Anemia prevalence and associated factors in patients with HIV at Ethiopian Hospitals

Anemia prevalence and associated factors in patients with HIV at Ethiopian Hospitals | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Anemia prevalence and associated factors in patients with HIV at Ethiopian Hospitals Alemayehu M. Bezabih¹, Yihienew M. Bezabih², Addisu A. Negatu³, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6912450/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Anemia is the most common hematologic complication in people with HIV and significantly impacts disease progression and quality of life. This study aims to determine anemia prevalence and associated factors in patients with HIV. Methods A cross-sectional study was conducted among 362 patients aged 15 years or older with HIV. Data on socio-demographics, clinical parameters, laboratory results, and medication history were collected using a pretested questionnaire. A logistic regression model was used to identify factors associated with anemia. Results Patients’ mean age ± standard deviation was 41.2 ± 11.5 years, and 59.1% were female. The prevalence of anemia in people with HIV was 22.9% (95% CI: 18.7–27.6), of which 14.6% was mild anemia, 6.9% moderate anemia, and 1.4% severe anemia. Only completing primary level education (adjusted odds ratio (AOR): 3.35; 95% CI: 1.48–7.55), being underweight (AOR: 2.92; 95% CI: 1.10–7.75), increased viral load (AOR: 2.48; 95% CI: 1.03-6.00), and antiretroviral therapy (ART) duration of less than 5 years (AOR: 1.96; 95% CI: 1.03–3.71) were significantly associated with anemia. Conclusion Anemia remains a prevalent condition in people with HIV and warrants regular monitoring through routine complete blood counts (CBC), especially for those who only completed primary education, were underweight and had high viral load. Prevalence Anemia HIV AIDS Risk facto Figures Figure 1 1. Introduction According to the World Health Organization (WHO), anemia is defined as a hemoglobin (Hb) level of < 12.0 g/dL in women and < 13.0 g/dL in men ( 1 ). It is a significant public health problem affecting people in developing countries ( 2 ). Approximately one-third of the global population (32.9%) was estimated to suffer from anemia in 2010 ( 3 ), which decreased to 22.8% (95% CI: 22.6%-23.1%) by 2019( 4 ). People with HIV are among the most vulnerable to anemia(with even higher prevalence rates of 66.7% in Nepal in 2020, 42.03% in Kenya in 2024, and 39.8% at Mizan-Tepi University Hospital, Southwest Ethiopia in 2021 ( 5 – 7 )). Ethiopia remains a high-burden country for HIV/AIDS, with an adult prevalence of 0.9%. Approximately 669,000 people are living with HIV, and 14,842 new infections were reported in 2019 ( 8 ). Anemia is one of the most common hematologic complications of HIV/AIDS, affecting up to 95% of patients at some point during their disease course ( 9 ). Its multifactorial etiology includes direct viral suppression of the bone marrow, chronic inflammation due to opportunistic infections, and toxicity related to antiretroviral therapy(ART) ( 10 ). The occurrence of anemia independently predicts faster disease progression, poorer treatment response, and increased mortality in patients with HIV/AIDS. It also contributes to reduced quality of life and complicates ART by reducing adherence and immune recovery ( 11 – 13 ). In 2015, the WHO introduced the “Treat All” policy, which initiates ART regardless of CD4 count or clinical stage and has been associated with reduced morbidity and mortality, improved quality of life, and overall health ( 14 ). However, its impact on anemia prevalence remains inadequately documented. The replacement of zidovudine (AZT) with tenofovir disoproxil fumarate (TDF) as the first-line antiretroviral regimen in 2013 and the introduction of dolutegravir (DTG) in 2019 have been associated with a decreased prevalence of anemia among people living with HIV ( 15 , 16 ). Data are limited about the prevalence of anemia following the policy change and the availability of safer antiretroviral agents. Therefore, this study aimed to determine the prevalence of anemia and its associated risk factors among people living with HIV. 2. Methods 2.1 Study design, area and period This institution-based, descriptive cross-sectional study was conducted between 1 January and 1 February, 2025, at two hospitals - Tibebe Ghion Specialized Hospital and Felege Hiwot Comprehensive Specialized Hospital in Bahir Dar, Ethiopia. The ART care was a multidisciplinary care led by nurses. Tibebe Ghion Specialized Hospital is located approximately 10 km south of Bahir Dar city. It is a tertiary-level university teaching hospital with a 450-bed capacity, providing inpatient and outpatient services across all major medical departments. The hospital also operates ART clinics that offer free diagnostic and therapeutic services to over 3500 clients annually, with 165 of them receiving chronic follow-up care. Felege Hiwot Comprehensive Specialized Hospital is situated within Bahir Dar city and has a capacity of 350 beds. Nurses and physicians led the ART clinic, providing care for approximately 7,000 patients. 