adults 18-49, and older adults ≥50 from two randomized trials in Uganda and Zimbabwe were evaluated from initiation of therapy through 96 weeks. We conducted logistic and multinomial regression to evaluate common and differential determinants for anemia at 96 weeks on therapy. Prior to initiation of ART, the prevalence of anemia (age 5-11 <10.5 g/dl, 12-14 <11 g/dl, adult females <11 g/dl, adult males <12 g/dl) was 43%, which decreased to 13% at week 96 (p<0.001). Older adults had a significantly higher likelihood of anemia compared to reproductive age adults (OR 2.60, 95% CI 1.44-4.70, p=0.002). Reproductive age females had a significantly higher odds of anemia compared to men at week 96 (OR 2.56, 95% CI 1.92-3.40, p<0.001), and particularly a greater odds for microcytic anemia compared to males in the same age group (p=0.001). Other common factors associated with anemia included low body mass index (BMI) and microcytosis; greater increases in CD4 count to week 96 were protective. Thus, while ART significantly reduced the prevalence of anemia at 96 weeks, 13% of the population continued to be anemic. Specific groups, such as reproductive age females and older adults, have a greater odds of anemia and may guide clinicians to pursue further evaluation and management.

Multivitamin supplementation improves haematologic status in children born to HIV-positive women in Tanzania

Introduction

Anaemia is prevalent among children born to HIV-positive women, and it is associated with adverse effects on cognitive and motor development, growth, and increased risks of morbidity and mortality.

Objective

To examine the effect of daily multivitamin supplementation on haematologic status and mother-to-child transmission (MTCT) of HIV through breastfeeding.

Methods

A total of 2387 infants born to HIV-positive women from Dar es Salaam, Tanzania were enrolled in a randomized, double-blind, placebo-controlled trial, and provided a daily oral supplement of multivitamins (vitamin B complex, C and E) or placebo at age 6 weeks for 24 months. Among them, 2008 infants provided blood samples and had haemoglobin concentrations measured at baseline and during a follow-up period. Anaemia was defined as haemoglobin concentrations<11 g/dL and severe anaemia<8.5 g/dL.

Results

Haemoglobin concentrations among children in the treatment group were significantly higher than those in the placebo group at 12 (9.77 vs. 9.64 g/dL, p=0.03), 18 (9.76 vs. 9.57 g/dL, p=0.004), and 24 months (9.93 vs. 9.75 g/dL, p=0.02) of follow-up. Compared to those in the placebo group, children in the treatment group had a 12% lower risk of anaemia (hazard ratio (HR): 0.88; 95% CI: 0.79–0.99; p=0.03). The treatment was associated with a 28% reduced risk of severe anaemia among children born to women without anaemia (HR: 0.72; 95% CI: 0.56–0.92; p=0.008), but not among those born to women with anaemia (HR: 1.10; 95% CI: 0.79–1.54; p=0.57; p for interaction=0.007). One thousand seven hundred fifty three infants who tested HIV-negative at baseline and had HIV testing during follow-up were included in the analysis for MTCT of HIV. No association was found between multivitamin supplements and MTCT of HIV.

Conclusions

Multivitamin supplements improve haematologic status among children born to HIV-positive women. Further trials focusing on anaemia among HIV-exposed children are warranted in the context of antiretroviral therapy.

Positive association between dietary iron intake and iron status in HIV-infected children in Johannesburg, South Africa

