Treating anaemia in the era of HIV: evidence from Malawi

Severe anaemia is common among non-pregnant adults admitted to hospital in Malawi. Few diagnostic tools are available, so standard practice for many years has been treatment for iron deficiency, worms and malaria. But now that more than half of adults admitted to medical wards have HIV, is this practice still valid?

Anaemia in people with HIV isusually the result of a number of factors including nutritional deficienciesand infections. Researchers working at the Queen Elizabeth Central Hospital inBlantyre, Malawi, investigated 105 severely anaemic patients for parasitic,infectious and nutritional causes of anaemia. They aimed to give hospitalclinicians an idea of likely treatable causes when facing this commonlife-threatening problem with limited diagnostic tools.

They found that:

• 83 patients (79percent) were HIV-positive and 56 were defined as having AIDS.
• One third ofpatients had TB and these were more likely than others to be HIV-positive.
• Bacterial bloodstream infections – most commonly non-typhisalmonella – were found in 21 percent of patients.
• Iron deficiency,hookworm infection and malaria were not common in HIV-positive anaemic adults.
• However, irondeficiency was more common in HIV-negative patients and heavy hookworminfections were found in 27 percent of the 22 HIV-negative anaemic adults.

Overall more than half ofthese patients had a potentially treatable infection that could cause anaemia. TBwas the most common, followed by bacterial bloodstream infection. A significantnumber of these cases showed no symptoms of the infection or had symptoms whichcould be confused with other diseases, such as malaria. In a few casesdiagnosis of TB was only made on bone marrow culture.

The researchers concludethat:

• In settings withhigh prevalence of HIV and infectious disease, current treatment for malaria,hookworm and iron deficiency is unlikely to be effective against anaemia.
• Instead,clinicians should investigate patients for TB and consider giving antibiotics effectiveagainst intestinal bacteria such as salmonella.
• A trial of TBtreatment may occasionally be justified in HIV-positive severely anaemicpatients when other causes of anaemia have been ruled out.

They point out that furtherstudies will be needed to prove that treating these infections reduces anaemiaand to investigate causes of anaemia at the community level, which may well bedifferent.