Anaemia in HIV Infected Children

Treatment options

Importance of anaemia in HIV

Haematological problems (including anaemia) are common in HIV Anaemia is associated with reduced quality of life. Symptoms: weakness, dizziness, headache, palpitations, breathlessness etc Anaemia is an independent risk factor for early disease progression and death The risk of death decreased among patients who recovered from anaemia

Treatment
Can be difficult and complex Ideally treatment should be directed at the underlying cause Therefore, important to try to identify a cause There is a place for palliative treatment to try to improve the quality of life

Basic mechanisms
Reduced red cell production
Micronutrient deficient: iron, folate, B12 Erythroid bone marrow failure

Increased red cell destruction

Haemolysis

Blood loss
Bleeding

Treatment options
Micronutrient deficiency: nutritional supplementation with iron, folic acid, B12 Myelosuppressive drugs, e.g. AZT, ddI: switch drugs AZT to d4T Opportunistic infections: treat specifically Direct effects of HIV on the haemopoetic marrow

Treatment options
HAART Evidence that HAART helps to improve or correct HIV-related anaemia HAART, use over a long period, also helps prevent the development of anaemia

Treatment options
Erythropoetin: human recombinant erythropoetin e.g. epoetin alfa, EPO HIV associated with a blunted erythropoetin response Increasing level of EPO leads to increased production of RBC with increase in reticulocyte count and PCV within 4 weeks

Treatment options
Good clinical evidence of improvement in patients with mild and moderate anaemia on EPO Also improved Hb in patients with AZT related anaemia Generally safe, no major toxicity Most effective in patients with a low level (<500 U/l) of endogenous EPO at the start

Treatment options

Treatment options
Androgens: oxymetholone, oxandrolone Increase the endogenous production of erythropoetin, leading to increased RBC production Associated with many adverse effects and generally contraindicated in children

Treatment options
Parvovirus B19 Treatment of persistent Parvovirus infection is associated with improvement in RBC production, with increased reticulocyte count and Hb in weeks Intravenous immunoglobulin once a day for 3 days. May need to be repeated

Treatment options
Blood transfusion May be lifesaving and is required for emergency treatment of severe anaemia Has been used to improve the quality of life, by giving regular top-up transfusions Potential risks are many, some yet unknown Eventually leads to iron overload Anecdotal evidence that transfusion may be transiently immunesuppressive

Conclusion
Anaemia is an important problem in HIV Treatment is not always straightforward Investigations to try and identify a cause are mandatory There are promising, new treatments but still inaccessible for most