Magnitude of anemia and its associated factors among adult patients with HIV/AIDS on anti-retroviral therapy at Jinka town public health facilities, South Omo zone, Southern Ethiopia; cross-sectional study

Abstract

Background: Anemia is Public health problem in persons living with Human immune virus/acquired immune deficiency syndrome particularly in peoples taking antiretroviral therapy. It has effect on their quality of life and disease progression to acquired immune deficiency syndrome (AIDS). Studies regarding anemia among Human immune virus/acquired immune deficiency syndrome (HIV/AIDS) patients taking antiretroviral therapy (ART) and its associated factors are scarce specifically in remote areas.

Method: An institution based Cross-sectional study was employed in Jinka town public health facilities from Feb 18, 2019-March 29, 2019. Systematic random sampling method was used, and a total sample size was 422 were determined. Data was entered using Epi data version 4.4 and analyzed by using SPSS version 25 statistical software. Variables which had a p-value ≤ 0.25 in bivariate analysis were considered as candidates for multivariable regression analysis and variables which had a p-value of ≤0.05 in the multivariable analysis were considered as statistically significant.

Result: The overall magnitude of anemia was 33.5 %( 95%CI: 28.8, 38.1). Multivariable analysis showed that unable to read and write (AOR:4.3; 95%CI:1.56,11.96), AZT users(AOR:3.0;95%CI:1.73,5.36), CD4 count less than 200 cells/mm3 (AOR:3.6;95%CI:1.63,8.09) and history of opportunistic infection (AOR:4.3; 95%CI:2.43,7.68) were significantly associated with the occurrence of anemia.

Conclusion:  More than one third of study participants were anemic. Unable to read and write, AZT users, CD4 count less than 200cells/mm³ and history of opportunistic infection were significantly associated with anemia.

Background

Anemia is a condition in which the number of red blood cells and consequently their oxygen carrying capacity is being insufficient to meet the body’s physiologic needs(1, 2). Specific physiologic needs vary with person’s age, gender, residential elevation above sea level (altitude), smoking behavior and different stages of pregnancy(1).

The world health organization (WHO) classifies persons living at sea level as anemic with hemoglobin value below 13 g/dl in men 15 and above years of age, below 12 g/dl in non-pregnant women over 15 years old and below 11 g/dl in pregnant women(3). Globally in 2013, anemia affects 1.93 billion people, which correspond to 27% of the population and developing countries account for more than 89% of the burden (4).

HIV infected individuals are at higher risk of developing hematological abnormalities like anemia. It is the most common hematologic abnormalities in patients with HIV infection and those taking anti-retroviral therapy(5). Prevalence of anemia among adult HIV/AIDS patients taking ART ranging from 23–50% in worldwide (6, 7) and 24–58% in Africa (8, 9).Anemia among adult HIV/AIDS patients taking ART in Ethiopia common problem, with prevalence ranging from 11.4–70.1% (10, 11). It occurs at any stage of HIV infection and severity are correlated with progression of the disease(12). The existence of co-morbid infections, malnutrition, the effect of ART as well as other therapeutics drugs and additional potentially predisposing or worsening conditions increase the probability of anemia in this population(13).

Beside its commonness in people living with HIV, there has been recognized linkage between anemia and decreased survival in this population. Studies have found an association between anemia during established infection and a faster progression to AIDS and death (14–16).The risk of death is up to 70% greater in anemic patients with AIDS compared with their non-anemic counterparts. With anemia in HIV, the need for transfusions is greater(17).

Anemia in HIV/AIDS patients cause fatigue, pale skin, shortness of breath, dizziness and other symptoms associated with impaired physical functioning, psychological distress, and decrements in quality of life, increases HIV disease progression and leads to shorter life expectancy(18). Thus, early diagnosis and treatment of anemia is essential to improve quality of life of the patients.

Though studies on the prevalence of anemia and its associated factors are available, to the best of our knowledge, there is no study conducted in the study area and previous studies did not consider important variables like dietary diversity, meal frequency and coffee or tea drinking, immediately after meal, Viral load. Therefore, this study tries to fill this gap.

Methods

Results

Socio-demographic and economic characteristics of study participants

A total of three hundred eighty eight study participants were involved; with a response rate of 92%. From the total participants, 250(64.4%) were females and the mean age was 34.74(SD± 9.23) years’. Among the total study groups, 146(37.6%) were in the age group of 30-39 years. More than half (64.4%) of the respondents were females. Regarding their residence, maximum of the respondents (89.7%) were come from urban area (Table 1).