Anemia is a common complication of pediatric HIV infection and is associated with suboptimal cognitive performance and growth failure. Routine iron supplementation is not provided to South African HIV-infected children. We hypothesized that dietary iron intake without supplementation is sufficient to protect against iron deficiency (ID) in HIV-infected children receiving highly active antiretroviral therapy. In this prospective study, the difference between dietary intakes of iron-deficient children (soluble transferrin receptor >9.4 mg/L) and iron-sufficient children after 18 months on highly active antiretroviral therapy was examined. The association between iron intake and hemoglobin (Hb) concentration was also assessed. Longitudinal data collected for 18 months from 58 HIV-infected African children were assessed by generalized estimation equations, with adjustment for demographic information, dietary intakes, growth parameters, and CD4%. After adjustment for covariates, the longitudinal association between dietary iron intake and Hb concentration remained significant. This association shows that for every 1-mg increase in iron intake per day, Hb increases by 1.1 g/L (P < .001). Mean Hb increased significantly after 18 months of follow-up (106 ± 14 to 129 ± 14 g/L, P < .01), but soluble transferrin receptor also increased (7.7 ± 2.7 to 8.9 ± 3.0 mg/L, P < .01). The incidence of ID increased from 15.2% at baseline to 37.2% after 18 months. Children with animal protein intakes greater than >20 g/d had significantly lower odds for ID at 18 months than did children with lower intakes (odds ratio, 0.40; 95% confidence interval, 0.21-0.77). Dietary iron intake was insufficient to protect against ID, pointing to a need for low-dose iron supplementation for iron-deficient HIV-infected children and interventions to increase the consumption of animal protein.

Does venesection reduce HIV viral load in patients with hereditary haemochromatosis?

It is recognized that iron overload is associated with excess mortality in HIV/AIDS, and that this may be due to iron acting as an HIV-1 transcriptional activator. In vitro evidence using iron chelators suggests that therapeutic iron depletion may be beneficial in HIV-1 infection. We describe the clinical course of a Caucasian man with hereditary haemochromatosis and HIV infection where a significant drop in HIV viral load accompanied venesection over an 18-month period in the absence of HAART. We propose that further research should be undertaken to explore the relationship between HIV viral load and serum iron markers in hereditary haemochromatosis, with a view to evaluating the therapeutic benefit of venesection on HIV viral load in this setting.

The prevalence and etiology of anemia among HIV-infected children in India

In this report, the prevalence and multifactorial etiology of anemia among Indian human immunodeficiency virus (HIV)-infected children are described. HIV-infected children aged 2-12 years were prospectively enrolled in 2007-2008. Measured parameters included serum ferritin, vitamin B(12), red-cell folate, soluble transferrin receptor, and C-reactive protein. Children received antiretroviral therapy (ART), iron and, folate supplements as per standard of care. Among 80 enrolled HIV-infected children (mean age 6.8 years), the prevalence of anemia was 52.5%. Etiology of anemia was found to be iron deficiency alone in 38.1%, anemia of inflammation alone in 38.1%, combined iron deficiency and anemia of inflammation alone in 7.1%, vitamin B(12) deficiency in 7.1%, and others in 9.5%. Median iron intake was 5.7 mg/day (recommended dietary allowance 18-26 mg/day). Compared to nonanemic children, anemic children were more likely to be underweight (weight Z-score -2.5 vs. -1.9), stunted (height Z-score -2.6 vs. -1.9), with lower CD4 counts (18% vs. 24%, p < 0.01), and higher log viral load (11.1 vs. 7.1, p < 0.01). Hemoglobin (Hb) improved significantly among those who started ART (baseline Hb 11.6 g/dl, 6-month Hb 12.2 g/dl, p = 0.03). Children taking ART combined with iron supplements experienced a larger increase in Hb compared to those receiving neither ART nor iron supplements (mean Hb change 1.5 g/dl, p < 0.01).

CONCLUSION

Anemia, particularly iron deficiency anemia and anemia of inflammation, is highly prevalent among children with HIV infection. Micronutrient supplements combined with ART improved anemia in HIV-infected children.

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.

Anemia and iron homeostasis in a cohort of HIV-infected patients in Indonesia

Background

Anemia is a common clinical finding in HIV-infected patients and iron deficiency or redistribution may contribute to the development of low hemoglobin levels. Iron overload is associated with a poor prognosis in HIV and Hepatitis C virus infections. Iron redistribution may be caused by inflammation but possibly also by hepatitis C co-infection. We examined the prevalence of anemia and its relation to mortality in a cohort of HIV patients in a setting where injecting drug use (IDU) is a main mode of HIV transmission, and measured serum ferritin and sTfR, in relation to anemia, inflammation, stage of HIV disease, ART and HCV infection.

