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Fatigue May Be Sign of Anemia

Treatment Spotlight

September 1999

A note from The field of medicine is constantly evolving. As a result, parts of this article may be outdated. Please keep this in mind, and be sure to visit other parts of our site for more recent information!

As many as 80 percent of people with HIV disease may experience anemia, or an abnormally low level of red blood cells.

Red blood cells, also called erythrocytes, are made in the bone marrow. These cells carry oxygen from the lungs to the tissues. You need oxygen to burn food for energy, so if you have a low supply of oxygen, you feel tired.

People with anemia cannot carry as much oxygen in their blood. Inadequate oxygen can lead to fatigue, difficulty breathing, an increased heart rate and a pale appearance.

Signs to heed

What are the signs of anemia?

The most common complaint of people with anemia is tiredness, or fatigue. Anemia can also cause headaches, ringing in the ears, chest pain, changes in a woman's period, and a decrease in sex drive. Anemia-related fatigue tends to show up primarily with physical activity, such as climbing up hills, carrying groceries, walking, running, cycling or swimming.

Factors that cause anemia include blood loss such as gastrointestinal bleeding, poor nutrition, iron deficiency, a malfunctioning thyroid, low hormone levels, an effect from medication or an infection that invades the bone marrow [tuberculosis (TB), lymphoma, mycobacterium avium complex (MAC) or a deep fungal infection]. By keeping the body from making enough red blood cells, HIV disease itself can cause anemia.

In women, excessive menstrual blood loss can also lead to anemia and iron deficiency.

Blame the drug?

If you are anemic, the first question to ask is: Are you anemic because of a drug?

HIV-associated anemia may be a side effect of antiretrovirals, resulting in inadequate production of red blood cells from the bone marrow. By stimulating the bone marrow or stopping a medicine that is causing the problem, such as AZT, Bactrim or certain forms of chemotherapy, anemia can be reversed.

Your clinician can measure hemoglobin and hematocrit by running a simple lab test, called a complete blood count (CBC). These labs are generally run every three months, less frequently if you are taking no medications. The hemoglobin test measures how much oxygen your red blood cells carry. The hematocrit test measures how many red blood cells you have.

A normal level of hemoglobin in men is between 14 to 18 gm/dl, and 12 to 16 gm/dl in women. A normal level of hematocrit in men is between 40 to 52 percent, and 35 to 46 percent in women. Menstrual blood loss accounts for the difference between genders.

If the anemia is not from a drug, the erythropoietin level should be tested.

Treatments for anemia

After identifying the cause of anemia, treating it is the next step.

Mild to moderate anemia can be treated by supplementing vitamin B12, iron or folic acid in your diet. Severe anemia may require a blood transfusion or erythropoietin (EPO).

Erythropoietin (EPO) is a hormone manufactured in the kidneys that stimulates the bone marrow to produce red blood cells. Epogen and Procrit, genetically engineered versions of the drug, are commercially available. EPO will not be effective if the anemia is caused by iron deficiency, infection, cancer, blood loss, vitamin deficiency, aluminum poisoning or inflammatory bone disease.

If the erythropoietin level is low, replacement therapy can be administered with shots which are given three times a week under the skin. Erythropoietin usually leads to an increase in hemoglobin and hematocrit within two to six weeks.

Transfusion is an option

People with AZT-induced anemia may choose to stay on AZT and have blood transfusions.

They may also stop AZT therapy or decrease the dosage until their red blood cells recover. Dose reductions, however, may decrease the concentration of AZT in the blood to levels that are ineffective in stopping HIV replication.

Due to the risk of infections, allergic reactions and other problems, blood transfusions should be used only in the presence of severe anemia. EPO is not an appropriate therapy for severe anemia and cannot replace the need for blood transfusions. However, early treatment of mild anemia with EPO may prevent the onset of severe anemia and the need for blood transfusions.

Nutritional interventions are recommended for treating anemia that is related to an iron or vitamin B-12 deficiency. Eating dark green, leafy vegetables like spinach, kale, beets and other iron-rich foods, and supplementation with vitamin B complex are types of nutritional interventions.

Injection with erythropoietin is recommended for treating HIV-related anemia.

If you suspect that you are anemic, discuss your options with your clinician. By preventing what can negatively affect your body, you can increase your survival and quality of life.

Nancy Wongvipat, M.P.H., is a health education specialist in AIDS Project Los Angeles' Education Division. She can be reached by calling (323) 993-1511 or by e-mail at

This article has been reprinted at The Body with the permission of AIDS Project Los Angeles (APLA).

A note from The field of medicine is constantly evolving. As a result, parts of this article may be outdated. Please keep this in mind, and be sure to visit other parts of our site for more recent information!

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This article was provided by AIDS Project Los Angeles. It is a part of the publication Positive Living.
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