Medication Related factor

From the total participants, 182 (46.9%) were taking ART containing AZT and 144(37.1%) of the respondents taken ART for 6-20 months and small proportion of respondents (16.2%) taken for more than five years (Table 2).

WHO staging and Comorbidity

The proportion of respondents categorized under WHO stage I, II, III and IV were 58%, 17%, 19% and 6% respectively. Forty-six (11.9%) of study participants had a history of malaria, 83(21.4%) of the study participant had a history of intestinal parasites and 23 (5.9%) of study participant had history of chronic illness. From the total participants, 163(42.0%) have had an opportunistic infection and 382(98.5%) were in working functional status.

Hematological and Nutritional Factor

The mean CD4 count of the respondents was 401± 186.5. The majority of the respondents (85.6%) have CD4 count >200cells/mm³ and 30 (7.7%) have had viral load >1000. Regarding the study participants nutritional status, nearly two third of the respondents (67%) had BMI at range of 18.5-24.9kg/m² and the remaining 15.2% and 7.8% of the respondents have a BMI under the category of below 18kg/m² and 25kg/m² and above respectively.  

The mean dietary diversity among study participant was 5.5±1.8. The number of food group consumed ranged from 1-9 and 52.8% of study participants having consumed above the mean (Table 3). Mean meal frequency among study participants was 3.6(±0.8). The range of meal frequency was 1-7 (Table 4).

Magnitude of Anemia among adult PLWHA patients taking ART

The mean ±SD hemoglobin level of study participant was 12.6 (±1.7). The overall magnitude of anemia among PLWHA in Jinka town public health facilities was130 (33.5%) ;( 95% CI: 28.8-38.1). Among those who were anemic, 69(17.8%) ;( 95% CI 14.0-21.6) had mild form of anemia, 53(13.7%); (95% CI: 10.3-17.1) moderate form of anemia and eight (2.1%) ;( 95% CI: 0.7-3.5) had severe form of anemia.

Among those who were anemic magnitude of anemia among adult male PLWHA, taking ART was 31.5% and female adult PLWHA taking ART was 68.5%.

Factors Associated with Anemia among study participant

Educational statuses, Type of ART drugs, CD4 count, History of opportunistic infection were significantly associated with Anemia. In this study, the odds of anemia among those participants who were unable to read and write were 4 times higher as compared to odds of anemia among college and above (AOR=4.33, 95% CI: 1.56, 11.96). The odds of anemia among participants who were taking AZT containing regimen were 2.9 times higher as compared to not taking AZT containing regimen (AOR=3.0, 95% CI: 1.73, 5.36). The odds of the likelihood of anemia among those participants with CD4 count less than 200 cells/mm³ were 3.6 times higher as compared to participants with CD4   count >200 cells/mm³ (AOR=3.6, 95% CI: 1.63, 8.09). The odds of anemia among participants having a history of opportunistic infection were 4.3 times higher as compared to odds of those without history of opportunistic infection (AOR=4.3, 95% CI: 2.43, 7.68) (Table 5).

Discussion

This study assessed magnitude and factors associated with anemia among people living with HIV/AIDS taking ART in Jinka town public health facilities, southern Ethiopia. It is clear that anemia is most common hematologic abnormalities in persons with HIV patients taking ART. The finding of this study revealed that, 33.5% of HIV/AIDS patients taking ART developed anemia. This study finding is higher than the research finding from Addis Abeba and Debretabor(10, 19). The higher magnitude of anemia in this study might be attributed to a relatively higher proportion of AZT users which is one of the factors for development of anemia.

However, this figure is lower than the studies conducted in Arba Minch and Gondar (11, 20). This variation may due to, in this study, the number of participant with CD4 count less than 200cells/mm³ is relatively lower than from Arba Minch and the other reason for the difference with study in Gondar may be selection of study participants where only 86% were on ART. This finding is also much lower than study from Iran, Nepal and Nigeria, ranging from 55.8% and 71% (21–23). This variation may be attributed to in our study participants in late WHO HIV/AIDS staging were lower and there is difference in study participants.

In this study, significant association between educational status and anemia were observed. Accordingly, participants unable to read and write were four times more likely to develop anemia as compared to participants with college and above educational status. This finding is consistent with study in Gondar (11). This may be due to participants who have college and above are aware about the benefit of appropriate nutrition consumption/and or have high socioeconomic condition compared to those who were unable to read and write.