2.2. Study Population, inclusion and exclusion criteria The study population consisted of patients with HIV aged 15 years and older who were receiving follow-up care at the ART clinics of Tibebe Ghion Specialized Hospital and Felege Hiwot Comprehensive Specialized Hospital in Bahir Dar. Patients were excluded if they were under 15 years of age, had a known hematologic disorder or bleeding tendency, had received a blood transfusion within the past three months, were pregnant or lactating, or had grossly incomplete data. 2.3 Study variables and operational definition 2.3.1 Dependent variable The primary outcome was the prevalence of anemia, defined according to WHO criteria as a haemoglobin level < 12 g/dL in women and < 13 g/dL in men. Anemia was further stratified by severity into mild (11–12.9 g/dL in men and 11–11.9 g/dL in women), moderate (8–10.9 g/dL), and severe (< 8 g/dL). 2.3.2 Independent variables Independent variables were broadly categorized into socio-demographic characteristics, clinical parameters, laboratory findings, and medication-related factors. Socio-demographic variables included age, sex, marital status, religion, place of residence, and educational status. Clinical parameters encompassed WHO clinical stage, presence of opportunistic infections (OIs), nutritional status, duration since HIV diagnosis, functional status, and ART adherence. Nutritional status was assessed using BMI, with BMI < 18.5 kg/m² classified as underweight, 18.5–24.9 kg/m² as normal, and ≥ 25 kg/m² as overweight. ART adherence was categorized based on doses missed in the last month as good (missed < 2 doses out of 30 doses or < 3 out of 60 doses), fair (missed 2–4 out of 30 doses or 4–9 out of 60 doses), or poor (missed ≥ 5 out of 30 doses or ≥ 10 out of 60 doses). Laboratory variables included the most recent CD4 cell count, viral load, Liver function tests (LFT), renal function tests (RFT), hemoglobin level, white blood cell (WBC) count, and platelet (PLT) count. Medication-related variables included the type of ART regimen (AZT-based vs. non-AZT-based), cotrimoxazole preventive therapy, and isoniazid preventive therapy. 2.4. Sample size determination and sampling technique The sample size was determined using a single population proportion formula, with the following assumptions: the prevalence of anemia among patients with HIV was estimated to be 31% based on a meta-analysis involving 20 studies( 17 ), a 5% margin of error, and a 95% confidence interval using online calculator. The calculated sample size was 329; taking into account 10% non-response or data incompleteness rate (approximately 33 participants), the final sample size was adjusted to 362. Additional sample size calculations for selected secondary outcome variables (associated risk factors) using a double population proportion formula yielded smaller required sample sizes; therefore, the final sample size for the study remained 362. We used the ART clinic registries as the sampling frame and applied systematic random sampling to select study participants. From Tibebe Ghion Specialized Hospital, one data collector collected data from 32 patients by selecting every 5th patient record. At Felege Hiwot Comprehensive Specialized Hospital, five data collectors extracted data from a total of 330 patients by selecting every 10th patient they evaluated. 2.5. Data collection and quality assurance After reviewing relevant literature and guidelines from the WHO and the Ministry of Health, a data extraction questionnaire was developed based on the study objectives (see supplementary file 1). Data collection was supplemented by patient interviews during follow-up evaluations. The clarity and completeness of the checklist were pretested on 5% of patient charts before the main data collection. Based on this pilot test and a review of previous studies, necessary corrections and modifications were made to the data collection format. Research nurses working in ART clinics received appropriate training and collected the data using KoBocollect app, which was installed on their smartphones. The principal investigator regularly reviewed submitted data for completeness and consistency. 