Methods

Patient characteristics, ART history and iron parameters were recorded from adult HIV patients presenting between September 2007 and August 2009 in the referral hospital for West Java, Indonesia. Kaplan-Meier estimates and Cox's regression were used to assess factors affecting survival. Logistic regression was used to identity parameters associated with high ferritin concentrations.

Results

Anemia was found in 49.6% of 611 ART-naïve patients, with mild (Hb 10.5 - 12.99 g/dL for men; and 10.5 - 11.99 g/dL for women) anemia in 62.0%, and moderate to severe anemia (Hb < 10.5 g/dL) in 38.0%. Anemia remained an independent factor associated with death, also after adjustment for CD4 count and ART (p = 0.008). Seroprevalence of HCV did not differ in patients with (56.9%) or without anemia (59.6%). Serum ferritin concentrations were elevated, especially in patients with anemia (p = 0.07) and/or low CD4 counts (p < 0.001), and were not related to hsCRP or HCV infection. Soluble TfR concentrations were low and not related to Hb, CD4, hsCRP or ART.

Conclusion

HIV-associated anemia is common among HIV-infected patients in Indonesia and strongly related to mortality. High ferritin with low sTfR levels suggest that iron redistribution and low erythropoietic activity, rather than iron deficiency, contribute to anemia. Serum ferritin and sTfR should be used cautiously to assess iron status in patients with advanced HIV infection.

Identification of a common variant in the TFR2 gene implicated in the physiological regulation of serum iron levels

The genetic determinants of variation in iron status are actively sought, but remain incompletely understood. Meta-analysis of two genome-wide association (GWA) studies and replication in three independent cohorts was performed to identify genetic loci associated in the general population with serum levels of iron and markers of iron status, including transferrin, ferritin, soluble transferrin receptor (sTfR) and sTfR-ferritin index. We identified and replicated a novel association of a common variant in the type-2 transferrin receptor (TFR2) gene with iron levels, with effect sizes highly consistent across samples. In addition, we identified and replicated an association between the HFE locus and ferritin and confirmed previously reported associations with the TF, TMPRSS6 and HFE genes. The five replicated variants were tested for association with expression levels of the corresponding genes in a publicly available data set of human liver samples, and nominally statistically significant expression differences by genotype were observed for all genes, although only rs3811647 in the TF gene survived the Bonferroni correction for multiple testing. In addition, we measured for the first time the effects of the common variant in TMPRSS6, rs4820268, on hepcidin mRNA in peripheral blood (n = 83 individuals) and on hepcidin levels in urine (n = 529) and observed an association in the same direction, though only borderline significant. These functional findings require confirmation in further studies with larger sample sizes, but they suggest that common variants in TMPRSS6 could modify the hepcidin-iron feedback loop in clinically unaffected individuals, thus making them more susceptible to imbalances of iron homeostasis.

Role of Nutrition in HIV Infection: Review of Evidence for more Effective Programming in Resource-Limited Settings

Background

HIV infection and malnutrition negatively reinforce each other.

Objective

For program guidance, to review evidence on the relationship of HIV infection and malnutrition in adults in resource-limited settings.

