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

Abstract

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).

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

“…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 …”

“…The effects of HIV on bone marrow mainly cause anemia and thrombocytopenia in peripheral blood, clinical conditions related to the increased risk of death in PLWHA. 6 Therefore, it is essential to monitor the evolution of the blood count during HIV infection, in order to detect the development of these hematological disorders and perform the necessary clinical interventions to avoid comorbidities. 7…”

“… 3 , 8 - 10 In addition, there are inconsistencies about the way in which the patient's clinical characteristics may aggravate or attenuate hematological manifestations, causing great heterogeneity between studies. 6 , 7 The introduction of antiretroviral therapy (ART) also seems to have a dichotomous effect on the hematological compartment, which, in some cases, may in fact exacerbate anemia. 11 Given the diversity of results, it becomes essential for the data available in the literature to be reviewed to demonstrate the complex effects of HIV on the hematopoietic system.…”