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Coverage provided by Robert J. Frascino, M.D.

July 9, 2001

• A Case-Control Study to Examine the Association of HIV/AIDS Progression with the Development and Treatment of Anemia: Results from the 1996 Enrollment Cohort (Poster 318)
  Authored by Creagh, T.; Mildvan, D.; Bohn, H.; Moore, R.; Ray, L.; Clinical and Epidemiology Research, Atlanta, GA; Beth Israel Medical Center, New York, NY, USA

Introduction and Background

Anemia is a common complication of HIV infection. Clinical studies conducted primarily in the era prior to the widespread use of highly active antiretroviral therapy (HAART) documented that HIV-related anemia has a deleterious effect on functional capacity and overall quality of life. It has also been associated with decreased survival. Sullivan and colleagues, in their review and analysis of over 32,000 HIV case histories from a CDC (Centers for Disease Control and Prevention) database, found a correlation between HIV-related anemia and decreased survival, with the shortest survival seen in patients who had both anemia and a low CD4+ cell count.

Other large multi-center studies (Moore et al. and Saah et al.) have found similar results when they examined the risk of death associated with anemia. Preliminary evidence from the EuroSIDA (multi-country study currently underway in Europe) and other clinical trials has suggested an association of anemia with poorer clinical outcomes, even in the HAART era.

The present study was designed and conducted to more accurately assess the relationship between anemia and progression of HIV/AIDS in the era of HAART. This report is an interim analysis of a case-controlled retrospective study. In essence, these physicians reviewed the HIV case histories (retrospective chart review) of over 500 patients seen in a large urban infectious disease clinic. HIV-positive patients with anemia (cases) were matched with HIV-positive patients who did not have anemia (controls). Cases and controls were matched for age, gender, HAART status, and CD4 count. Anemia was defined as hemoglobin less than 11 g/dL on 2 or more occasions from 1996-1998. Disease progression was defined as any HIV-related opportunistic infection or death.

Results

The study revealed that 21% (104 patients) of the study population met the case definition for anemia. HIV disease progression (new opportunistic infection or death) was 5.2 times more likely in patients with anemia (cases) compared to matched HIV-positive patients without anemia (controls).

Discussion

Why Was This Study Important to Physicians?

Previous studies have shown a relationship between anemia and increased mortality in the pre-HAART era. This study demonstrated that anemia predicts progression of HIV disease (new opportunistic infection or death) in the era of HAART. Approximately 75% of the cases and matched controls were on HAART therapy at the time of this analysis. In addition, this study confirms other studies showing that HIV-positive African Americans are more likely to develop anemia. The risk of disease progression among HIV-positive patients with anemia was approximately 90% for both men and women. Overall, HIV-positive patients with anemia were 5.2 times more likely to progress than matched HIV-positive patients without anemia.

As the use of HAART has improved the overall health of patients with HIV, anemia has been perceived by some physicians as a less important issue. This study clearly shows that, even in the era of HAART, anemia remains a very real problem, as it has a significant impact on HIV disease progression and mortality.

Why Is This Study Important for Patients?

First, a growing body of evidence including this study suggests that anemia is associated with increased mortality risk and disease progression. Clinical trials have also shown that treatment of HIV-related anemia with epoetin alpha can improve survival. Early diagnosis and appropriate treatment of HIV-related anemia should continue to improve the prognosis in HIV/AIDS.

Second, anemia in the setting of HIV disease compromises functional capacity, energy level, and overall quality of life. As HIV-infected individuals live longer and more productive lives, maintaining quality of life becomes an increasingly important goal of treatment. Fatigue -- frequently associated with anemia -- is the most common and troublesome side effect experienced by HIV-positive individuals. Treatment of HIV-related anemia with epoetin alpha has been associated with increased energy, enhanced quality of life, and improved survival. Given this documented impact of anemia in HIV-positive individuals, there is clinical value in maintaining normal hemoglobin levels. It is important for patients and clinicians to be more vigilant in the monitoring for and treatment of HIV-related anemia.

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