Interpreting tests for iron deficiency among adults in a high HIV prevalence African setting: routine tests may lead to misdiagnosis

Practical Management of HIV-Associated Anemia in Resource-Limited Settings: Prospective Observational Evaluation of a New Mozambican Guideline

“…In Malawians with severe anemia, iron deficiency (assessed by complete blood count, serum ferritin, serum transferrin, and bone marrow aspirate) was present in only 16% of HIV-infected patients vs. 59% of HIV-uninfected patients. 46 In pregnant HIV-infected Tanzanian women, although 48.3% were anemic, fewer than half of the anemic women were iron deficient (based on measurement of hemoglobin, serum ferritin, serum transferrin receptor, and C-reactive protein). 4 Recent mass deworming campaigns may have decreased the historically high prevalence of helminth infections in Mozambique.…”

“…Within the study, we believe that there was considerable underascertainment of many anemia-associated clinical entities: (1) advanced immunosuppression, because of slow CD4 turnaround times and the difficulty of clinical staging in the study environment; 46 (2) adverse drug reactions, given low standard Hb thresholds for discontinuation of ZDV in the setting of ADR and frequent absence of baseline pre-ART Hb measurements; (3) TB, with long turnaround times for AFB smears, frequent stockouts of AFB reagents, and the scant availability of chest radiography; (4) other micronutrient deficiencies (e.g., vitamin A) that could not be evaluated in the study setting but were likely prevalent in this malnourished population; and/or (5) most Stage IV conditions, given the limited availability of diagnostics. Failure to diagnose and treat these possible causes of anemia may have led to anemia treatment failures.…”

“…Further improvements to non-physician clinician management of anemic HIV-infected adults in Mozambique might include improved access to point-of-care CD4 and TB testing and to blood cultures; more specific instructions for management of Hb that is very low, falling, or slow to rise; the eventual introduction of laboratory tests that can accurately detect iron deficiency in the setting of HIV infection 46 ; and the re-evaluation of thresholds for the definition of Hb ''improvement'' and for discontinuation of specific medications when ADR is suspected. More aggressive initiation of ART in eligible patients is critical.…”

Micronutrient deficiencies in maternity and child health: a review of environmental and social context and implications for Malawi

“…Only 36% of women surveyed had a blood test during their pregnancy; anaemia was established by the pallor of conjunctivae (eye test), which is known not to be an accurate diagnostic tool, particularly when used in isolation. It has been shown that pallor of a single anatomic site does not have adequate sensitivity to detect moderate anaemia (Getaneh et al 2000;Lewis et al 2007). A more patient-specific approach is needed, involving the accurate identification and appropriate treatment of women with severe anaemia, rather than a blanket distribution of supplements.…”

Commentary: Iron deficiency and hair loss

“…In contrast, in HIV-positive patients ferritin showed a sensitivity of only 20%, with specificity of 93%. 20 Both C-reactive protein (CRP) and ESR have been paired with ferritin measurements as markers of chronic inflammation, and enzymelinked immunosorbent sandwich techniques have been used to create inexpensive tests that provide a combined measurement of ferritin, sTfR, and CRP. 21,22 In a study of 96 patients on hemodialysis, serum ferritin was shown to correlate with CRP (P = .006).…”