Anaemia and neutropenia

Anaemia is a condition in which red blood cells cannot carry enough oxygen to supply the body’s needs. This may be due either to a shortage of red blood cells or of the oxygen-transporting molecule haemoglobin. When this happens, fatigue, weakness, dizziness, headache, shortness of breath, and heart palpitations may result.

Anaemia is quite common in populations with endemic malaria. Menstruating women are also more prone to develop anaemia. Anaemia is associated with more advanced HIV disease, lower CD4 cell count, and higher viral load.1 The advent of highly active antiretroviral therapy has reduced incidence of anaemia,it does remain an independent risk factor for death in people with HIV.2

Drugs can cause anaemia by different mechanisms. All types of blood cells are produced in the bone marrow; drug that damage the bone marrow can cause shortages in all of these cells. Among the antiretroviral drugs, AZT (zidovudine, Retrovir) is most often associated with bone marrow toxicity. Drugs, including foscarnet (Foscavir) and ganciclovir (Cymevene), for cytomegalovirus and high-dose cotrimoxazole (Bactrim / Septrin) can also cause bone marrow suppression, as do many cancer chemotherapy agents.

A different type of anaemia occurs when red blood cells are destroyed faster than they can be produced. Haemolytic anaemia , is caused by ribavirin (Copegus / Rebetol / Virazole), a drug used in combination with interferon to treat hepatitis C. There are also several non-drug-related causes of anaemia, including nutritional deficiencies of vitamin B12, iron, and folate. A case report has also suggested that anaemia can be a side-effect of efavirenz (Sustiva).3

Treatment for anaemia depends on its cause. The most straightforward approach to drug-induced anaemia is discontinuation of the offending drug. For patients taking AZT, this is often appropriate because other nucleoside reverse transcriptase inhibitors (NRTIs) and other drug classes are available. If a drug cannot be safely discontinued or the dose reduced, recombinant erythropoietin (Eprex/ NeoRecormon) may be used. This is a genetically engineered version of a natural hormone that stimulates the bone marrow to produce more red blood cells.

Drugs that cause bone marrow toxicity may also lead to reduced levels of white blood cells (a condition called neutropenia), which can increase the risk for infection. A different bone marrow-stimulating hormone, G-CSF (granulocyte colony-stimulating factor, Neupogen / Filgrastim) can treat this condition.


  1. Nadler JP et al. Anemia prevalence among HIV patients: antiretroviral therapy and other risk factors. Second International AIDS Society Conference on HIV Pathogenesis and Treatment, Paris, abstract 1151, 2003
  2. Buskin SE et al. Transmission cluster of highly drug-resistant HIV-1 among 9 men who have sex with men in Seattle/King County, WA, 2005 – 2007. J Acquir Immune Defic Syndr 49: 205-212, 2008
  3. Freercks RJ et al. Haemolytic anaemia associated with efavirenz. AIDS 20: 1212-1213, 2006
Community Consensus Statement on Access to HIV Treatment and its Use for Prevention

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We can end HIV soon if people have equal access to HIV drugs as treatment and as PrEP, and have free choice over whether to take them.

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