Epidemiology of Anemia in Human Immunodeficiency Virus (HIV)-Infected Persons: Results From the Multistate Adult and Adolescent Spectrum of HIV Disease Surveillance Project

Burden of Anemia among Human Immunodeficiency Virus-Positive Adults on Highly Active Antiretroviral Therapy at Hawassa University Compressive Specialized Hospital, Hawassa, Ethiopia

Background

Anemia is the most common hematologic abnormality associated with human immunodeficiency virus (HIV)-infected patients and affects 60% to 80% of patients in late-stage disease. It has a considerable impact on the progression of HIV to advanced stages. This study aimed at assessing the burden of anemia in adult HIV-infected patients who are on highly active antiretroviral therapy (HAART) and have follow-up at Hawassa University Comprehensive Specialized Hospital (HUCSH) Antiretroviral therapy (ART) clinic.

Methods

A hospital-based retrospective study was conducted among HIV-positive adults on HAART at Hawassa University Compressive Specialized Hospital. The systematic sampling method was used to choose a total of 244 study participants. Data on demographic characteristics, related factors of anemia, latest hemoglobin, CD4, and ART regimens were collected using a structured data abstraction format. The data were cleaned and analyzed using SPSS version 21.0 after being manually checked for completeness. Multivariable logistic regression was carried out to detect elements associated with anemia. A P value of <0.05 was used as a cutoff point to announce statistical significance.

Results

The records of 244 patients were examined in total. Anemia was present in 29.9% (95% CI 23.8-35.2) among adult HIV patients. Female sex (AOR: 2.576, 95% (CI: 1.295-5.127)), having tuberculosis (TB) (AOR: 4.873, 95% (CI: 1.534-15.484)), taking a zidovudine (ZDV)-containing ART regimen (AOR: 5.216, 95% (CI: 1.239-21.962)), having clinical WHO stage IV and III diseases (AOR: 3.077, 95% CI (1.244-7.612)), having body mass index (BMI) <18.5 kg/m2 (AOR: 2.391, 95% (CI: 1.138-5.023)), and taking cotrimoxazole prophylaxis (AOR: 3.860 95% (CI: 1.097-13.576)) were substantially linked to the development of anemia among adult HIV patients. Conclusion and Recommendation. This study showed that anemia is still a problem among HIV patients on HAART. The burden of anemia was found to be high among patients with advanced WHO clinical stages, having a BMI less than 18.5 kg/m2, TB/HIV coinfection, being on AZT-based ART regimens, and taking cotrimoxazole preventive therapy (CPT). Consequently, it is suggested that early preventative interventions, such as serial hemoglobin follow-up, iron supplementation, and education about dietary consumption, be undertaken targeting the aforementioned groups. In addition, the preferred first-line ART regimen as per the latest national and WHO guidelines is recommended, especially for the above groups.

Anemia of chronic diseases: current state of the problem and perspectives

Anemia of chronic diseases is a condition, that accompanies several chronic conditions, that have inflammation as an underlying cause. The article covers current concepts of pathogenesis, evaluation and treatment of this type of anemia. The new perspectives in the development of investigational methods and treatment are discussed. The new methods of iron deficiency assessment in patients with systemic inflammation are discussed separately.

Towards a combined prognostic index for survival in HIV infection: the role of 'non-HIV' biomarkers

BACKGROUND

As those with HIV infection live longer, 'non-AIDS' condition associated with immunodeficiency and chronic inflammation are more common. We ask whether 'non-HIV' biomarkers improve differentiation of mortality risk among individuals initiating combination antiretroviral therapy (cART).

METHODS

Using Poisson models, we analysed data from the Veterans Aging Cohort Study (VACS) on HIV-infected veterans initiating cART between 1 January 1997 and 1 August 2002. Measurements included: HIV biomarkers (CD4 cell count, HIV RNA and AIDS-defining conditions); 'non-HIV' biomarkers (haemoglobin, transaminases, platelets, creatinine, and hepatitis B and C serology); substance abuse or dependence (alcohol or drug); and age. Outcome was all cause mortality. We tested the discrimination (C statistics) of each biomarker group alone and in combination in development and validation data sets, over a range of survival intervals, and adjusting for missing data.

RESULTS

Of veterans initiating cART, 9784 (72%) had complete data. Of these, 2566 died. Subjects were middle-aged (median age 45 years), mainly male (98%) and predominantly black (51%). HIV and 'non-HIV' markers were associated with each other (P < 0.0001) and discriminated mortality (C statistics 0.68-0.73); when combined, discrimination improved (P < 0.0001). Discrimination for the VACS Index was greater for shorter survival intervals [30-day C statistic 0.86, 95% confidence interval (CI) 0.80-0.91], but good for intervals of up to 8 years (C statistic 0.73, 95% CI 0.72-0.74). Results were robust to adjustment for missing data.

