Anemia is a topic covered in the Johns Hopkins HIV Guide.

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  • Prevalence 1-10% in asymptomatic HIV, 10-25% with CD4-defined AIDS, 30-60% with AIDS-defining illness
  • Hypoproliferative anemia more common than hemolytic anemia
  • Earliest Sx affect functional status: easy fatigue, weakness, exertional dyspnea, slowed cognition (Hgb < 10-11)
  • Later Sx include rapid heart rate, bounding pulse, dyspnea, severe fatigue, confusion, angina, CHF (Hbg < 8-9)
  • HIV can directly cause suppression of hematopoietic precursor cells in marrow through inflammatory cytokine suppression, inhibition of endogenous erythropoietin response
  • Hypogonadism (low testosterone level) can cause anemia.
  • Anemia associated with worse survival in HIV, but unlikely causal. May be impaired erythropoiesis from HIV associated chronic inflammation. Hgb independent factor in prognostic indices for mortality and morbidity.




Decreased RBC Production
1. HIV-induced (probably inflammation-associated)
2. Iron-deficiency (blood loss, most commonly GI, or menstrual in pre-menopausal women)
3. Neoplasm infiltrating bone marrow (lymphoma, KS, other)
4. Infection in marrow (MAC, MTB, parvovirus B19, CMV, fungal)
5. Drugs (zidovudine, cancer chemotherapy, interferon-alfa, gancyclovir, pyrimethamine, amphotericin, phenytoin)

Reticulocyte count low
Indirect bilirubin normal
MCV low in iron-deficiency, anemia of chronic disease
MCV high with zidovudine

Ineffective RBC Production
1. Folic acid deficiency
2. Vitamin B12 deficiency

Reticulocyte count low
Indirect bilirubin high
MCV high

RBC Destruction (Hemolysis)
1. Coomb’s positive hemolytic anemia
2. TTP
3. DIC
4. Drugs: sulfonamides, oxidant drugs such as dapsone, primaquine with G6PD deficiency, ribavirin

Reticulocyte count high
Indirect bilirubin high
High LDH, low haptoglobin,
Peripheral smear may have fragmented RBCs, spherocytes, schistocytes

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Last updated: February 1, 2015