title: Practical Management of HIV-Associated Anemia in Resource-Limited Settings: Prospective Observational Evaluation of a New Mozambican Guideline.
abstract: Mozambique's updated guideline for management of HIV-associated anemia prompts clinicians to consider opportunistic conditions, adverse drug reactions, and untreated immunosuppression in addition to iron deficiency, intestinal helminthes, and malaria. We prospectively evaluated this guideline in rural Zambézia Province. Likely cause(s) of anemia were determined through prespecified history, physical examination, and laboratory testing. Diagnoses were "etiologic" if laboratory confirmed (sputum microscopy, blood culture, Plasmodium falciparum malaria rapid test) or "syndromic" if not. To assess hemoglobin response, we used serial point-of-care measurements. We studied 324 ambulatory, anemic (hemoglobin <10 g/dl) HIV-infected adults. Study clinicians treated nearly all [315 (97.2%)] for suspected iron deficiency and/or helminthes; 56 (17.3%) had laboratory-confirmed malaria. Other assigned diagnoses included tuberculosis [30 (9.3%)], adverse drug reactions [26 (8.0%)], and bacteremia [13 (4.1%)]. Etiologic diagnosis was achieved in 79 (24.4%). Of 169 (52.2%) subjects who improved (hemoglobin increase of ≥1 g/dl without indications for hospitalization), only 65 (38.5%) received conventional management (iron supplementation, deworming, and/or antimalarials) alone. Thirty (9.3%) died and/or were hospitalized, and 125 (38.6%) were lost to follow-up. Multivariable linear and logistic regression models described better hemoglobin responses and/or outcomes in subjects with higher CD4(+) T-lymphocyte counts, pre-enrollment antiretroviral therapy and/or co-trimoxazole prophylaxis, discontinuation of zidovudine for suspected adverse reaction, and smear-positive tuberculosis. Adverse outcomes were associated with fever, low body mass index, bacteremia, esophageal candidiasis, and low or missing CD4(+) T cell counts. In this severely resource-limited setting, successful anemia management often required interventions other than conventional presumptive treatment, thus supporting Mozambique's guideline revision.
authors.affiliation: 1 Friends in Global Health , LLC, Maputo, Mozambique, and Quelimane, Mozambique .
authors.forename: Paula E
authors.initials: PE
authors.lastname: Brentlinger
authors.affiliation: 1 Friends in Global Health , LLC, Maputo, Mozambique, and Quelimane, Mozambique .|2 Vanderbilt Institute for Global Health, Vanderbilt University , Nashville, Tennessee.|3 Department of Pathology, Microbiology, and Immunology, Vanderbilt University , Nashville, Tennessee.
authors.forename: Wilson P
authors.initials: WP
authors.lastname: Silva
authors.affiliation: 1 Friends in Global Health , LLC, Maputo, Mozambique, and Quelimane, Mozambique .|2 Vanderbilt Institute for Global Health, Vanderbilt University , Nashville, Tennessee.|4 Department of Pediatrics, Vanderbilt University , Nashville, Tennessee.
authors.forename: Sten H
authors.initials: SH
authors.lastname: Vermund
authors.affiliation: 1 Friends in Global Health , LLC, Maputo, Mozambique, and Quelimane, Mozambique .|5 Department of Health Policy, Vanderbilt University , Nashville, Tennessee.
authors.forename: Emilio
authors.initials: E
authors.lastname: Valverde
authors.affiliation: 1 Friends in Global Health , LLC, Maputo, Mozambique, and Quelimane, Mozambique .
authors.forename: Manuel
authors.initials: M
authors.lastname: Buene
authors.affiliation: 1 Friends in Global Health , LLC, Maputo, Mozambique, and Quelimane, Mozambique .|2 Vanderbilt Institute for Global Health, Vanderbilt University , Nashville, Tennessee.|4 Department of Pediatrics, Vanderbilt University , Nashville, Tennessee.
authors.forename: Troy D
authors.initials: TD
authors.lastname: Moon
mesh_terms: D000328:Adult; D000740:Anemia / Q000175:diagnosis / Q000188:drug therapy* / Q000473:pathology; D000871:Anthelmintics / Q000627:therapeutic use; D019380:Anti-HIV Agents / Q000627:therapeutic use; D000962:Antimalarials / Q000627:therapeutic use; D000995:Antitubercular Agents / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D060085:Coinfection; D003906:Developing Countries; D019468:Disease Management; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000821:virology; D006373:Helminthiasis / Q000175:diagnosis / Q000188:drug therapy* / Q000469:parasitology; D006454:Hemoglobins / Q000378:metabolism; D006801:Humans; D059012:Lost to Follow-Up; D016778:Malaria, Falciparum / Q000175:diagnosis / Q000188:drug therapy* / Q000469:parasitology; D008297:Male; D009073:Mozambique; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012424:Rural Population; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis / Q000188:drug therapy* / Q000382:microbiology
chemical_list: D000871:Anthelmintics; D019380:Anti-HIV Agents; D000962:Antimalarials; D000995:Antitubercular Agents; D006454:Hemoglobins