Results and conclusions

Adequate nutritional status supports immunity and physical performance. Weight loss, caused by low dietary intake (loss of appetite, mouth ulcers, food insecurity), malabsorption, and altered metabolism, is common in HIV infection. Regaining weight, particularly muscle mass, requires antiretroviral therapy (ART), treatment of opportunistic infections, consumption of a balanced diet, physical activity, mitigation of side effects, and perhaps appetite stimulants and growth hormone. Correcting nutritional status becomes more difficult as infection progresses. Studies document widespread micronutrient deficiencies among HIV-infected people. However, supplement composition, patient characteristics, and treatments vary widely across intervention studies. Therefore, the World Health Organization (WHO) recommends ensuring intake of 1 Recommended Nutrient Intake (RNI) of each required micronutrient, which may require taking micronutrient supplements. Few studies have assessed the impact of food supplements. Because the mortality risk in patients receiving ART increases with lower body mass index (BMI), improving the BMI seems important. Whether this requires provision of food supplements depends on the patient's diet and food security. It appears that starting ART improves BMI and that ready-to-use fortified spreads and fortified-blended foods further increase BMI (the effect is somewhat less with fortified-blended foods). The studies are too small to assess effects on mortality. Once ART has been established and malnutrition treated, the nutritional quality of the diet remains important, also because of ART's long-term metabolic effects (dyslipidemia, insulin resistance, obesity). Food insecurity should also be addressed if it prevents adequate energy intake and reduces treatment initiation and adherence (due to the opportunity costs of obtaining treatment and mitigating side effects).

Management of HIV-infected patients with ESRD

Patients infected with human immunodeficiency virus (HIV) often progress to ESRD. In the era of highly active antiretroviral therapy, the care of these patients has become increasingly complex as survival has improved. Patients infected with HIV who also have ESRD are at risk for critical interactions between medication regimens to treat both of these conditions. Within this population, hemo- and peritoneal dialysis as well as kidney transplantation are life sustaining but present a host of obstacles related to HIV monitoring and risk of transmission, access thrombosis, infection, and rejection. Knowledge of antiretroviral regimens, drug interactions, and HIV resistance as well as the management of ESRD in the presence of HIV infection will improve the care of these unique patients.

Patterns and predictors of CD4 T-cell counts among children born to HIV-infected women in Tanzania

We assessed age-specific CD4 T-cell counts and their determinants among Tanzanian children born to HIV-infected mothers to address a major research gap. A total of 474 HIV-uninfected and 69 HIV-infected children were followed until age of 12 months. Maternal predictors were measured during pregnancy and child predictors at birth and throughout the follow up. Child CD4 T-cell counts were evaluated at the age of 3 months and subsequent 3-month intervals; they decreased linearly among HIV-infected (beta = -8 cells per week; 95% CI -12 to -4; P = 0.0003) and increased linearly among HIV-uninfected children (beta = 4 cells/week; 95% CI 2-7; P = 0.0008). Decreased child counts were predicted by low child anthropometry, maternal HIV stage > or =2, and maternal mid-upper arm circumference <27 cm among HIV-infected children; and by weight-for-height <-2 z-score, maternal HIV stage > or =2, maternal erythrocyte sedimentation rate <81 mm/h and maternal haemoglobin <8.5 g/dl among HIV-uninfected children. The maternal and child predictors described may serve as intervention targets among HIV-exposed children.

Mortality in HIV infection is independently predicted by host iron status and SLC11A1 and HP genotypes, with new evidence of a gene-nutrient interaction

BACKGROUND

Iron-related genes and iron status may independently contribute to variable HIV outcomes. The nature of the biologically plausible gene-nutrient interaction remains unknown.

OBJECTIVES

The objectives were to investigate whether iron-related genotypes and clinically abnormal iron status independently predict mortality in HIV and whether a gene-nutrient interaction exists.

DESIGN

Baseline plasma, DNA, and clinical data were obtained from 1362 HIV-seropositive Gambian adults followed for 11.5 y to ascertain all-cause mortality. Iron status was estimated on the basis of plasma iron, soluble transferrin receptor (sTfR), ferritin, transferrin, transferrin index, and log(sTfR/ferritin). One haptoglobin (HP) and 5 SLC11A1 (NRAMP1) polymorphisms were genotyped.