2.6. Data management and analysis After data collection, the data was exported to SPSS version 29 for analysis. The data were carefully cleaned and checked for completeness before analysis. Categorical variables were summarised using proportions and frequencies and continuous variables with means and standard deviations. The findings were presented in tables and bar graphs. A binary logistic regression model was used to identify factors associated with anemia incidence. We selected variables with p < 0.25 in the univariable logistic model to be included in the final multivariable logistic regression based on clinical relevance, statistical significance (p ≤ 0.05), and number of events per variable (≥ 10) as suggested by Peduzzi et al ( 18 ). In the final model, variables with a p ≤ 0.05 were considered statistically associated with anemia. Model adequacy was evaluated using the Hosmer-Lemeshow goodness-of-fit test, with a p-value greater than 0.05 indicating a good fit. Multicollinearity among independent variables was assessed using the variance inflation factor, with values less than 10 considered acceptable. 3. Results 3.1. Socio-demographic factors In this study, 362 patient charts were reviewed. Their ages range from 15 to 70 years with mean ± SD of 41.2 ± 11.5 years. The most common age groups were 40-59 years (50.8%) and 20-39 years (42%), accounting for 92.8% of the study population. Of the total, 214 (59.1%) were female. Most were married (57.5%) and lived in urban areas (80.7%). Most participants identified as Ethiopian Orthodox Christian (95.3%) and had completed primary or secondary education (60.3%) (Table 2). 3.2. Clinical factors Clinically, 92.8% of patients were classified as WHO clinical stage I or II, indicating asymptomatic or mildly symptomatic disease. Additionally, 87.8% were not experiencing opportunistic infections or cancers at the time of assessment. Around 97.2% demonstrated good adherence to ART, missing fewer than 2 doses out of 30 doses (within 1 month) or 3 doses out of 60 doses (within 2 months). The duration of ART among participants ranged from 1 month to 22 years, with a median (interquartile range (IQR) of 10.1 (4-15) years. More than two-thirds of the patients (68.5%) had been on ART for over five years, while 31.5% had been on ART for less than five years. Based on BMI, 85.1% of patients had a normal nutritional status (BMI 18.5–24.9), 6.1% were overweight, and 8.5% were underweight. Functionally, 94.75% of participants worked at the workplace or at home to support their families. 3.3. Laboratory and medication factors The CD4 count among patients ranged from zero to 1852 cells/mm 3 . The median (IQR) CD4 count was 460 (322-635) cells/mm³. Around 72.6% of patients had CD4 count more than 350 cells/mm 3 , 15.2% had a count between 200 and 350 cells/mm³, and 11.6% had a count of less than 200 cells/mm³. Regarding viral load, 89.8% of patients had a suppressed viral load (1000 copies/mL) viremia. Additionally, 1.1% (4/362) of patients had liver function test results above the laboratory-specific upper limit of normal (ULN), and 1.4% (5/362) had elevated renal function test results exceeding the ULN. Around 97.5% (353/362) were on a non-AZT-based regimen and only 2.5 %( 9/362), were on an AZT-based regimen. Moreover, 19.3% (70/362) were on Cotrimoxazole Preventive Therapy, and 1.1% (4/362) were on Isoniazid Preventive Therapy (Table 1). Table 1: Sociodemographic and clinical characteristics of patients included in this study Variable Category Count (%) Anemia Status Yes No COR (95% CI) P-value Age ≤19 7 (1.9%) 2 5 1 0.06 20-39 152 (42.0%) 42 110 0.95(0.17-5.11) 40-59 184 (50.8%) 32 152 0.52(0.09-2.83) ≥60 19 (5.2%) 7 12 1.45(0.22-9.61) Sex Male 148 (40.9%) 39 109 1.38(0.84-2.26) 0.19 Marital Status Never Married 61 (16.9%) 16 45 1 0.88 Married 208 (57.5%) 45 163 0.86(0.44-1.65) Divorced 66 (18.2%) 16 50 1.11(0.49-2.47) Widowed 27 (7.5%) 6 21 0.89(0.30-2.59) Religion Orthodox 345 (95.3%) 77 268 1 0.22 Muslim 17 (4.7%) 6 11 0.52(0.18-1.47) Level of Education Tertiary 87 (24.0%) 12 75 1 0.01 Secondary 108 (29.9%) 23 85 1.69(0.78-3.63) Primary 110 (30.4%) 36 74 3.04(1.46-6.29) No Education 56 (15.5%) 12 44 1.70(0.70-4.12) Residence Urban 292 (80.7%) 69 223 1 0.51 Rural 70 (19.3%) 14 56 1.23(0.64-2.35) Functional Status Working 343 (94.8%) 72 271 1 <0.001 Ambulatory/Bed-ridden 17 (4.7%) 11 6 6.90(2.46-19.29) BMI (kg/m²) Normal (18.5-24.99) 308 (85.1%) 63 245 1 <0.001 Underweight (<18.5) 31 (8.5%) 17 14 4.72(2.20-10.09) Overweight (25-29.99) 22 (6.1%) 3 19 0.61(0.17-2.14) ART duration (years) ≤5 114 (31.5%) 42 72 2.94 (1.77-4.89) 5 248 (68.5%) 41 207 1 WHO Clinical Stage Stage 1/2 336 (92.8%) 67 269 1 <0.001 Stage 3/4 26 (7.2%) 16 10 6.42(2.78-14.79) Opportunistic Infections Yes 44 (12.2%) 21 23 3.77(1.96-7.24) <0.001 ART Adherence Good 352 (97.2%) 78 274 1 0.05 Fair/Poor 10 (2.8%) 5 5 3.51(0.99-12.44) CD4 Category (cells/mm 3 ) <200 42 (11.6%) 20 22 4.17(2.11-8.27) 350 263 (72.7%) 47 216 1 Viral Load (copies/mL) <50 325 (89.8%) 67 258 1 0.01 ≥50 29 (8.0%) 12 17 2.71(1.23-5.96) Abnormal LFT Yes 4 (1.1%) 3 1 10.42(1.07-101.59) 0.04 Renal Impairment Yes 5 (1.4%) 3 2 5.19(0.85-31.62) 0.07 HAART Regimen AZT-Based 9 (2.5%) 4 5 0.36(0.09-1.37) 0.13 Cotrimoxazole preventive therapy Yes 70 (19.3%) 30 40 3.38(1.93-5.91) <0.001 Isoniazid preventive therapy Yes 4 (1.1%) 0 4 1.10(0.11-10.89) 0.47 Abbreviations: ART: Antiretroviral Therapy; AZT: Zidovudine; BMI: Body Mass Index; CD4: Cluster of Differentiation 4; COR: Crude Odds Ratio; HAART: Highly Active Antiretroviral Therapy; LFT: Liver Function Test; WHO: World Health Organization. 