Samantha Vogt, M.D., M.P.H., Richard D. Moore, M.D.


  • In the current ART era, prevalence of anemia is 7-50%; increasing incidence occurs when CD4 count < 200 cells/microL.
  • Hypoproliferative anemia (normochromic, normocytic anemia with low reticulocyte count and normal iron stores) most common type of anemia associated with HIV infection.
  • 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.


Work-up and differential should be guided by acuity, severity and CD4 count of patient.

  • Patients acutely ill with a low CD4 count (< 200 cells/microL), need to consider underlying opportunistic infections, malignancies and other rare causes (TMAs - thrombotic microangiopathies; HLH - hemophagocytic lymphohistiocytosis; HHV-8 - human herpes virus 8-associated disorders). Patients may also have other cytopenias in addition to anemia.
  • Stable patients with CD4 count >200 cells/microL on ART, need to consider non-HIV-associated causes starting with a review of medications and guided by MCV, reticulocyte count and iron studies.
  • Stable patients with CD4 count >200 cells/microL not on ART, need to consider starting patient on ART and reassessing.

Table below is not exhaustive but outlines some of the most common causes of anemia in HIV patients and their associated laboratory findings.



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: March 12, 2023