Anemia, Iron Deficiency, and Iron Supplementation in Relation to Mortality among HIV-Infected Patients Receiving Highly Active Antiretroviral Therapy in Tanzania

Batool A. Haider Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts;
Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts;

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Donna Spiegelman Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts;
Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts;
Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts;
Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts;

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Ellen Hertzmark Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts;

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David Sando Management and Development for Health, Dar es Salaam, Tanzania;

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Christopher Duggan Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts;
Center for Nutrition, Boston Children’s Hospital, Boston, Massachusetts;

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Abel Makubi Management and Development for Health, Dar es Salaam, Tanzania;
School of Medicine, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania

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Christopher Sudfeld Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts;

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Eric Aris Management and Development for Health, Dar es Salaam, Tanzania;

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Guerino E. Chalamilla Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts;
Management and Development for Health, Dar es Salaam, Tanzania;

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Wafaie W. Fawzi Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts;
Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts;
Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts;

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Anemia in HIV-infected patients improves with highly active antiretroviral therapy (HAART); however, it may still be associated with mortality among patients receiving treatment. We examined the associations of anemia severity and iron deficiency anemia (IDA) at HAART initiation and during monthly prospective follow-up with mortality among 40,657 adult HIV-infected patients receiving HAART in Dar es Salaam, Tanzania. Proportional hazards models were used to examine the associations of anemia severity and IDA at HAART initiation and during follow-up with mortality. A total of 6,261 deaths were reported. Anemia severity at HAART initiation and during follow-up was associated with an increasing risk of mortality (trend tests P < 0.001). There was significantly higher mortality risk associated with IDA at HAART initiation and during follow-up versus no anemia or iron deficiency (both P < 0.001). These associations differed significantly by gender, body mass index, and iron supplement use (all interaction test P < 0.001). The magnitude of association was stronger among men. Mortality risk with severe anemia was 13 times greater versus no anemia among obese patients, whereas it was only two times greater among underweight patients. Higher mortality risk was observed among iron supplement users, irrespective of anemia severity. Anemia and IDA were significantly associated with a higher mortality risk in patients receiving HAART. Iron supplementation indicated an increased mortality risk, and its role in HIV infections should be examined in future studies. Given the low cost of assessing anemia, it can be used frequently to identify high-risk patients in resource-limited settings.

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Author Notes

Address correspondence to Batool A. Haider, Departments of Epidemiology and Nutrition, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA 02115. E-mail: bah201@mail.harvard.edu

Financial support: This study was supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the Harvard School of Public Health and by the Ministry of Health and Social Welfare, Tanzania, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (K24HD058795). The funding source had no role in the design, analysis, manuscript writing, or submission for publication.

Deceased.

Authors’ addresses: Batool A. Haider, Department of Epidemiology, Harvard School of Public Health, Boston, MA, and Department of Nutrition, Harvard School of Public Health, Boston, MA, E-mail: bah201@mail.harvard.edu. Donna Spiegelman, Department of Epidemiology, Harvard School of Public Health, Boston, MA, Department of Nutrition, Harvard School of Public Health, Boston, MA, Department of Biostatistics, Harvard School of Public Health, Boston, MA, and Department of Global Health and Population, Harvard School of Public Health, Boston, MA, E-mail: stdls@hsph.harvard.edu. Ellen Hertzmark, Department of Epidemiology, Harvard School of Public Health, Boston, MA, E-mail: stleh@channing.harvard.edu. David Sando and Eric Aris, Management and Development for Health, Dar es Salaam, Tanzania, E-mails: dms466@mail.harvard.edu and aeric@mdh-tz.org. Christopher Duggan, Department of Nutrition, Harvard School of Public Health, Boston, MA, and Center for Nutrition, Boston Children’s Hospital, Boston, MA, E-mail: christopher.duggan@childrens.harvard.edu. Abel Makubi, Management and Development for Health, Dar es Salaam, Tanzania, and School of Medicine, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania, E-mail: makubi55@gmail.com. Christopher Sudfeld, Department of Global Health and Population, Harvard School of Public Health, Boston, MA, E-mail: crsudfeld@gmail.com. Guerino E. Chalamilla, Department of Nutrition, Harvard School of Public Health, Boston, MA, and Management and Development for Health, Dar es Salaam, Tanzania. Wafaie W. Fawzi, Department of Epidemiology, Harvard School of Public Health, Boston, MA, Department of Nutrition, Harvard School of Public Health, Boston, MA, and Department of Global Health and Population, Harvard School of Public Health, Boston, MA, E-mail: mina@hsph.harvard.edu.

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