This study assessed the time to detection of anemia and its predictors among time to detection of anemia and its predictors among children receiving Antiretroviral Therapy at Debre Tabor referral Hospital and university of Gonder Compressive Specialized Hospital, Ethiopia, Northwest, Ethiopia; 2020. Almost one-in-six HIV infected children (16.5%, n = 58) with anemia were recorded in the follow-up period. The incidence rate of anemia was 6.9 per 100 child-years. Moreover, the median survival time was 137 months. WHO clinical staging III/IV, CD4 count below the threshold level, CPT non-user, poor adherence, and before test and treat strategies (pre-ART) were found to be the main predictors of anemia.
Our finding is comparable with a cohort study conducted in northwest Ethiopia in 2012 and 2017, were 19.8% and 12.26% respectively27,28. Moreover, a cross sectional study in Addis Ababa, Ethiopia in 2016 was 17.59%29. This could be justified in two ways. Firstly, cut-off value of Hgb to define anemia. Secondly, study participants having similar age group (i.e.., children < 15 years). In addition to this, it may be due the data extraction tools of all studies were prepared from a standard HIV/AIDS Care and treatment guidelines ART service in Ethiopia.
However, this study showed a lower incidence rate of anemia than a cross sectional and prospective cohort in India were 21.9%30 and 47.1%31 respectively. In Jimma, Ethiopia in 2007, was 21.9%30, in Nigeria among aged between 5 and 12 years, was 54.2%32, in Cameron from November 2012 to May 2013, was 49.6% 12, in South Africa, was 73% 33, in Gahan 2091 among under Five Years, was 53.8%34, Malawi, was 45.7%9, in Mozambique among 6–59 months of children, was 88%7, in Kenya 2008, was 35.9%23, and in Tanzania in 2015, was 27.7% respectively19. This difference could be due to the cut-off point of anemia, study design since most of the above studies were cross sectional, whereas our study was a cohort. In addition, the variations might be due to the difference in the study area, duration of time on ART, and differences in the follow-up periods. A shorter follow-up period is likely to find a higher probability of anemia when compared with a study with a longer follow-up period. Besides, the discrepancy may be due to monitoring of anemia in every three months in our study area whereas frequently in others settings. Likewise, the discrepancy may be due to the study participants (i.e. aged b/n 5–12 years and under five years).
On the other hand, the incidence rate of anemia has been observed in this study is higher than a study conducted in Hawassa Ethiopia, in 2018, which was 11.4%35. In Asia-Pacific region, between January 2003 and September 2013, severe anemia was 5.5%36, a study conducted from November 2007 to June 2009 in the region of Africa, 4.8% of children with severe anemia20 in 2016 Uganda, Anemia was 11.8% among 12–14 years respectively37. This difference could be explained by the differences in the outcome measurement, ethnicity, sample size, study design, and follow up period. Moreover, the heterogeneity of the data inherent in a multinational cohort, the type’s health care service and study setting.
Children who were WHO clinical staging III and IV increased a risk of anemia by 4.2 times as compared with WHO clinical staging I and II. The median duration of free from anemia was significantly shorter in persons with WHO clinical staging III and IV in follow-up period. The finding is in line with a study from Mozambique, west Africa, and Kenya 7,20,23. This might be due to having advanced WHO clinical staging might compromise immunity, and can lead to severe illness due to viral replication, depletion of CD4 count, and the added burden of disease. Moreover, children who had CD4 count below the threshold level were increased a risk of anemia by 1.9 times as compared with CD4 count above the threshold level. Besides, the median survival time of free from anemia was significantly longer time in persons with CD4 count above the threshold level. This finding was also supported by several studies conducted in Asia, Malawi, and Nigeria 3,9,32. Moreover, the finding was also similar in a study conducted in Black Lion and Zewuidtu referral hospital in Ethiopia < 350 cells/µl 21,22. This could be explained by low CD4 count elicited dysfunction of the immune system and increased vulnerability of the host to infection, immunological deficiency that enhances the severity of the disease, and delayed recovery time and increase viral load across time.
Children who were CPT non-users increased the risk 2.2 times higher than those who had those CPT users. A study conducted in Ethiopia revealed that CPT non-users anemia as an independent predictor of anemia38. Moreover, the median survival time of free from anemia was significantly shorter in persons with CPT non-users. Indeed, CPT can prevent or reduce the occurrence of opportunistic infection and further complication, therefore, it is important to increase the immune status of the children to decrease viral replication which increases their survival rate by preventing and treating OI infection of which is supported, by a study conducted northwest Ethiopia24. CPT prophylaxis has been recommended for the benefit of HIV/AIDS-infected individuals to prevent opportunistic infection since it is a simple and effective intervention to reduce morbidity, and to improve the quality 39. Besides, children presenting with poor level of adherence was increased a risk of anemia by 2.4 times as compared with good level of adherence. Furthermore, the median of survival time to develop anemia was significantly longer time in persons with good level of adherence. This could be explained poor level of adherence has been shown to influence the natural history of HIV disease by accelerating the rate of disease progression, opportunistic infection, and mortality. Moreover, counseling about the importance of adherence has been provided in ART service to prevent opportunistic infection since it is a simple and effective intervention.
This study has some limitations. First, data were collected from routine medical care records and there were limited data on possible predictors of anemia, such as viral load level and psychological support. Second, age, educational, and occupation status of the care givers, as the presence of these variables might be causal for the occurrence of anemia during the initiation of ART.