The Association of Anemia With Survival Among People With HIV Following Antiretroviral Initiation in the NA-ACCORD 2007-2016.

BACKGROUND

Anemia is an independent predictor of mortality, which may be utilized as a signal of deteriorating health. We estimated the association between anemia severity categories and mortality following the initiation of antiretroviral therapy (ART) among people with HIV (PWH) in North America.

METHODS

Within the NA-ACCORD, annual median hemoglobin measurements between January 01, 2007, and December 31, 2016, were categorized using World Health Organization criteria into mild (11.0-12.9 g/dL men, 11.0-11.9 g/dL women), moderate (8.0-10.9 g/dL men/women), and severe (<8.0 g/dL men/women) anemia. Discrete time-to-event analyses using complementary log-log link models estimated mortality hazard ratios adjusted for demographics, comorbidities, and HIV clinical markers with 95% confidence intervals for the association between anemia and mortality.

RESULTS

Among 67,228 PWH contributing a total of 320,261 annual median hemoglobin measurements, 257,293 (80%) demonstrated no anemia, 44,041 (14%) mild, 18,259 (6%) moderate, and 668 (0.2%) severe anemia during follow-up. Mortality risk was 5.6-fold higher among PWH with (vs. without) anemia. The association was greater among men (adjusted hazard ratios = 5.8 [5.4, 6.2]) versus women (adjusted hazard ratios = 4.1 [3.2, 5.4]). Mortality risk was 3.8-fold higher among PWH with mild anemia, 13.7-fold higher with moderate anemia, and 34.5-fold higher with severe anemia (vs. no anemia). Median hemoglobin levels decreased significantly in the 4 years before death, with a maximum decrease in the year before death. Macrocytic anemia was associated with an increased mortality risk and microcytic anemia was associated with a decreased mortality risk (vs. normocytic anemia).

CONCLUSIONS

Anemia among PWH who have initiated ART is an important predictive marker for mortality with macrocytic anemia having an increased association and microcytic anemia having a decreased association with mortality compared with normocytic anemia.