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Anemia and Depression in Women With HIV

Spring 2007

"Women are the mules of the world."

-- Zora Neale Hurston

Women carry a heavy load when it comes to living with HIV. Poverty and access to health care are among the predominant factors causing poorer health outcomes for women with HIV. The HIV Cost and Services Utilization Study (HCSUS), a national study of people with HIV receiving regular medical care, found that women with HIV were disproportionately living in poverty. Nearly 64% of the women in the study had annual incomes below $10,000, compared to 41% of men. At the same time, many of these women were also the primary caretakers of children under the age of 18. Postponing medical care due to lack of transportation, being too sick, or having to take care of others are familiar reasons that women are more likely to receive delayed treatment than men.

The CDC reports that women are significantly more likely to die of AIDS than men because treatment is started late, if at all. After highly active antiretroviral therapy (HAART) became available in 1996, the decline in AIDS-related deaths was 44% for men but only 35% for women. More than ten years later, such dramatic differences have lessened, but women's survival rates after an AIDS diagnosis are still slightly lower than men's. The CDC reports that during the first two years post AIDS diagnosis, women in the U.S. live as long as men, but by year three their survival rate drops 2% compared to men's survival.

According to Punkin Clay Stephens, Assistant Professor of Epidemiology and Biostatistics at the School of Public Health, SUNY Albany, the real difference occurs before the AIDS diagnosis. "Once in treatment, women and men respond equally to medication. The issue is what happens early in HIV infection, before a person receives health care."

Herein lies the disparity. The CDC reports that 59% of men progress to an AIDS diagnosis after one year of testing HIV positive, compared to 64% of women (according to 2004 data from the 33 states that have confidential names reporting for both HIV and AIDS). Socioeconomic factors play an important role in access to care for women with HIV -- poverty, substance use, or gender-based violence are all associated with delayed treatment and, possibly, disease progression.

Besides the factors above, what are the biological factors or co-morbid illnesses that place women at increased risk of disease progression and increased mortality? Two such conditions, anemia and chronic depression, have recently received needed attention by researchers.

Women, HIV and Anemia

Anemia has long been associated with HIV disease. A study of 31,000 people with HIV, done before the advent of HAART, found rates of severe anemia from 3% in people with asymptomatic HIV infection to 37% in people with AIDS. Despite its prevalence among HIV-positive women, it is often unrecognized and untreated. If left untreated, anemia is strongly associated with HIV disease progression and increased risk of death.

Fortunately, the rate of serious, death-related anemia has decreased since the advent of HAART. However, moderate anemia still affects approximately 30% of people using HAART. Researchers at Beth Israel Medical Center in New York and the Clinical and Epidemiology Research Center in Atlanta examined anemia and HIV disease. In their study of 4,183 patients receiving medical care, women had an 80% greater risk of anemia than men. In addition, the risk of anemia was 2.6 times greater for African-American patients compared to white patients.

"I'm sick and tired of being sick and tired."

-- Fannie Lou Hamer, civil rights activist

What Is Anemia?

Anemia is a shortage of red blood cells that can occur when the body either produces too few red blood cells or loses too many. As important as the red blood cell count is, hemoglobin levels must also be monitored. Hemoglobin is important because red blood cells use it to carry oxygen from the lungs to the rest of the body, providing energy and strength. When hemoglobin levels are low, anemia can also occur.

Symptoms of anemia include extreme fatigue, dizziness or fainting, feeling cold, difficulty breathing, and depression. In terms of the HIV connection, anemia is linked to higher viral load and lower CD4 counts. For a woman coping with both anemia and HIV, it is not hard to imagine the impact on daily functioning, her quality of life, and her ability not only to receive treatment, but to remain in treatment.

Among the factors linked to anemia in people with HIV are:

  • Being a woman
  • Being African-American
  • Having a lower CD4 count
  • Having a higher viral load
  • Taking Retrovir (AZT)

Recent studies show that maintaining normal hemoglobin levels in women is linked to successful treatment adherence and to maintaining undetectable viral loads after 6 months. In some cases, hemoglobin level may be as useful an indicator for predicting disease progression as CD4 counts and viral load.