RESULTS

SLC11A1-SLC3 and CAAA polymorphisms were the best independent genetic predictors of mortality [adjusted mortality rate ratio (95% CI)]: SLC3:G/C = 0.59 (95% CI: 0.45, 0.85), CAAA:del/ins = 1.51 (95% CI: 1.10, 2.07). In an adjusted model that included all polymorphisms, SLC1:199/199, SLC1:other/other, SLC6a:A/A, and CAAA:del/ins were associated with significantly greater mortality, whereas Hp 2-1 and SLC3:G/C were protective. In unadjusted analyses, all biomarker concentrations were significantly associated with mortality. In an extension of previous findings, both low and elevated iron states were associated with mortality, but the nature of the risk was variable, with linear, inversely linear, and U-shaped associations depending on the biomarker. Mortality was significantly lower in HIV-2 than in HIV-1 infection in the presence of abnormal (low or elevated) iron status. A gene-iron interaction was detected (likelihood-ratio test P = 0.018); however, subject numbers restricted category-specific interpretation.

CONCLUSIONS

Iron-related genes, iron status, and their interaction predict mortality in HIV. These findings illustrate the complexity and uncertainty surrounding best practice for managing abnormal iron status and anemia during HIV infection and in regions with a high risk of infection.

Iron, folate and vitamin B12 parameters in HIV-1 infected patients with anaemia in southern Brazil

We conducted a study to determine the role of iron, folate and vitamin B12 in HIV-infected patients with anaemia attending a tertiary-care hospital in southern Brazil. Low serum folate levels were found in 14 (41%) HIV-infected patients; parameters of iron deficiency such as low transferring saturation index and ferritin in 10 (30%); and combined folate and iron deficiency in five (14%). Vitamin B12 deficiency was found in only two (6%) patients who presented with mean corpuscular volumes within the normal range. Our study has shown that folate and iron deficiency were frequently detected in HIV-infected patients at our institution, and should be considered in the differential diagnosis of anaemia in all HIV-infected patients independent of their HIV stage of progression.

Iron supplementation for reducing morbidity and mortality in children with HIV

BACKGROUND

The most prevalent haematologic disturbance associated with HIV in children (apart from CD4 lymphocytopenia) is anaemia. Anaemia associated with HIV arises from multiple mechanisms, including the direct inhibitory effect of HIV on red cell precursors, other locally prevalent and/or opportunistic infections, micronutrient deficiency, anaemia of chronic disease, and as a consequence of medicines given for HIV and/or other concurrent illnesses. Iron deficiency is the most common cause of nutritional anaemia globally. There is significant geographical overlap of areas of the world where iron deficiency anaemia (IDA) and paediatric HIV are distributed. Given the high prevalence of IDA, it is likely that many HIV-infected children also are iron deficient. The contribution of iron deficiency to anaemia in HIV-infected children has been described but is incompletely understood. Currently, iron supplementation for anaemic infants and children is routinely practiced without any obvious effect in most developing countries, which bear most of the burden of global paediatric HIV infections.Because iron deficiency and IDA are common in HIV-infected children in high-prevalence areas and because there are concerns about possible deleterious effects of iron, this review aims to assess the evidence for iron supplementation for reducing morbidity and mortality in HIV-infected children.

OBJECTIVES

To determine whether iron supplementation improves clinical, immunologic, and virologic outcomes in children infected with HIV SEARCH STRATEGY: We used the comprehensive search strategy developed specifically by the Cochrane HIV/AIDS Review Group to identify HIV/AIDS randomised controlled trials, and searched the following electronic databases: MEDLINE (searched November 2007); Embase (searched December 2007); and CENTRAL (December 2007). This search was supplemented with a search of AIDSearch (searched December 2007) and NLM Gateway (searched December 2007) to identify relevant conference abstracts, as well as a search of the reference lists of all eligible articles. The search was not limited by language or publication status.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of iron supplementation in any form and dose in HIV-infected children aged 12 years and younger.

DATA COLLECTION AND ANALYSIS

We independently screened the results of the search to select potentially relevant studies and to retrieve the full articles. We independently applied the inclusion criteria to the potentially relevant studies. No studies were identified that fulfilled the selection criteria.

MAIN RESULTS

No RCTs of iron supplementation in HIV-infected children were found.

IMPLICATIONS FOR CLINICAL PRACTICE

The current clinical practice of iron supplementation in HIV-infected children is based on weak evidence comprising observational studies and expert opinions.

