Anemia has always been a problem for HIV+ people. Almost half of all HIV+ people have mild or moderate anemia. Factors that are linked to a higher rate of anemia in HIV+ people include:

• Being a woman
• Being African-American
• Lower CD4 cell counts
• Higher viral load
• Taking AZT (Retrovir or zidovudine)

Although anemia is a common condition for HIV+ women, it often goes unrecognized and untreated. If left untreated, anemia is strongly associated with HIV disease progression and an increased risk of death. In fact, recent studies show that low hemoglobin levels may be as useful an indicator for predicting disease progression as low CD4 cell counts and other common prognostic methods. The good news is that with diagnosis and treatment the affects of anemia can be greatly reduced.

Anemia and HAART

Although the rate of serious anemia has dropped considerably since people started using HIV drug combinations, anemia continues to affect up to 30% of HIV positive people on HAART. 

Recent studies show that when starting HAART treatment, individuals with a hemoglobin level greater than 12 were more likely to adhere to treatment and achieve viral suppression within 6 months. These study results suggest that treating hemoglobin may produce better outcomes for adherence and viral suppression. 

Anemia is a shortage of red blood cells. It occurs:

• When the body produces too few red blood cells
• When the body loses too many red blood cells
• When red blood cells are destroyed faster than they can be replaced

Anemia can also occur when there is a shortage of hemoglobin (HGB). HGB is a protein found in red blood cells. Its job is to carry oxygen from the lungs to the rest of the body. People who have anemia cannot carry as much oxygen in their blood and don't feel as good as people with a normal level of HGB.

Anemia causes fatigue and can lower quality of life. Symptoms include:

• Severe fatigue
• Difficulty breathing
• Rapid heart rate
• Pale skin
• Decreased pinkness of the lips, gums, lining of the eyelids, nail beds, and palms
• Feeling cold
• Confusion or loss of concentration
• Dizziness or fainting
• Sadness or depression

Among HIV+ women, anemia is often caused by a shortage of iron, vitamin B12, or folic acid (a vitamin in the B complex group).

• Low iron is most commonly due to blood loss from internal bleeding, frequent nosebleeds, or excessive or prolonged menstrual periods
• A shortage of folic acid can lead to megaloblastic anemia. This causes the red blood cells to become pale and enlarged

Other causes of anemia include:

• HIV infection itself
• Many opportunistic infections related to HIV disease
• Kidney or bone marrow damage
• Some thyroid conditions
• Many drugs that are commonly used to treat HIV and related infections

Simple blood tests can usually diagnose anemia by measuring hemoglobin and hematocrit (the percentage of red blood cells in the total blood volume) as part of a complete blood count (CBC).

• Hemoglobin levels for women should be at least 12 g/dL. A hemoglobin level of less than 6.5 g/dL is too low and could lead to a life-threatening situation
• Hematocrit levels for women should be 35 percent to 46 percent

Treating anemia improves the health and survival of HIV+ people. Like most conditions, the key to treating anemia is directly linked to the cause. If chronic bleeding is the main source of the problem, it should be identified and controlled.

If iron levels are low, they should be corrected. (Iron is often low in women.) Taking iron tablets can restore levels, but too much iron isn't a good thing.

Some studies show that supplementing with iron should be done with caution in people with HIV infection, HCV infection, or both because iron has been shown to make some drugs less effective. There is also a suggestion that iron might increase HIV replication.

If your anemia is due to a shortage in iron or vitamins, you may be able to modify your diet to include foods rich in these nutrients. Iron is found in red meat, seafood, fish, and fortified bread and cereals. Folic acid is found in dark greens, asparagus, lima beans, spinach, and beef liver. If your vitamin B12 levels are low, you may need B12 injections or formulations of B12 you put under your tongue, no matter how much you get in your diet. This is because some people cannot absorb this vitamin from food or oral supplements.

If a drug you are taking is causing anemia, it may be necessary to stop taking that drug. When advanced HIV is the cause of anemia, HIV treatment may improve symptoms.

There are also medications available to treat anemia directly. These include the injectable drug erythropoietin (EPO, Epogen, and Procrit), which has been used to treat mild-to-moderate anemia. In some cases, blood transfusions may be required.

Anemia is a common condition in HIV+ women. It can cause feelings of fatigue, lower your quality of life and increase the risk of HIV disease progression. If you are experiencing any of the symptoms listed above, talk to your doctor. He or she can run tests to determine if anemia is the problem. If so, your doctor will look for the cause of the anemia and suggest treatment options.

1		Keruly, J.C. & Moore, R.D. (2003). The relationship between hemoglobin and HIV-1 viral load with receipt of first HAART regimen. Poster Presentation at the 2003 IDSA Annual Meeting.
2		Levine, A.M., et. al. (2001). Prevalence and correlates of anemia in a large cohort of HIV-infected women: Women’s interagency HIV study. Journal of Acquired Immune Deficiency Syndromes 26(1). 28-35.
3		Nadler, J.P. (2003). Anemia prevalence among HIV patients: Antiretroviral therapy and other risk factors. Poster Presentation at the 2003 IAS Annual Meeting.
4		Semba, R.D., et. al. (2002). Prevalence of iron deficiency and anemia among female injection drug users with and without HIV infection. Journal of Acquired Immune Deficiency Syndromes 29(2). 142-144.