3.4. The magnitude of anemia The prevalence of anemia in our study was 22.9% (83/362, 95% CI: 18.7-27.6). In terms of severity, the majority of anemia cases were mild (14.6% (53/362), 6.9% (25/362) moderate anemia, and 1.4 %( 5/362) severe anemia (Figure 1). The mean hemoglobin level ± SD was 13.24 ± 1.78 g/dL. In addition to anemia, 13.0% (47/362) of patients had leukopenia, and 6.1% (22/362) had thrombocytopenia. 3.5. Associated factors of anemia In the univariable logistic model, several factors demonstrated significant associations with anemia. These included being underweight (BMI <18.5 kg/m²), having advanced HIV disease (WHO clinical stage 3/4 or CD4 count <200 cells/mm 3 ), and experiencing opportunistic infections or cancers. Additional risk factors were elevated LFTs, detectable viral load (≥50 copies/mL), and the use of cotrimoxazole preventive therapy. Functional impairment (ambulatory/bedridden status), ART duration less than 5 years and completion of primary education also showed a significant association. However, after adjusting for potential confounders in the multivariable logistic regression, completion of primary education, being underweight, increased viral load and ART duration of less than 5 years remained independently associated with anemia. Patients with a primary level of education had significantly higher odds of anemia compared to those with tertiary education (AOR: 3.35; 95% CI: 1.48–7.55). Underweight patients were also more likely to be anemic, with nearly three times higher odds than those with a normal BMI (AOR: 2.92; 95% CI: 1.10-7.75). Additionally, patients with an elevated viral load (>50 copies/mL) had a significantly increased risk of anemia compared to those with fully suppressed viral loads (<50 copies/mL) (AOR: 2.48; 95% CI: 1.03-6.00). Lastly, a shorter duration of ART, less than 5 years, was associated with nearly twice increased likelihood of anemia compared to durations of more than 5 years (AOR: 1.96; 95% CI: 1.03-3.71) (Table 2). Table 2: Unadjusted and adjusted odds of developing anemia using a logistic regression model. Variable Category COR (95% CI) AOR (95% CI) Age Category (in years) ≤19 1 1 20-39 0.95 (0.17-5.11) 2.04 (0.12-34.80) 40-59 0.52 (0.09-2.83) 1.78 (0.10-30.31) ≥60 1.45 (0.22-9.61) 5.02 (0.25-99.54) Education Level Tertiary 1 1 Secondary 1.69(0.78-3.63) 1.73(0.72-4.13) Primary 3.04(1.46-6.29) 3.35(1.48-7.55) No education 1.70 (0.70-4.12) 1.93 (0.70-5.29) BMI(in Kg/m 2 ) Normal (18.5-24.99) 1 1 Underweight (<18.5) 4.72 (2.20-10.09) 2.92 (1.10-7.75) Overweight (25-29.99) 0.61 (0.17-2.14) 0.56 (0.14-2.23) Functional Status Working 1 1 Ambulatory and Bedridden 6.90 (2.46-19.29) 0.97 (0.22-4.37) WHO clinical Stages Stages 1 and 2 1 1 Stages 3 and 4 6.42 (2.78-14.79) 1.52 (0.45-5.18) Opportunistic Infections/CAs 3.77 (1.96-7.24) 1.46 (0.54-3.91) CD4 Count (cells/mm 3 ) >350 1 1 200-350 1.72(0.88-3.37) 1.32 (0.55-3.18) <200 4.17(2.11-8.27) 1.54 (0.56-4.27) Viral Load (copies/mL) 5 1 1 Cotrimoxazole preventive therapy 3.38 (1.93-5.91) 1.52 (0.63-3.68) Abbreviations: AOR: Adjusted Odds Ratio; ART: Antiretroviral Therapy; BMI: Body Mass Index; COR: Crude Odds Ratio; CD4 : Cluster of differentiation 4; WHO: World Health Organization 4. Discussion This multisite study assessed the prevalence of anemia among people with HIV following the full implementation of the WHO “Treat All” policy. The findings indicate a decline in anemia prevalence compared to earlier reports. This finding aligns with international studies showing a declining trend in the overall prevalence of anemia among people with HIV, from approximately 33% in 2007 to 20% in 2017 (19). This reduction has been largely attributed to the implementation of the WHO’s “Treat All” policy in Sept 2015 and the subsequent optimization of ART regimens (20). A similar trend has been observed in Ethiopia. Prior to the full implementation of the WHO “Treat All” policy, which occurred between 2017 and 2018, studies reported anemia prevalence among people with HIV ranging from 32.9% to 36.5% (21–23). Following broader adoption, later studies documented a decline to 23–26% (24–26), suggesting a positive impact of expanded access to and optimization of ART. The lower anemia prevalence in our study and recent reports(27,28), compared to earlier higher rates(29,30), may reflect improvements in several contributing factors. The WHO