Haemoglobin recovery among HIV-1 infected patients on zidovudine-based antiretroviral therapy and other regimens in north-central Nigeria

Prevalence and risk factors for anemia severity and type in Malawian men and women: urban and rural differences

BACKGROUND

The global burden of anemia is large especially in sub-Saharan Africa, where HIV is common and lifestyles are changing rapidly with urbanization. The effects of these changes are unknown. Studies of anemia usually focus on pregnant women or children, among whom the burden is greatest. We describe prevalence and risk factors for anemia among rural and urban men and women of all ages in Malawi.

METHODS

We analyzed data from a population-wide cross-sectional survey of adults conducted in two sites, Karonga (rural) and Lilongwe (urban), commencing in May 2013. We used multinomial logistic regression models, stratified by sex to identify risk factors for mild and moderate-to-severe anemia.

RESULTS

Anemia prevalence was assessed among 8,926 men (age range 18-100 years) and 14,978 women (age range: 18-103 years). Weighted prevalence levels for all, mild, and moderate-to-severe anemia were 8.2, 6.7 and 1.2% in rural men; 19.4, 12.0 and 7.4% in rural women; 5.9, 5.1 and 0.8% in urban men; and 23.4, 13.6 and 10.1% in urban women. Among women, the odds of anemia were higher among urban residents and those with higher socioeconomic status. Increasing age was associated with higher anemia prevalence in men. Among both men and women, HIV infection was a consistent risk factor for severity of anemia, though its relative effect was stronger on moderate-to-severe anemia.

CONCLUSIONS

The drivers of anemia in this population are complex, include both socioeconomic and biological factors and are affecting men and women differently. The associations with urban lifestyle and HIV indicate opportunities for targeted intervention.

Enrolment trends in a comprehensive HIV programme in rural north-central Nigeria: improved care indices, but declining quality of clinical data over time

BACKGROUND

Vanderbilt University affiliate Friends in Global Health was funded in 2008 to support comprehensive HIV/AIDS services in north-central Nigeria. We summarise programme characteristics and trends in enrolment and quality of data collection in this rural, resource-limited environment.

METHODS

We used routinely collected programme data in supported sites from June 1 2009 to September 30, 2013.Baseline characteristics were defined as those collected closest to a 90-day window period before and after enrolment. Summary characteristics were compared by site and enrolment year.

RESULTS

We enrolled 3,960 HIV-infected patients into care (68% women), median age of 32 years [interquartile range (IQR): 27-40]. Most clients were married (79%) and unemployed (60%). At enrolment, median CD4+ cell count was 230 cells/μL (IQR: 114-390) and haemoglobin was 10.7 g/dL (IQR: 9.3-11.9). Advanced clinical disease [World Health Organization (WHO) clinical stage III/IV] at enrolment was documented in 29% of clients. Cumulative enrolment increased from 377 patients in 2009 to 3,960 patients by 2013.With each successive year, more clients were enrolled at earlier stages of disease; in 2009, 37% of patients were identified as WHO clinical stage I, while in 2013, 55% of patients were so classified. While documentation of clinical staging remained stable, the completeness of CD4+ cell count and haemoglobin data declined with time.

CONCLUSION

Expanded testing in a comprehensive HIV programme in rural Nigeria brought persons to care at earlier stages of illness. Yet, as clinical services expanded, data collection quality declined. The paradox of successful scaling up HIV services but deteriorating quality of data underscores the importance of data management training and quality improvement efforts.

Anemia, Blood Transfusion Requirements and Mortality Risk in Human Immunodeficiency Virus-Infected Adults Requiring Acute Medical Admission to Hospital in South Africa

Background. Morbidity and mortality remain high among hospitalized patients infected with human immunodeficiency virus (HIV) in sub-Saharan Africa despite widespread availability of antiretroviral therapy. Severe anemia is likely one important driver, and some evidence suggests that blood transfusions may accelerate HIV progression and paradoxically increase short-term mortality. We investigated the relationship between anemia, blood transfusions, and mortality in a South African district hospital.

Methods. Unselected consecutive HIV-infected adults requiring acute medical admission to a Cape Town township district hospital were recruited. Admission hemoglobin concentrations were used to classify anemia severity according to World Health Organization/AIDS Clinical Trials Group criteria. Vital status was determined at 90 days, and Cox regression analyses were used to determine independent predictors of mortality.

Results. Of 585 HIV-infected patients enrolled, 578 (98.8%) were included in the analysis. Anemia was detected in 84.8% of patients and was severe (hemoglobin, 6.5–7.9 g/dL) or life-threatening (hemoglobin, <6.5 g/dL) in 17.3% and 13.3%, respectively. Within 90 days of the date of admission, 13.5% (n = 78) patients received at least 1 blood transfusion with red cell concentrate and 77 (13.3%) patients died. In univariable analysis, baseline hemoglobin and receipt of blood transfusion were associated with increased mortality risk. However, in multivariable analysis, neither hemoglobin nor receipt of a blood transfusion were independently associated with greater mortality risk. Acquired immune deficiency syndrome-defining illnesses other than tuberculosis and impaired renal function independently predicted mortality.

Conclusions. Newly admitted HIV-infected adults had a high prevalence of severe or life-threatening anemia and blood transfusions were frequently required. However, after adjustment for confounders, blood transfusions did not confer an increased mortality risk.

Correlates of suboptimal entry into early infant diagnosis in rural north central Nigeria

BACKGROUND

Despite an estimated 59,000 incident pediatric HIV infections in 2012 in Nigeria, rates of early infant diagnosis (EID) of HIV service uptake remain low. We evaluated maternal factors independently associated with EID uptake in rural North Central Nigeria.

METHODS

We performed a cohort study using HIV/AIDS program data of HIV-infected pregnant women enrolled into HIV care/treatment on or before December 31, 2012 (n = 712). We modeled the probability of initiation of EID using multivariable logistic regression.

RESULTS

Three hundred fifty-seven HIV-infected pregnant women enrolled their infants in EID across the 4 study sites. Women who enrolled their infants in EID vs. those who did not were similar across age, occupation, referral source, and select laboratory variables. Clinic of enrollment and date of enrollment were strong predictors for EID entry (P < 0.001). Women enrolled more recently were less likely to have their infants undergo EID than those enrolled at the beginning of the project (January 2011 vs. January 2010, adjusted odds ratio = 0.35, 95% confidence interval: 0.22 to 0.56; January 2012 vs. January 2010, adjusted odds ratio = 0.30, 95% confidence interval: 0.14 to 0.61). Women who received care in the more urban setting of Umaru Yar Adua Hospital were more likely to have their infants enrolled in EID than those who received care in the other 3 clinics.

CONCLUSIONS

HIV-infected women in our prevention of mother-to-child HIV transmission program were more likely to bring in their infants for EID if they were enrolled in a more urbanized clinic location, and if they presented during an earlier phase of the program. The need for more intensive family engagement and program quality improvement is apparent, especially in rural settings.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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