October 26, 2002
Anemia is a common complication in persons with HIV disease. In addition to causing fatigue and decreased quality of life, several studies have suggested that anemia is associated with decreased survival in persons with HIV/AIDS. In the era of HAART, anemia may be less common and less severe, but it seems to remain a persistent problem.
This study sought to determine the frequency and the severity of anemia in the "modern" era. In addition, the investigators wanted to look at the association of anemia with gender, race as well as with markers of disease including CD4 cell counts and viral load.
The study looked at data from almost 10,000 patients who were receiving outpatient care at clinics and practices that contributed records to this database. It was a cross-sectional study, meaning it looked at patients at a single point in time, and included patients on no therapy as well as those on protease inhibitor (PI)-based or NNRTI-based HAART.
Women comprised 23 percent of the study patients and 43 percent of the patients were white/non Hispanic. The overall prevalence of anemia was higher in women than in men. About one third of the women had abnormal hemoglobin levels (a measure of anemia) compared to expected levels for women. Most of the anemia cases were very mild, but 15 percent had hemoglobin levels less than 11g/dL and 7 percent were less than 10g/dL, representing anemia that was likely to cause symptoms. Among men, mild anemia was also common, with one third having hemoglobin levels less than 14g/dL. However, more severe levels were less common among men.
Low hemoglobin was more common among those with CD4 counts less than 200 (as expected) and among those with viral loads greater than 30,000 copies. The association with therapy and with specific drugs was not reported, but the analysis is ongoing and may be reported at future meetings.
Another interesting finding is that anemia was most common among African-American women. Almost 20 percent had hemoglobin levels less than 11g/dL.
One implication of this study is that patients and providers must be aware of the prevalence of anemia in women, especially African-American women. Treatable causes such as iron deficiency should be corrected. However, it is not clear whether this means different types of HAART might be more likely to cause anemia in some groups. It is also not clear if the anemia seen here is associated with decreased survival, as seen in earlier studies.
If anemia is a marker of decreased survival, the next question is a chicken and egg question. Does mild anemia act as a marker of worse immune function or decreased ability to tolerate therapy, or is it possible that the anemia actually leads to decreased survival? The first explanation seems to be the most likely.
Another implication will arise in the face of the issue of deciding to treat hepatitis C in persons with HIV. Treatment with interferon and ribavirin (including the new pegylated interferons) frequently leads to anemia. This may be severe anemia that requires treatment with erythropoietin. The treatment trials will need to be explored to see if gender and ethnicity lead to a higher risk of anemia for some people when they are being treated for hepatitis C.