CONCLUSIONS

When added to HIV biomarkers, 'non-HIV' biomarkers improve differentiation of mortality. When evaluated over similar intervals, the VACS Index discriminates as well as other established indices. After further validation, the VACS Index may provide a useful, integrated risk assessment for management and research.

Kidney Function and Anemia Prevalence in Patients with HIV Infection

Background: Recent guidelines from the Infectious Diseases Society of America (IDSA) for the management of Chronic Kidney Disease (CKD) in HIV+ patients highlight that up to 30% of HIV+ patients have abnormal kidney function. These guidelines also discuss the effects of CKD on HIV disease progression and the need to diagnose and manage CKD in patients with HIV. While the presence of CKD is associated with an increased rate of anemia in the general population, the prevalence of anemia among HIV patients with CKD is less well known. This is of particular importance as anemia is known to occur in at least 20% of HIV patients overall. The current analysis was undertaken to determine the distribution of kidney function levels among HIV patients and to stratify anemia risk based on these levels.

Methods: In a retrospective cross-sectional analysis of data collected between 1996 and 2004 from an integrated, commercial database of claims and laboratory values, subjects with HIV infection designated by ICD-9 code were identified. Subjects were included if they were at least 17.5 years old and had at least 1 value during this time period for plasma creatinine (PCr), serum urea nitrogen (SUN), albumin (Alb) and hemoglobin (Hb). If a subject had multiple lab values recorded, only the most recent lab value was utilized for the analysis. Subjects with any diagnosis or procedure code pertaining to dialysis were excluded. Kidney function was assessed by glomerular filtration rate (GFR) and calculated using the modification of diet in renal disease (MDRD) method as follows: GFR= 170 x [PCr]−0.999 x [Age] −0.176 x [SUN] −0.170 x [Alb]+0.318 x [0.762 if female] x [1.18 if black]. Since race was not reported in the database, this parameter was not included in the calculation. Anemia was defined as Hb <13 g/dL for men; <12 g/dL for women.

Results: Of the 2,032 subjects identified with HIV, 840 (41%) met the inclusion criteria. The mean age of these subjects was 43.7±12.6 years; 72% were male; mean Hb was 14.3±1.6 g/dL. Mean GFR was 91.1±21.1 mL/min/1.73m3. See Table 1 for the incidence of anemia associated with increasing severity of CKD.

Conclusions: Overall prevalence of GFR <90 mL/min/1.73m3 among HIV patients was 48.5%. This is similar to the 43.5% demonstrated in a recent analysis of HIV patients,1 and higher than the 35.9% seen in the general population.2 It may, however, be an overestimate of the actual prevalence of CKD, since race was not analyzed. In addition, patients with GFRs ≥ 60 mL/min/1.73m3 require data on proteinuria to diagnose CKD. As is the case in the general population, anemia increases in prevalence with severity of CKD. Anemia in either CKD or HIV patients is associated with increased morbidity and mortality3,4; therefore, a prompt diagnosis of anemia is warranted, as it may impact clinical treatments and outcomes in this population.

Table 1: Incidence of anemia associated with worsening GFR GFR (mL/min/1.73m3)* N (%) Anemia N (% total) *lower values mean worsening kidney function. ≥ 90 433 (51.5) 52 (12) 60–89 359 (42.7) 32 (9) 30–59 44 (5.3) 11 (25) 15–29 4 (0.5) 3 (75) <15 0 0

HIV-1 subtype E progression among northern Thai couples: traditional and non-traditional predictors of survival

BACKGROUND

In the continuing effort to introduce antiretroviral therapy in resource-limited settings, there is a need to understand differences between natural history of HIV in different populations and to identify feasible clinical measures predictive of survival.

METHODS

We examined predictors of survival among 836 heterosexuals who were infected with HIV subtype CRF01_AE in Thailand.

RESULTS

From 1993 to 1999, 269 (49.4%) men and 65 (25.7%) women died. The median time from the estimated seroconversion to death was 7.8 years (95% confidence interval 7.0-9.1). Men and women with enrolment CD4 counts <200 cells/microl had about 2 and 11 times greater risk of death than those with CD4 counts of 200-500 and >500, respectively. Measurements available in resource-limited settings, including total lymphocyte count (TLC), anaemia, and low body mass index (BMI), also predicted survival. Men with two or more of these predictors had a median survival of 0.8 (0.5-1.8) years, compared with 2.7 (1.9-3.3) years for one predictor and 4.9 (4.1-5.2) years for no predictors.

CONCLUSIONS

The time from HIV infection to death appears shorter among this Thai population than among antiretroviral naive Western populations. CD4 count and viral load (VL) were strong, independent predictors of survival. When CD4 count and VL are unavailable, individuals at high risk for shortened HIV survival may be identified by a combination of low TLC, anaemia, and low BMI. This combination of accessible clinical measures of the disease stage may be useful for medical management in resource-limited settings.