Type of ART drugs was significantly associated with occurrence of anemia in this study. As a result, patients who were taking AZT containing regimen were nearly 3 times more likely to develop anemia as compared to patients who were not taking AZT containing regimen. This finding supported by study done in South Africa (24), North western Tanzania (25), Tikur Anbessa specialized hospital (26) and Debretabor hospital (19). This is usually due to the side effect of the ART drug AZT resulting in manifestation of granulocytopenia, anemia, malaise, fatigue, and other gastrointestinal symptoms(27).

CD4 count found to be significantly associated with the occurrence of anemia in this study. Those patients who have had CD4 count of less than 200cells/mm3 were 3.6 times more likely to have anemia as compared to patients who have had CD4 count of 200cells/mm3 or more. Similar results reported in studies done at South Africa (24), Debretabor hospital (19) and Arba Minch town public health facilities(20). The possible explanation for this association might be due to the decrease in CD4 count of HIV infected individuals lead to increase in progression of the disease(28).

Opportunistic infection was associated with likelihood of developing anemia in this study. Those patients who have had history of opportunistic infection were 4.3 times more likely to have anemia as compared to patients who have no history of opportunistic infection. The possible reason might be, these opportunistic infections may also cause dietary problems which would led to nutritional deficiencies and problems of absorbing nutrients which in turn would led to anemia(29).

Conclusion

More than one third of study participants were anemic. In multivariable analysis participants who were unable to read and write, participants taking AZT based regimen, having CD4 count less than 200cell/mm3 and history of opportunistic infection were factors that increase the odds of anemia.

Therefore, strength the procedures for the early diagnosis of opportunistic infection, frequent monitoring of HIV-infected individuals CD4 count and in addition monitor hemoglobin level on each of the follow up periods by focusing on those people taking ART drug regimen containing AZT and take appropriate action to combat anemia if detected.

Abbreviations

AIDS: Acquired immune deficiency syndrome

AOR: Adjusted odd ratio

ART: Anti retro viral therapy

AZT: Zidovudine

BMI: Body mass index

CD4: Cluster of differentiation 4

COR: Crude odd ratio

Hgb: Hemoglobin

HIV: Human Immune virus

OI: Opportunistic infections

PLWHI: Peoples living with HIV/AIDS

WHO: World health organization

Declarations

Ethics approval and consent to participate

The ethical clearance was obtained from ethical review board of Arba Minch University, college of medicine and health sciences Institutional review board. Support letter was obtained from South Omo zone health Bureau.  After explaining the purpose of the study, permission was obtained from the Hospital administrators and the medical Director. Written informed consent was obtained from all study participants. Privacy and Confidentiality were maintained throughout the whole period.

Consent for publication

Not applicable

Availability of data and materials

The data sets generated and/or analyzed are available with a reasonable request through the corresponding author.

Competing interest

I declare that all the authors have no any conflict of interest.

Funding

Not applicable

Author’s contribution

YS conceived and designed the study, supervise the data collection, analyze the data and draft the manuscript. SD, MG and EZ supervise the data collection, analyze the data and reviewed the manuscript critically. All authors read and approve the final manuscript.

Acknowledgement

We would like to acknowledge Arba Minch University College of medicine and health sciences, all the staffs of Jinka Town public health facilities, Study participants and data collectors for their support and encouragement.

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Tables

Table 1: Socio demographic and economic characteristics of PLWHA on ART in Jinka town public health facilities, South Omo zone, Southern Ethiopia, June 2019(n=388)

Table 2:Medication related PLWHA taking ART in Jinka town public health facilities, South Omo zone, Southern Ethiopia, June 2019(n=388)

N.B: 1c=AZT+3TC+Nevirapine, 1d=AZT+3TC+Evaferenz, 1e=TDF+3TC+Evaferenz, 1f=TDF+3TC+Nevirapine

Table 3: Most frequent consumed food groups during 24 hour recall among total sample size (n=388) in Jinka town public health facilities, southern Ethiopia, June 2019.

Table 4: Meal frequency among PLWHA in Jinka town public health facilities), Southern Ethiopia, 2019(n=388).

Table 5:Bivariate and multivariable analysis of factor associated with anemia among adult PLWHA taking ART in Jinka town public health facilities, South Omo zone, Southern Ethiopia, 2019 (n=388)