IMPLICATIONS FOR RESEARCH

High-quality RCTs of iron supplementation are urgently required, especially in areas with significant overlap of high prevalence of HIV, iron deficiency anaemia, and malaria. Policy makers should prioritise funding for these trials.

Elevated iron stores are associated with HIV disease severity and mortality among postpartum women in Zimbabwe

OBJECTIVES

The relationship between Fe status and HIV infection is complex and poorly understood. While anaemia is a major complication of HIV infection, higher Fe stores may be associated with disease progression. There is limited and conflicting data available from Africa.

DESIGN

Cross-sectional and prospective cohort study. SETTING, SUBJECTS AND METHODS: We examined the association between postpartum Fe status (Hb, serum ferritin (SF) and transferrin receptor (TfR)) and viral load (VL) and HIV-related mortality in 643 HIV-positive Zimbabwean women over a period of 12 months.

RESULTS

In non-anaemic women a log10 increase in SF was associated with a 2.3-fold increase in VL (P = 0.019); this association was absent in anaemic women. In prospective analyses, a log10 increase in SF was associated with a 4-fold increase in mortality by 12 months (P = 0.002). Hb was negatively associated with VL (P = 0.001) and mortality (P = 0.047). The adverse associations between SF and both VL and mortality were found at SF concentrations > 45 microg/l (P < 0.05). Controlling for alpha1 acid glycoprotein, a marker of inflammation, attenuated the association between both SF and VL and mortality, but these remained significant.

CONCLUSIONS

These results are consistent with the hypothesis that high Fe stores have adverse consequences in HIV infection. If adverse consequences are real, our data suggest that they occur at SF concentrations exceeding those consistent with adequate Fe nutriture.

Micronutrient supplementation has limited effects on intestinal infectious disease and mortality in a Zambian population of mixed HIV status: a cluster randomized trial

BACKGROUND

Diarrheal disease remains a major contributor to morbidity and mortality in Africa, but host defense against intestinal infection is poorly understood and may depend on nutritional status.

OBJECTIVE

To test the hypothesis that defense against intestinal infection depends on micronutrient status, we undertook a randomized controlled trial of multiple micronutrient supplementation in a population where there is borderline micronutrient deficiency.

DESIGN

All consenting adults (> or =18 y) living in a carefully defined sector of Misisi, Lusaka, Zambia, were included in a cluster-randomized (by household), double-blind, placebo-controlled trial with a midpoint crossover. There were no exclusion criteria. Participants were given a daily tablet containing 15 micronutrients at just above the recommended nutrient intake or placebo. The primary endpoint was the incidence of diarrhea; secondary endpoints were severe episodes of diarrhea, respiratory infection, nutritional status, CD4 count, and mortality.

RESULTS

Five hundred participants were recruited and followed up for 3.3 y (10,846 person-months). The primary endpoint, incidence of diarrhea (1.4 episodes/y per person), did not differ with treatment allocation. However, severe episodes of diarrhea were reduced in the supplementation group (odds ratio: 0.50; 95% CI: 0.26, 0.92; P = 0.017). Mortality was reduced in HIV-positive participants from 12 with placebo to 4 with supplementation (P = 0.029 by log-rank test), but this was not due to changes in CD4 count or nutritional status.

CONCLUSION

Micronutrient supplementation with this formulation resulted in only modest reductions in severe diarrhea and reduced mortality in HIV-positive participants. The trial was registered as ISRCTN31173864.

Viral infection and iron metabolism

Fundamental cellular operations, including DNA synthesis and the generation of ATP, require iron. Viruses hijack cells in order to replicate, and efficient replication needs an iron-replete host. Some viruses selectively infect iron-acquiring cells by binding to transferrin receptor 1 during cell entry. Other viruses alter the expression of proteins involved in iron homeostasis, such as HFE and hepcidin. In HIV-1 and hepatitis C virus infections, iron overload is associated with poor prognosis and could be partly caused by the viruses themselves. Understanding how iron metabolism and viral infection interact might suggest new methods to control disease.