July 14, 2003
Anemia adversely affects functional ability and quality of life. It can cause fatigue, shortness of breath, rapid heartbeat, exercise intolerance, headaches, inability to concentrate and other symptoms, ranging from mild to disabling. Anemia is also associated with decreased survival in HIV-positive individuals. The association between anemia and decreased survival has been found to be independent of CD4 cell count or HIV viral load. Anemic HIV-positive individuals who recover from anemia have better survival rates than those who do not recover.
Initial data from the early HAART era indicated that severe anemia was less frequent, and anemia was subsequently perceived by many (both physicians and patients) to be less of a clinical issue. Additional studies suggested mild-to-moderate anemia continued to be common despite HAART. These more recent data, again collected during the HAART era, show that anemia continues to be associated with a worse prognosis, decreased survival time, increased risk of clinical progression and reduced quality of life. Consequently, the present study's primary objective was to determine the prevalence of anemia in HIV-positive patients seeking care within a single public health center (Hillsborough County Health Department, Florida, U.S.A.), and to evaluate the association of anemia with the use of HAART.
The overall prevalence of anemia was 30.3 percent. The prevalence of anemia was higher in women (54 percent) than in men (20.2 percent). Anemia was also more prevalent in patients with lower CD4 cell counts and higher viral loads.
There was no significant difference in anemia prevalence (using the 12.5 g/dL definition) between patients receiving HAART and patients not receiving HAART. However, there was an increased prevalence of anemia in patients whose HAART regimen contained AZT. Detailed analysis of the variables identified that, in this study, the following were associated with a significantly increased risk of anemia:
HIV-related anemia can involve multiple causal mechanisms, and often several of these are operative in the same patient at the same time. These causal mechanisms include HIV itself, which can induce chronic inflammation and slow red blood cell production. In addition, drug toxicities, opportunistic infections, malabsorption syndromes leading to folate or vitamin B12 deficiency, blood loss, iron deficiency, lymphoma and other AIDS-related malignancies can all cause or contribute to anemia.
With the increased use of HAART, we have witnessed a decline in opportunistic infections, malignancies and infection-related malabsorption syndromes. Also, HAART may reduce levels of HIV chronic inflammation. All of these factors can improve anemia, and are most likely responsible for the decrease in cases of severe anemia noted during the HAART era. The present study indicates that in spite of these advances, mild-to-moderate anemia remains common. This information, in conjunction with previous studies suggesting that recovery from anemia is associated with improved survival and that treatment of mild-to-moderate anemia in HIV-positive patients enhances functional ability as well as improves quality of life, is important to both patients and treating physicians. Taken together, this information underscores the continuing importance of monitoring for anemia and maintaining normal hemoglobin levels as a treatment goal, even as antiretroviral therapies continue to improve.