April / May 1995
That Sinking Feeling
by Mark Mascolini
Anemia is avoidable, identifiable and treatable
That wiped-out feeling. That washed-out face. The sneaking suspicion that you’re climbing the three flights to your apartment just a little more slowly. They al sound like the nuisance symptoms that HIV positive people learn to expect, then learn to live with. But clinicians who study blood disorders warn that they’re also the first signs of a common, often avoidable, easily spotted and eminently treatable disease: Anemia, a drop in red blood cells.
The list of the things that can cause anemia is long as the catalog of Don Giovanni’s conquests—and as familiar to people with HIV as Donna Elvira was to the Don. Right up at the top is AZT. According to Dr. Ronald Mitsuyasu at the University of California Los Angeles, AZT-related anemia can slow down about one in 10 asymptomatic people and as many as 80 to 90 percent of those with late-stage disease. Other possible culprit drugs are Bactrim, dapsone and ganciclovir.
“HIV itself can cause anemia,” say Dr. John Doweiko of Boston’s Deaconess Hospital. The virus may slow the assembly line in the body’s blood-cell factory, the bone marrow, by infecting marrow cells or by stirring up cellular chemicals called cytokines. Many opportunistic microbes, including Mycobacterium avium, some fungal infections, tuberculosis and, rarely, Pneumocystis carinii can trigger anemia. Another microbe that causes anemia, parvovirus, is actually not an opportunistic infection: It infects people with healthy and impaired immune systems and has a particularly avid appetite for rapidly dividing cells—such as new blood cells.
Kaposi’s sarcoma, ulcers, gut infections, menstruation, anything that causes blood loss, Dr. Mitsuyasu notes, may drain away enough red cells to bring on anemia. But a common type of anemia in the general population, iron-deficiency anemia, is among the rarest anemias in people with HIV, says Dr. Julie Hambelton of the University of California San Francisco. So Mom’s anti-anemia remedies—popping iron pills and learning to love calf’s liver—won’t help prevent the disease unless your iron is low. But fighting mild anemia can start at home. A diet rich in protein (that means soy and other beans for vegetarians) can keep the red cells flowing. Dr. Mitsuyasu thinks a daily multivitamin is a good idea, too.
“The most important thing people can do is try to avoid [even minor] infections,” Dr. Dowiko says. And alcohol is notorious for causing anemia, adds Dr. Mitsuyasu, both because it punches ulcers into the digestive tract lining and because it clogs cell-making machinery. He also underlines the importance of getting enough rest, having your blood count checked regularly, and getting good general medical care.
There’s a fine line between occasionally feeling wiped and fatigue that makes daily living a literal drag, Dr. Hambelton says. But symptoms are fairly clear cut signals of more-than-mild anemia. Watch for shortness of breath or headaches caused by exertion, palpitations or a racing pulse and light-headedness. Any of these problems should raise a red flag that says, “Call the doctor.” A good clinician who hears any of these complaints will do a blood count to check for anemia before considering more esoteric causes.
Monitoring your red blood cells and taking early measures to strengthen them if they start to drop are vital. Sometimes AZT-induced anemia can be alleviated by reducing the dose of AZT or switching to another anti-Parvovirus infection responds to intravenous immunoglobulin (IVIG), a solution of infection-fighting antibodies made from human plasma.
General anemia can be treated with erythropoietin, which goes by the brand names Procrit and Epogen but is usually just called EPO. This synthetic drug mimics natural proteins that pump up production of red blood cells. Both brands are quite costly—although cheaper than blood transfusions, which is the last-ditch treatment option. Procrit manufacturer Ortho Biotech offers a compassionate use program for people who can’t afford the drug, and the company will fully reimburse all patients and their insurers after the first $8,500 in total Procrit expenses. NO comparable programs are available for Epogen.
EPO is a preferred alternative to a blood transfusion, says Dr. David Hardy of the University of California Los Angeles. “But EPO takes six to eight weeks to work, so the treatment must be initiated before severe anemia sets in. This underscores the importance of monitoring red count.”
Transfusions are safer now than several years ago but still involve some risk. “Most—but not all—blood banks screen for the hepatitis B and C viruses and the chance of reinfection with HIV are one in 250,000. Most gay men shouldn’t be concerned about transmission of cytomegalovirus (CMV) because 90 percent already harbor the virus. But most large medical centers will test for CMV before a transfusion if you ask and produce a blood test that proves you are CMV negative,” Dr. Hardy says.
Anemia must be serious before doctors will turn to transfusions, Dr. Mitsuyasu says, but even at this stage hospital admission is usually not required. Dr. Mitsuyasu says he prefers to have people go to outpatient centers specializing in transfusions. Transfusions can even be done in the home, but not all states permit home transfusions. How many transfusions are needed varies from person to person.
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