replaced AZT with TDF as the preferred first-line ART regimen in 2013(31) due to AZT's strong association with long-term toxicities such as anemia and neutropenia, as well as its potential to induce resistance mutations that compromise the efficacy of second- and third-line treatment options (32,33). This is evident from our study, where only 2.5% of patients were on AZT, compared to 48.8% to 62.5% in previous studies (21,24,34), where AZT-associated anemia may have contributed to the higher prevalence. DTG, which became the first-line ART regimen in 2019, has also been associated with increased serum iron levels after six months of treatment (35). Furthermore, DTG has been shown to improve hemoglobin concentration, white blood cell count, and platelet levels within three months of initiation (16). Anemia tends to decline in ART-naïve patients after initiating treatment, with noticeable improvements in hemoglobin levels observed at 6 months, and 12 months from the baseline (21,36). Since the majority of our patients (94%) had been on ART for over 12 months, it is likely that their disease course had stabilised, contributing to the lower prevalence of anemia. Lastly, improved HIV care and better drug adherence, leading to enhanced viral load suppression, likely contributed to the lower anemia prevalence observed in our study by reducing the burden of opportunistic infections. This is further supported by previous studies reporting higher proportions of participants with CD4 counts below 200 cells/mm³ (23%–83%) and WHO stage III or IV conditions (40%–72.6%) (20, 35, 38) compared to our study (11.9% and 6.3%, respectively), both of which are well-established risk factors for anemia. This study identified several factors significantly associated with anemia. Completing primary education, being underweight, increased viral load (more than 50 copies/ml) and ART duration of less than 5 years were found to increase the risk of anemia. Lower educational status was associated with a higher risk of anemia among HIV+ patients, as shown in studies from Debre Tabor, Ethiopia (AOR: 3.2; 95% CI: 1.24–8.40) and Buenos Aires, Argentina (65.4% vs. 34.6% anemia prevalence compared to those with higher education)(38,39). Similarly, our study found that individuals with primary education were 3.35 times more likely to develop anemia than those with tertiary education. Those with no education also lean toward having increased risk of anemia although not significant (AOR: 1.93; 95% CI (0.7-5.29). This association may be attributed to unmeasured factors such as better economic status, improved nutritional intake, and healthier lifestyle behaviours, including greater access to healthcare and contraceptive use, among those with higher education levels (40) . Being underweight has been consistently linked to a significantly increased risk of anemia, with studies reporting odds ratios ranging from 1.98 to 6.6(15,22,41,42). In our study, underweight patients were 2.92(1.10-7.75) times more likely to develop anemia; due to nutritional deficiencies, impaired nutrient absorption, inflammation-related suppression of red blood cell production, and increased susceptibility to infections (43) . Additionally, an increased viral load of more than 50 copies/mL was also found to increase the chance of anemia by nearly 2.5(1.03-6.0) times in our study. Our findings are in line with studies that assessed the prevalence and correlates of anemia at the University of Southern California (44) and another multisite study in the USA (AOR-1.43(1.23-1.64)) (45). This is due to heightened immune activation and chronic inflammation, which lead to bone marrow suppression and increased vulnerability to opportunistic infections(19). The final finding of our study indicated that a shorter duration of ART was associated with a higher likelihood of anemia. Specifically, being on ART for less than five years increased the risk of anemia by two fold. This finding is supported by a retrospective cohort study in which the prevalence of anemia significantly declined from 32.9% at baseline to 14.4% at six months and 9.4% at 12 months following ART initiation(21). Similarly, a study conducted in Malawi in 2016 reported that being on ART for more than ten years was associated with a significantly lower risk of anemia (AOR: 0.4; 95% CI: 0.2–0.9) (46). The observed protective effect of long-term ART may be attributed to improved viral suppression, immune reconstitution, and overall health status over time. This study was well-powered, with a sufficient sample size, and employed systematic random sampling from a registration frame, ensuring representativeness. Research nurses were trained to collect data using KoBocollect, a tool that minimises errors. The study met key assumptions of logistic regression, including a binary outcome, linearity, and