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Hemoglobin concentration increment is associated with a
better prognosis in HIV patients with anemia
The most used biological markers in HIV patients are the CD4
count1and HIV-1 RNA level,1as they are independent predictors of
survival. Other markers of disease severity are clinical manifesta-
tions,2compliance to treatment,3and hematological alterations.4
These alterations are due to many factors including the direct
effect of HIV on hematopoietic cells, opportunistic infections,
drugs, and chronic inflammation.4Anemia is the most common
hematological abnormality in HIV patients and has been shown to
be associated with disease progression.5It is usually normocytic
and normochromic, with a low reticulocyte level.6Almost 95% of
HIV patients present anemia during the course of the disease.5
Furthermore, it has been demonstrated that anemia is associated
with increased mortality, and that mortality decreases when
anemia is resolved.5,7This characterizes hemoglobin concentra-
tion (Hb) as an independent mortality factor, regardless of the
baseline CD4 count.5The objective of the current study was to
evaluate the impact of Hb increment on mortality in HIV patients.
We reviewed the data of 701 consecutive HIV patients followed
at our institution between August and November 2009.6Among
these patients, 261 had anemia (Hb < 12.0 g/dl for women and
<14.0 g/dl for men). Hb of 167 patients was registered 3 months
after the first evaluation. After 2 years of follow-up, the number of
deaths was recorded. Statistical analyses were performed using SAS
version 9.1 (SAS Institute Inc., Cary, NC, USA). A p-value of less than
0.05 was considered significant.
A total of 83 patients presented Hb increments (median 0.9 g/
dl; range 0.1–5.6 g/dl), of whom only six died. In parallel, 27 deaths
were seen in the group of 84 patients who had no increment (odds
ratio 6.079; confidence interval 2.354–15.7; p < 0.0001) (Figure 1).
Anemia is the most common hematological abnormality
observed in HIV patients.5It is associated with a reduced quality
of life and an increased disease severity.5,7Hemoglobin level is a
marker of severity in a number of diseases, such as cancer.8In HIV
infection it is a reliable predictor of disease progression,5–7and, as
can be seen in this study, the persistence of anemia for more than
3 months identifies a group of patients with a higher death rate.
In conclusion, patients whose Hb increased showed a signifi-
cantly reduced mortality. Once it becomes an inexpensive and
sensitive test, accessible to emergent countries, the determination
of Hb could be a useful marker of disease progression and severity,
and permit the identification of a group of patients more
vulnerable to complications who deserve special care.
Conflict of interest: The authors have no conflicts of interest to
Ethical approval: This study was approved by the local ethics
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Denise Menezes Brunettab
Fernando Crivelenti Vilara
Alcyone Artioli Machadoa
Gil Cunha De Santisb,*
aInfectious Diseases, Medical School of Ribeirao Preto,
University of Sao Paulo, Sao Paulo, Brazil
bCenter for Cell Based Therapy, Medical School of Ribeirao Preto,
University of Sao Paulo, Rua Tenente Cata ˜o Roxo, 2501, Campus
Universita ´rio, CEP 14051-140, Ribeirao Preto, SP, Brazil
*Corresponding author. Tel.: +55 16 21019300;
fax: +55 16 21019309.
E-mail address: firstname.lastname@example.org (G.C. De Santis).
Corresponding Editor: William Cameron, Ottawa, Canada
21 November 2011
International Journal of Infectious Diseases xxx (2012) xxx.e1–xxx.1
Figure 1. Kaplan–Meier curve of survival for HIV patients by hemoglobin
IJID-1463; No. of Pages 1
Please cite this article in press as: Nardo M, et al. Hemoglobin concentration increment is associated with a better prognosis in HIV
patients with anemia. Int J Infect Dis (2012), http://dx.doi.org/10.1016/j.ijid.2012.04.008
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