Treatment Options

Dr. Keith Rawlings, President of the Integrated Minority Network, Inc. in Dallas, recommends the following strategies for managing anemia in people with HIV:

  • Monitor hemoglobin levels and red blood count
  • Monitor physical functioning and quality of life regularly
  • Determine the treatable causes of anemia
  • Initiate appropriate therapy

The key to corrective treatment is linked to the cause. Women who experience heavy menstrual bleeding may be at increased risk for anemia and may consider gynecological treatment options to decrease bleeding. Is the anemia caused by advanced HIV disease, thus warranting HAART, or is the anemia in fact caused by HAART? Answers may mean either starting a new drug, such as injectable erythropoietin (Epogen or Procrit), or stopping a drug that can cause anemia, such as Retrovir (AZT). Dietary changes, such as increasing foods rich in iron, vitamin B12, and folic acid, can also help.

Women. HIV and Depression

Data from the Women's Interagency HIV Study (WIHS) were analyzed to consider the relationship between chronic depression, HIV disease progression, and mortality. From 1994 through 2001, 1,716 women with HIV from Brooklyn, Bronx, Chicago, Los Angeles, San Francisco, and Washington D.C. were interviewed and given blood tests as part of a research study published in the July 2004 issue of the American Journal of Public Health. The researchers were careful to control for other factors that might be associated with death, such as CD4 and viral load counts, antiretroviral therapy, and the use of drugs such as cocaine and heroin.

The study found that women with both chronic depression and HIV were almost twice as likely to die from AIDS-related causes as HIV-positive women who were not also battling chronic depression, even after controlling for CD4 counts. In 2002, another study in the American Journal of Psychiatry suggested that, like anemia, chronic depression may be a physical condition and not purely a mental health problem. The researchers examined depression, viral load, and the immune system in women with HIV and found a link between depression, increased viral load, and lower levels of natural killer cells.

According to Dr. Judith Rabkin, a clinical psychology researcher at Columbia University, depression manifests in women similarly to anemia:

  • Between 5 and 20% of people with HIV also have major depression
  • Women with HIV are more likely to suffer from depression than men
  • Clinical depression has been consistently associated with poorer medication adherence

Another HCSUS study reported in the August 2001 Archives of General Psychiatry, found that almost half of the over 2,800 people studied experienced some form of psychiatric disorder, signaling the need for appropriate mental health care for women, who are more vulnerable to such conditions. Dr. Eric Bing, lead author of the HCSUS report, observes that multiple HIV-related symptoms are strong signals for health care providers to screen for depression. HIV infection by itself is not a predictor of depression; it is a complex association, not cause, leading providers to consider other factors, such as poverty, violence, and substance abuse, to determine risk and treatment for women.

Treatment Options

Appropriate and sensitive mental health treatment throughout HIV disease has been shown to decrease the death rate of HIV positive women with chronic depression by half.

Individual or group psychotherapy may help with depressive symptoms and provide needed support. Exercise, even though difficult due to fatigue, can actually provide a boost and has been linked to improving mood and energy. Antidepressants should be carefully selected so as not to interfere with antiretrovirals such as Norvir. Providers commonly use a class of antidepressants such as Paxil, Zoloft, and Celexa in the treatment of depression in HIV.


Identifying co-morbid conditions in women with HIV is critical for addressing the disparities in their survival rates compared to men. When two such conditions, anemia and chronic depression, are treated, it leads to improved quality of life and survival rates for women with HIV infection.

According to a recent CDC study of more than 19,500 patients with HIV in ten U.S. cities, women were slightly less likely than men to receive prescriptions for the most effective treatments for HIV infection. When women are 33% more likely to die than men due to delayed treatment, identifying treatable co-morbid conditions that can slow disease progression and risk of death is critical for women's survival.

Similarly, treating chronic depression also leads to increased quality of life and the ability to adhere to treatment. Women need providers who can help them separate the symptoms of HIV, anemia, depression, and the side effects of HIV drugs. Proper and consistent monitoring will lead to early detection, diagnosis, and treatment, which in turn are associated with a decrease in disease progression and mortality.

Both anemia and depression are common in women with HIV disease. Both are treatable, which can lead to increased energy, improved ability to function, and enhanced quality of life. Women, who often carry the weight of the world on their shoulders, need to know that help is available not only to lighten the load, but to help them live healthier and longer.

Kim-Monique Johnson is a health care consultant and is the NYS HIV Prevention Planning Group Community Vice Co-Chair.

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This article was provided by AIDS Community Research Initiative of America. It is a part of the publication ACRIA Update. Visit ACRIA's website to find out more about their activities, publications and services.