absence of multicollinearity. However, its cross-sectional design limits causal inference, and the use of CBC results from the past six months may not fully reflect the current anemia status. Additionally, some independent variables ( viral load, CD4 ) contained outliers, which could impact the accuracy of the results. Anemia remains a significant issue, contributing to increased morbidity and mortality in HIV/AIDS patients (17). Therefore, we recommend routine CBC testing at regular intervals, particularly for patients at higher risk. Given the strong association between being underweight and anemia, it is crucial to provide continuous nutritional counselling during follow-ups. Hospitals or local health offices could support this by developing educational brochures. Moreover, targeted health education efforts should be prioritized for patients with lower educational attainment, as limited education was associated with increased anemia occurrence. Additionally, optimizing overall management, especially at the initiation of therapy, can help achieve early viral load suppression. As patients stabilize on their regimen, the likelihood of anemia decreases, reinforcing the importance of early intervention. 5. Conclusion Anemia is common in people with HIV, especially in those who are underweight, completed primary education, are on ART for less than 5 years, and have increased viral load. These findings underscore the importance of routine anemia screening and targeted interventions in those high risk patients. Abbreviations ART Antiretroviral Therapy AZT Zidovudine BMI Body Mass Index CD4 Cluster of Differentiation 4 COR Crude Odds Ratio HAART Highly Active Antiretroviral Therapy LFT Liver Function Test WHO World Health Organization. Declarations Ethical approval and consent to participate Ethical clearance was obtained from the Bahir Dar University Ethics Review Committee (Institutional Review Board Reference Number: 004/2024). Permission letters were obtained from Bahir Dar University, and the Amhara National Regional State Laboratory Center. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. An informed consent was obtained from each patient before data collection. No patient identifiers were collected to ensure confidentiality, and all electronic data were stored securely on a password-protected computer. Access to patient data was restricted to the research team only. Consent for publication : not applicable Competing interests The authors declare no conflict of interest. Authors' contributions A.M.B. (First Author) conceived and designed the study, collected data, wrote the initial manuscript draft, and coordinated revisions. W.M.B. (Last Author) supervised the research, validated results, co-led the thesis-to-manuscript conversion, and provided critical revisions. Y.M.B. performed data analysis and editing. A.A.N. contributed to data collection and methodological design. Y.M. and E.M. provided expert commentary on methodology and manuscript content. All authors reviewed and approved the final manuscript. Funding: This research received no external funding. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Khusun H, Yip R, Schultink W, Dillon DHS. World Health Organization Hemoglobin Cut-Off Points for the Detection of Anemia Are Valid for an Indonesian Population. J Nutr. 1999;129(9):1669–74. Peña-Rosas JP, WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. Geneva, World Health Organization, 2011 ( WHO/NMH/NHD/MNM/11.1 ). [cited 2022 May 12]; Available from: https://www.academia.edu/4215770/WHO_Haemoglobin_concentrations_for_the_diagnosis_of_anaemia_and_assessment_ of_severity_Vitamin_and_Mineral_Nutrition_Information_System_Geneva_ World_Health_Organization_2011_WHO_NMH_NHD_MNM_11_1_ Chaparro CM, Suchdev PS. Anemia epidemiology, pathophysiology, and etiology in low- and middle-income countries. Ann N Y Acad Sci. 2019;1450(1):15–31. Gardner W, Kassebaum N. Global, Regional, and National Prevalence of Anemia and Its Causes in 204 Countries and Territories, 1990–2019. Curr Dev Nutr. 2020;4:nzaa053035. Duguma TA, Bambo GM, Kebede SS. Prevalence of anemia and associated factors among patients living with HIV/AIDS at Mizan-Tepi University Teaching Hospital, Southwest Ethiopia. HIV AIDS Rev. 2024;23(1):58–65. Sah SK, Dahal P, Tamang GB, Mandal DK, Shah R, Pun SB. Prevalence and Predictors of Anemia in HIV-Infected Persons in Nepal. HIVAIDS Auckl NZ. 2020;12:193–200. Kamau DM, Kangethe S, Essuman S. Prevalence and Underlying Factors of Anemia Among Adult HIV Patients Undergoing Highly Active Antiretroviral Therapy at Murang’a Level 5 Hospital, Kenya. J Med Biomed Lab Sci Res [Internet]. 2024 Jun 27 [cited 2025 May 26];4(1). Available from: http://jmblsr.com/index.php/JMBLSR/article/view/31 HIV AIDS National Strategic Plan For Ethiopia. 