Anaemia is associated with monocyte activation in HIV-infected adults on antiretroviral therapy

Mechanisms and Cardiorenal Complications of Chronic Anemia in People with HIV

Chronic anemia is more prevalent in people living with HIV (PLWH) compared to the general population. The mechanisms that drive chronic anemia in HIV are multifaceted and include functional impairment of hematopoietic stem cells, dysregulation of erythropoietin production, and persistent immune activation. Chronic inflammation from HIV infection adversely affects erythropoiesis, erythrocyte lifespan, and erythropoietin response, leading to a heightened risk of co-infections such as tuberculosis, persistent severe anemia, and increased mortality. Additionally, chronic anemia exacerbates the progression of HIV-associated nephrotoxicity and contributes to cardiovascular risk through immune activation and inflammation. This review highlights the cardinal role of chronic inflammation as a link connecting persistent anemia and cardiovascular complications in PLWH, emphasizing the need for a universal understanding of these interconnected pathways for targeted interventions.

The changing prevalence of anemia and risk factors in people with HIV in North America who have initiated ART, 2007-2017

OBJECTIVE

To characterize the prevalence of anemia and risk factors between 2007 and 2017 for moderate/severe anemia among people with HIV (PWH) in North America who have initiated antiretroviral therapy (ART).

DESIGN

Observational study of participants in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD).

METHODS

We estimated the annual prevalence between 1 January 2007 and 31 December 2017 of mild (11.0-12.9 g/dl men, 11.0-11.9 g/dl women), moderate (8.0-10.9 g/dl regardless of sex) and severe (<8.0 g/dl regardless of sex) anemia. Poisson regression models with robust variance and general estimating equations estimated crude and adjusted prevalence ratios (aPR) with 95% confidence intervals ([-]) comparing risk factors for moderate/severe vs. no/mild anemia between 2007 and 2017.

RESULTS

Among 73 898 PWH we observed 366 755 hemoglobin measurements following ART initiation, 37 301 (50%) had one or more measures of anemia during follow-up (mild = 17 743 [24%]; moderate = 13 383[18%]; severe = 6175 [8%]). Moderate/severe anemia was more prevalent among women, non-Hispanic Black and Hispanic PWH (vs. non-Hispanic white), those with underweight body mass index (<18.5 kg/m2) and with comorbidities and coinfections. Older age had increased prevalence of moderate/severe anemia among males and decreased prevalence among females. Prevalence of moderate/severe anemia was greater among those with lower CD4+ cell count (≤200 cells/μl) [aPR = 2.11 (2.06-2.17)] unsuppressed HIV viral load (>200 copies/ml) [aPR = 1.26 (1.23-1.29)] and within the first 6 months of ART initiation (vs. >1 year of ART) [aPR = 1.66 (1.61-1.72)].

CONCLUSION

The prevalence of anemia among PWH is reduced after ART initiation but remains high. Risk factors differ by sex and include comorbidities and HIV disease severity. The persistent, substantial prevalence of anemia among PWH merits further investigation, targeted screening, and clinical interventions.

Decreases in markers of monocyte/macrophage activation after hepatitis C eradication in HIV/hepatitis C virus coinfected women

OBJECTIVE

Eradication of hepatitis C virus (HCV) in HIV disease decreases liver and non-liver-related morbidity and mortality. Elevated markers of monocyte/macrophage activation (soluble CD163 and sCD14) are associated with excess non-AIDS morbidity and mortality in HIV. We examined the effect of HCV eradication on these markers in relation to change in hepatic fibrosis.

DESIGN

A nested substudy within a longitudinal observational cohort.

METHODS

We studied 126 HIV/HCV-coinfected women successfully treated for HCV, with undetectable HCV RNA at least 12 weeks after therapy completion. sCD163 and sCD14 were measured in serum collected before and after HCV eradication. Results were correlated with changes in markers of hepatic fibrosis.

RESULTS

Mean age of participants was 56.3 years, mean CD4+ cell count was 615, and 72% had suppressed HIV RNA. After treatment, sCD163 and sCD14 levels significantly decreased from pre-treatment levels in unadjusted analyses. After adjusting for age, race, hepatic fibrosis status, baseline HCV RNA, CD4 count and HIV RNA status, cigarette smoking, and alcohol use, the decreases in sCD163 and sCD14 remained significant. Decrease in pre-treatment to post-treatment sCD163 were significantly positively correlated with changes in FIB-4 (r = 0.250, P = 0.005) and APRI (r = 0.262, P = 0.003); similarly decrease in sCD14 was significantly positively correlated with changes in FIB-4 (r = 0.333, P = 0.0001) and APRI (r = 0.457, P < 0.0001).

CONCLUSION

HCV eradication is associated with significant reductions in monocyte/macrophage activation markers that correlate with reductions in markers of hepatic fibrosis. These findings support broad access to and early initiation of HCV treatment in order to decrease immune activation and improve health in HIV-infected persons.

