title: Resolution of anaemia in a cohort of HIV-infected patients with a high prevalence and incidence of tuberculosis receiving antiretroviral therapy in South Africa.
abstract: BACKGROUND
  Anaemia is frequently associated with both HIV-infection and HIV-related tuberculosis (TB) in antiretroviral therapy (ART)-naïve patients in sub-Saharan Africa and is strongly associated with poor prognosis. However, the effect of ART on the resolution of anaemia in patient cohorts with a high prevalence and incidence of tuberculosis is incompletely defined and the impact of TB episodes on haemoglobin recovery has not previously been reported. We therefore examined these issues using data from a well-characterised cohort of patients initiating ART in South Africa.
  
  
  METHODS
  Prospectively collected clinical and haematological data were retrospectively analysed from patients receiving ART in a South African township ART service. TB diagnoses and time-updated haemoglobin concentrations, CD4 counts and HIV viral loads were recorded. Anaemia severity was classified according to WHO criteria. Multivariable logistic regression analysis was used to determine factors independently associated with anaemia after 12 months of ART.
  
  
  RESULTS
  Of 1,140 patients with baseline haemoglobin levels, 814 were alive in care and had repeat values available after 12 months of ART. The majority of patients were female (73%), the median CD4 count was 104 cells/uL and 30.5% had a TB diagnosis in the first year of ART. At baseline, anaemia (any severity) was present in 574 (70.5%) patients and was moderate/severe in 346 (42.5%). After 12 months of ART, 218 (26.8%) patients had anaemia of any severity and just 67 (8.2%) patients had moderate/severe anaemia. Independent predictors of anaemia after 12 months of ART included greater severity of anaemia at baseline, time-updated erythrocyte microcytosis and receipt of an AZT-containing regimen. In contrast, prevalent and/or incident TB, gender and baseline and time-updated CD4 cell count and viral load measurements were not independent predictors.
  
  
  CONCLUSIONS
  Although anaemia was very common among ART-naive patients, the anaemia resolved during the first year of ART in a large majority of patients regardless of TB status without routine use of additional interventions. However, approximately one-quarter of patients remained anaemic after one year of ART and may require additional investigations and/or interventions.
authors.affiliation: George Washington University School of Medicine and Health Sciences, 2300 I St, NW, 20037, Washington, DC, USA. andrewkerkhoff@gmail.com.|Department of Global Health, Academic Medical Center, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, the Netherlands. andrewkerkhoff@gmail.com.|The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. andrewkerkhoff@gmail.com.
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Kerkhoff
authors.affiliation: The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. Robin.Wood@hiv-research.org.za.
authors.forename: Robin
authors.initials: R
authors.lastname: Wood
authors.affiliation: Department of Global Health, Academic Medical Center, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, the Netherlands. frank.cobelens@kncvtbc.org.|KNCV Tuberculosis Foundation, The Hague, the Netherlands. frank.cobelens@kncvtbc.org.
authors.forename: Frank G
authors.initials: FG
authors.lastname: Cobelens
authors.affiliation: Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK. ankurgupta@doctors.org.uk.
authors.forename: Ankur
authors.initials: A
authors.lastname: Gupta-Wright
authors.affiliation: The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. Linda-Gail.Bekker@hiv-research.org.za.
authors.forename: Linda-Gail
authors.initials: LG
authors.lastname: Bekker
authors.affiliation: The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. Stephen.Lawn@lshtm.ac.uk.|Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK. Stephen.Lawn@lshtm.ac.uk.
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Lawn
mesh_terms: D000328:Adult; D000740:Anemia / Q000097:blood* / Q000453:epidemiology; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D015897:Comorbidity; D005260:Female; D015658:HIV Infections / Q000097:blood / Q000188:drug therapy* / Q000453:epidemiology; D006454:Hemoglobins / Q000032:analysis*; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008297:Male; D015995:Prevalence; D012189:Retrospective Studies; D013019:South Africa / Q000453:epidemiology; D016896:Treatment Outcome; D014376:Tuberculosis / Q000097:blood* / Q000453:epidemiology
chemical_list: D006454:Hemoglobins