2021–2025 Final Printed | PDF [Internet]. [cited 2025 Apr 28]. Available from: https://www.scribd.com/document/568428232/HIV-AIDS-National-Strategic-Plan-for-Ethiopia-2021-2025-Final-Printed Opie J. Haematological complications of HIV Infection. S Afr Med J. 2012;102(6):465. Bain BJ. Pathogenesis and pathophysiology of anemia in HIV infection. Curr Opin Hematol. 1999;6(2):89–93. Department of Medical Laboratory Science, University KI, Obeagu U, Obeagu EI, Alum GU et al. EU, Department of Biochemistry, Ebonyi State, Abakaliki, Ebonyi State, Nigeria,. Anemia as a Prognostic Marker for Disease Progression in HIV Infection. IAA J Biol Sci. 2023;11(1):33–44. Volberding PA, Levine AM, Dieterich D, Mildvan D, Mitsuyasu R, Saag M, et al. Anemia in HIV Infection: Clinical Impact and Evidence-Based Management Strategies. Clin Infect Dis. 2004;38(10):1454–63. The impact of anemia on quality of life and healthcare resource utilization in patients with HIV/AIDS receiving antiretroviral therapy*. Current Medical Research and Opinion: Vol 23, No 4 [Internet]. [cited 2025 Apr 29]. Available from: https://www.tandfonline.com/doi/abs/ 10.1185/030079907X178775 Ford N, Vitoria M, Doherty M. Providing antiretroviral therapy to all who are HIV positive: the clinical, public health and programmatic benefits of Treat All. J Int AIDS Soc. 2018;21(2):e25078. Berhane Y, Haile D, Tolessa T. Anemia in HIV/AIDS Patients on Antiretroviral Treatment at Ayder Specialized Hospital, Mekele, Ethiopia: A Case-Control Study. J Blood Med. 2020;11:379–87. Gudina A, Wordofa M, Urgessa F. Immuno-hematological parameters among adult HIV patients before and after initiation of Dolutegravir based antiretroviral therapy, Addis Ababa, Ethiopia. PLoS ONE. 2024;19(10):e0310239. Negesse A, Getaneh T, Temesgen H, Taddege T, Jara D, Abebaw Z. Prevalence of anemia and its associated factors in human immuno deficiency virus infected adult individuals in Ethiopia. A systematic review and meta-analysis. BMC Hematol. 2018;18:32. Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol. 1996;49(12):1373–9. Lang R, Gill MJ, Coburn SB, Grossman J, Gebo KA, Horberg MA, et al. The changing prevalence of anemia and risk factors in people with HIV in North America who have initiated ART, 2007–2017. AIDS Lond Engl. 2023;37(2):287–98. Wei L, Zhao Y, Gan X, Zhao D, Wu Y, Dou Z, et al. The burden of anemia among Chinese HIV-infected patients following the initiation of antiretroviral therapy in the treat-all era: a nationwide cohort study. BMC Infect Dis. 2023;23(1):704. Yesuf T, Muhie OA, Shibru H. Prevalence and predictors of anemia among adult HIV infected patients at the University of Gondar Hospital, Northwest Ethiopia. HIVAIDS - Res Palliat Care. 2019;11211–7. Ageru TA, Koyra MM, Gidebo KD, Abiso TL. Anemia and its associated factors among adult people living with human immunodeficiency virus at Wolaita Sodo University teaching referral hospital. PLoS ONE. 2019;14:(10):e0221853. Deressa T, Damtie D, Workineh M, Genetu M, Melku M. Anemia and thrombocytopenia in the cohort of HIV-infected adults in northwest Ethiopia: a facility-based cross-sectional study. EJIFCC. 2018;29(1):36–47. Gebreweld A, Fiseha T, Girma N, Haileslasie H, Gebretsadik D. Prevalence of cytopenia and its associated factors among HIV infected adults on highly active antiretroviral therapy at Mehal Meda Hospital, North Shewa Zone, Ethiopia. PLoS ONE. 2020;15(9):e0239215. Mengistu A, Egata G, Hawulte B, Markos M, Lolaso T. Anemia and Associated Factors Among Adults with Human Immune Deficiency Virus on Antiretroviral Therapy in Public Health Facilities of Kembata Tembaro Zone, Southern Ethiopia: A Cross-Sectional Study. HIVAIDS Auckl NZ. 2020;12:341–9. Aynalem YA, Shibabaw Shiferaw W, Woldiye Z. Prevalence of Anemia and Its Associated Factors in Antiretroviral-Treated HIV/AIDS-Positive Adults from 2013 to 2018 at Debre Berhan Referral Hospital, Ethiopia. Adv Hematol. 2020;2020:2513578. Xie B, Huang W, Hu Y, Dou Y, Xie L, Zhang Y, et al. Anemia and opportunistic infections in hospitalized people living with HIV: a retrospective study. BMC Infect Dis. 2022;22(1):912. Kaudha R, Amanya,Richard K et al. Demiano, Muhumuza Atwooki, Roggers, Mutebi Muyoozi, Ronald, Wagubi, Robert,. Anemia in HIV Patients Attending Highly Active Antiretroviral Therapy Clinic at Hoima Regional Referral Hospital: Prevalence, Morphological Classification, and Associated Factors. HIVAIDS - Res Palliat Care. 2023;15:621–32. Shen Y, Wang Z, Lu H, Wang J, Chen J, Liu L, et al. Prevalence of Anemia among Adults with Newly Diagnosed HIV/AIDS in China. PLoS ONE. 2013;8(9):e73807. Omoregie R, Omokaro EU, Palmer O, Ogefere HO, Egbeobauwaye A, Adegue JE et al. Prevalence of anaemia among HIV-infected patients in Benin City, Nigeria. Tanzan J Health Res [Internet]. 