Severe anaemia complicating HIV in Malawi; Multiple co-existing aetiologies are associated with high mortality.

Minke H W Huibers,Sarah E Coupland,Job C Calis,Theresa J Allain,Kamija S Phiri,Michael Boele Van Hensbroek,Chimota Phiri,Imelda Bates,Steve Mckew

doi:10.1371/journal.pone.0218695

Abstract

Severe anaemia is a major cause of morbidity and mortality in HIV-infected adults living in resource-limited countries. Comprehensive data on the aetiology are lacking but are needed to improve outcomes. HIV-infected adults with severe (haemoglobin ≤70g/l) or very severe anaemia (haemoglobin ≤ 50 g/l) were recruited at Queen Elizabeth Central Hospital, Blantyre, Malawi. Fifteen potential causes and associations with anaemia severity and mortality were explored. 199 patients were enrolled: 42.2% had very severe anaemia and 45.7% were on ART. More than two potential causes for anaemia were present in 94% of the patients including iron deficiency (55.3%), underweight (BMI<20: 49.7%), TB infection (41.2%) and unsuppressed HIV infection (viral load >1000 copies/ml) (73.9%). EBV/CMV co-infection (16.5%) was associated with very severe anaemia (OR 2.8 95% CI 1.1-6.9). Overall mortality was high (53%; 100/199) with a median time to death of 17.5 days (IQR 6-55) days. Death was associated with folate deficiency (HR 2.2; 95% CI 1.2-3.8) and end stage renal disease (HR 3.2; 95% CI 1.6-6.2). Mortality among severely anaemic HIV-infected adults is strikingly high. Clinicians should be aware of the urgent need for a multifactorial approach including starting or optimising HIV treatment, considering TB treatment, nutritional support and optimising renal management.

Highlights

Anaemia is recognized as the most common haematological complication of Human Immunodeficiency Virus (HIV) infection worldwide [1,2] The World Health Organization (WHO) defines anaemia as a haemoglobin level below 110–120 g/l
199 patients were enrolled: 42.2% had very severe anaemia and 45.7% were on Antiretroviral treatment (ART)
More than two potential causes for anaemia were present in 94% of the patients including iron deficiency (55.3%), underweight (BMI

Summary

Introduction

Anaemia is recognized as the most common haematological complication of Human Immunodeficiency Virus (HIV) infection worldwide [1,2] The World Health Organization (WHO) defines anaemia as a haemoglobin level below 110–120 g/l. To prevent and treat severe anaemia in HIV-infected patients, a comprehensive understanding of the aetiology and pathophysiology is essential. A few studies have comprehensively studied the multifactorial aetiology and pathophysiology of HIV-associated severe anaemia in sub-Saharan Africa despite the high burden of HIV infection in this region [2]. Evidence to inform preventive or treatment guidelines for severe anaemia in HIV-infected patients in sub-Saharan Africa is scarce. Severe anaemia management in HIV-infected patients is often still based on the same strategies used for non-HIV infected patients, including iron supplementation, malaria treatment and deworming [2,15]. Comprehensive data on the aetiology are lacking but are needed to improve outcomes

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