High Prevalence of Anemia among Human Immunodeficiency Virus-Infected Patients: A Cross-sectional Study in Bali-Indonesia

Anemia is a common condition found among Human Immunodeficiency Virus (HIV)-infected patients. T-cells that are infected with HIV virus can directly suppress the growth of progenitor cells in the bone marrow so that affecting the hemopoiesis resulted in anemia. These hematological abnormalities could potentially cause serious clinical implications. This study was conducted to determine the prevalence of anemia in HIV-infected patients in Bali. It was ahospital based cross-sectional studyconducted at two public hospital in Bali-Indonesia. A total of 243 medical record data from HIV-infected patients atWangaya Hospital Denpasar Bali and Sanjiwani Hospital Gianyar Bali between 2009 -2017 were included in analysis. Prevalence of anemia in antiretroviral (ART)-naïve patients and in patients on ART were 60.8% and 40.3%, respectively. Leucopenia and thrombocytopenia were found 8.2% and 9.4%, respectively, in ART-naïve group. While in patients with ART group leucopenia and thrombocytopenia were accounted for 6.9% and 4.3%, respectively. There was a significant difference in prevalence of anemia between ART-naïve patients and patients on ART (60.8% vs. 40.3%; p < 0.05). Although the prevalence of anemia was lower in patients on ART, but anemia continues to be common in a substantial portion of HIV-infected persons. Another studies are still needed to addressing the impact of anemia on HIV-infected individuals, as well as treatment strategies and future research directions.

High levels of serum IL-6 and serum hepcidin and low CD4 cell count were risk factors of anemia of chronic disease in HIV patients on the combination of antiretroviral therapy

Purpose: This study aimed to determine whether high levels of serum IL-6 and serum hepcidin and CD4<350 cells/ul were risk factors for the anemia of chronic disease (ACD) in HIV-infected patients on the combination of antiretroviral (cARV) therapy with successful clinically and immunological responses.

Patients and Methods: A matched case–control study was conducted in the VCT clinic of Sanglah General Hospital, Indonesia, between January 1 and September 1, 2016. The case group was HIV patients with ACD, while the control group was HIV patients without ACD. Purposive consecutive sampling was employed in HIV patients aged 15–65 years who have received cARV therapy for >6 months, had >95% adherence of cARV within 6 months, did not have any clinical failure, did not have any immunological failure and did not receive switch therapy within 6 months. Chi-square test and logistic regression analysis were performed.

Results: A total of 42 cases and 42 controls were included in this study. Significant differences were found between case and control, which included serum IL-6, serum hepcidin, smoking, creatinine clearance, anemia at the initiation of cARV, CD4 at the initiation of cARV and actual CD4 (cell/µL). High levels of serum IL-6, high levels of serum hepcidin and CD4< 350 cells/µl were risk factors for ACD. After adjusted with anemia at cARV initiation and BMI, we found that high levels of serum IL-6 (adjusted OR: 17.682; 95% CI: 3.442–90.826), high levels of serum hepcidin (adjusted OR: 10.562; 95% CI: 2.531–44.076) and CD4 <350 cells/µl (adjusted OR: 4.181; 95% CI: 5.6–12.381) remain as risk factors for ACD.

Conclusion: High levels of serum IL-6, high levels of serum hepcidin and CD4 count <350 cells/µL were risk factors for ACD in HIV patients with cARV therapy.

The impact of antiretroviral therapy on iron homeostasis and inflammation markers in HIV-infected patients with mild anemia

Background

Anemia is frequent during HIV infection and is predictive of mortality. Although cART has demonstrated to reduce its prevalence, several patients still experience unresolved anemia. We aimed to characterize iron homeostasis and inflammation in HIV-infected individuals with mild anemia in relation to cART.

Methods

In this retrospective cohort study, HIV-infected patients with mild anemia, CD4⁺ cells > 200/mm³ at baseline, maintaining virological response for 12 months after cART starting were selected within the Standardized Management of Antiretroviral Therapy Cohort (MASTER) cohort. Several inflammation and immune activation markers and iron homeostasis indexes were measured in stored samples, obtained at cART initiation (T0) and 12 months later (T1). Patients were grouped on the basis of hemoglobin values at T1: group A (> 13 g/dl) and B (< 13 g/dl). Wilcoxon rank sum test was used to compare biomarker values. Pearson correlation coefficients were calculated for all variables.

Results

cART improved CD4⁺ and CD8⁺ cell counts and their ratio, but this effect was significant only in group A. Only these patients had mild iron deficiency at T0 and showed higher transferrin and lower percentage of transferrin saturation than patients of group B, but differences disappeared with cART. cART decreased inflammation in all patients, but group B had higher levels of all markers than group A, reaching statistical significance only for IL-8 values at T1 (16 vs 2.9 pg/ml; p = 0.017). Hepcidin and IL-6 levels did not show significant differences between groups. Hemoglobin levels both at T0 and T1 did not correlate with any marker.

Conclusions

Baseline mild anemia in HIV-infected patients cannot always be resolved with durable efficient cART, possibly due to residual inflammation or immune activation rather than unbalanced iron homeostasis. Further research is needed on cytokine profiling to understand the mechanisms that induce anemia in HIV with suppressive cART.

Electronic supplementary material

The online version of this article (10.1186/s12967-017-1358-6) contains supplementary material, which is available to authorized users.