Anemia risk factors among people living with HIV across the United States in the current treatment era: a clinical cohort study

Abstract

Background: Anemia is common among people living with HIV infection (PLWH) and is associated with adverse health outcomes. Information on risk factors for anemia incidence in the current antiretroviral therapy (ART) era is lacking. Methods: Within a prospective clinical cohort of adult PLWH receiving care at eight sites across the United States between 1/2010-3/2018, Cox proportional hazards regression analyses were conducted among a) PLWH free of anemia at baseline and b) PLWH free of severe anemia at baseline to determine associations between timeupdated patient characteristics and development of anemia (hemoglobin < 10 g/dL), or severe anemia (hemoglobin < 7.5 g/dL). Linear mixed effects models were used to examine relationships between patient characteristics and hemoglobin levels during follow-up. Hemoglobin levels were ascertained using laboratory data from routine clinical care. Potential risk factors included: age, sex, race/ethnicity, body mass index, smoking status, hazardous alcohol use, illicit drug use, hepatitis C virus (HCV) coinfection, estimated glomerular filtration rate (eGFR), CD4 cell count, viral load, ART use and time in care at CNICS site.Results: This retrospective cohort study included 15,126 PLWH. During a median follow-up of 6.6 (interquartile range [IQR] 4.3-7.6) years, 1086 participants developed anemia and 465 participants developed severe anemia. Factors that were associated with incident anemia included: older age, female sex, black race, HCV coinfection, lower CD4 cell counts, VL ≥400 copies/ml and lower eGFR. Conclusion: Because anemia is a treatable condition associated with increased morbidity and mortality among PLWH, hemoglobin levels should be monitored routinely, especially among PLWH who have one or more risk factors for anemia.

Anemia and thrombocytopenia in people living with HIV/AIDS: a narrative literature review

“…A retrospective cohort study showed that a lower CD4 + T lymphocyte count was associated with anemia and severe anemia and that women with a CD4 + T lymphocyte count of <100 cells/μL were at an increased risk of developing anemia. 12 Also, blood hemoglobin levels, mean corpuscular volume and mean corpuscular hemoglobin were shown to be lower in PLWHA with a CD4 + T lymphocyte count of <200 cells/μL than in PLWHA with asymptomatic HIV infection. 4 …”

“…In a recent cohort study of PLWHA receiving care at eight sites across the USA, 7.2% of individuals developed anemia after 6 y of follow-up, indicating an incidence of anemia of 1.95/100 person-years. 12 In Denmark, a longitudinal study detected the prevalence of 6.9% of anemia; however, PLWHA evaluated had an undetectable viral load, which may have contributed to the low rate of anemia observed. 15 …”

“…Our research generated 27 articles reporting the prevalence and/or hematological features of anemia in adult PLWHA in the last 10 y (Table 1 ): 6 cohort, 18 cross-sectional, 1 longitudinal, 1 case-control and 1 randomized clinical trial. These studies reported an overall prevalence of anemia from 6.3% to 84% 3 , 6 , 10 , 12 - 34 in PLWHA worldwide and demonstrated they have significantly lower hemoglobin levels than healthy controls in peripheral blood. 32…”

“…The prevalence of anemia is higher in PLWHA with an HIV viral load upper than 400 or 1000 copies of HIV RNA per mL of blood. 6 , 12 Thus, ART, while suppressing the individual's viral load, may indirectly improve hemoglobin levels because it improves the erythropoietic dysfunction resulting from the increased viral load. In fact, a longitudinal study 15 revealed a prevalence of 6.9% of anemia in PLWHA with undetectable viral load, suggesting that patients with controlled disease have fewer hematological comorbidities.…”

“… 37 , 39 In fact, hepatitis C, Epstein–Barr virus infection, cytomegalovirus infection and TB are some of the infections associated with the presence of anemia. 6 , 12 …”