2009 [cited 2025 Jun 14];11(1). Available from: https://www.ajol.info/index.php/thrb/article/view/43242 The 2013 WHO Guidelines For Antiretroviral. 3 | PDF | Management Of Hiv/Aids | Hiv/Aids [Internet]. [cited 2025 Jun 15]. Available from: https://www.scribd.com/document/338177865/The-2013-WHO-Guidelines-for-Antiretroviral-3 Patel DM, Moyo C, Bositis CM. A Review of the 2010 WHO Adult Antiretroviral Therapy Guidelines: Implications and Realities of These Changes for Zambia. Med J Zambia. 2010;37(2):118–24. Updated recommendations on first-. line and second-line antiretroviral regimens and post-exposure prophylaxis and recommendations on early infant diagnosis of HIV [Internet]. [cited 2025 May 20]. Available from: https://www.who.int/publications/i/item/WHO-CDS-HIV-18.51?utm_source=chatgpt.com Gebremedhin KB, Haye TB. Factors Associated with Anemia among People Living with HIV/AIDS Taking ART in Ethiopia. Adv Hematol. 2019;2019:9614205. Kamurai B, Chikwati RP, Vhanda D, Nyamayaro T, Manasa J, Kouamou V. Effect of dolutegravir on ferritin, iron, and C-reactive protein among people living with HIV and co-infections. South Afr J HIV Med 25(1):1543. Kerkhoff AD, Wood R, Cobelens FG, Gupta-Wright A, Bekker LG, Lawn SD. Resolution of anaemia in a cohort of HIV-infected patients with a high prevalence and incidence of tuberculosis receiving antiretroviral therapy in South Africa. BMC Infect Dis. 2014;14(1):1–12. Zenebe WA, Anbese AT, Tesfaye TS. Anemia And Associated Factors Among Adult People Living With HIV/AIDS Receiving Anti-Retroviral Therapy At Gedeo Zone, SNNPR, Ethiopia, 2018. HIVAIDS - Res Palliat Care. 2019;11351–6. Gonzalez L, Seley C, Martorano J, Garcia-Moreno I, Troncoso A. Infections and inequalities: anemia in AIDS, the disadvantages of poverty. Asian Pac J Trop Biomed. 2012;2:(6):485–8. Zerihun KW, Bikis GA, Muhammad EA. Prevalence and associated factors of anemia among adult human immune deficiency virus positive patients on anti-retroviral therapy at Debre tabor Hospital, Northwest Ethiopia. BMC Res Notes. 2019;12:168. Tilahun WM, Gebreegziabher ZA, Geremew H, Simegn MB. Prevalence and factors associated with anemia among HIV-infected women in sub-saharan Africa: a multilevel analysis of 18 countries. BMC Public Health. 2024;24(1):2236. Mengistu A, Egata G, Hawulte B, Markos M, Lolaso T. Anemia and Associated Factors Among Adults with Human Immune Deficiency Virus on Antiretroviral Therapy in Public Health Facilities of Kembata Tembaro Zone, Southern Ethiopia: A Cross-Sectional Study. HIVAIDS Auckl NZ. 2020;12:341–9. Aynalem YA, Shibabaw Shiferaw W, Woldiye Z. Prevalence of Anemia and Its Associated Factors in Antiretroviral-Treated HIV/AIDS-Positive Adults from 2013 to 2018 at Debre Berhan Referral Hospital, Ethiopia. Adv Hematol. 2020;2020:2513578. Kreuzer KA, Rockstroh JK. Pathogenesis and pathophysiology of anemia in HIV infection. Ann Hematol. 1997;75(5–6):179–87. Levine AM, Berhane K, Masri-Lavine L, Sanchez ML, Young M, Augenbraun M, et al. Prevalence and Correlates of Anemia in a Large Cohort of HIV-Infected Women: Women’s Interagency HIV Study. JAIDS J Acquir Immune Defic Syndr. 2001;26(1):28. Harding BN, Whitney BM, Nance RM, Ruderman SA, Crane HM, Burkholder G, et al. Anemia risk factors among people living with HIV across the United States in the current treatment era: a clinical cohort study. BMC Infect Dis. 2020;20(1):238. Ngongondo M, Rosenberg NE, Stanley CC, Lim R, Ongubo D, Broadhurst R, et al. Anemia in people on second line antiretroviral treatment in Lilongwe, Malawi: a cross-sectional study. BMC Infect Dis. 2018;18(1):39. Additional Declarations No competing interests reported. Supplementary Files QuestionaireSupplementaryfile1.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 30 Jul, 2025 Reviews received at journal 22 Jul, 2025 Reviewers agreed at journal 20 Jul, 2025 Reviewers invited by journal 20 Jul, 2025 Editor assigned by journal 16 Jul, 2025 Editor invited by journal 25 Jun, 2025 Submission checks completed at journal 24 Jun, 2025 First submitted to journal 24 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6912450","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":477229304,"identity":"18c8b4ef-73ae-449c-ac3f-d9aca775b87c","order_by":0,"name":"Alemayehu M. Bezabih¹","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYDACdgglx8beAKQMLIjQwgyhjPl4DoC0SBCvJXGeRAKIJkILfzPzMakbFdaMbZLPr274USDBwN/enYBXi8RhtmTjnDPpzGzSOWU3e4AOkzhzdgN+aw7zGD7ObTvMBtSSdoMHqMVAIhe/FvnD/B8O5/47zMMmeSbt5h9itBgc5mF8nNtwWIJNgv3YbaJsMTzMZmyccyzdgI0nh+22jIEED0G/yB1vfiadU2NdP7/9+LObb/7YyPG39xLwPgSAYofHAMTiIUY5TAv7A2JVj4JRMApGwQgDAFHWQZRHKHtBAAAAAElFTkSuQmCC","orcid":"","institution":"Bahir Dar University","correspondingAuthor":true,"prefix":"","firstName":"Alemayehu","middleName":"M.","lastName":"Bezabih¹","suffix":""},{"id":477229305,"identity":"ad6383ed-304d-4058-97d7-f0040c6f16f0","order_by":1,"name":"Yihienew M. Bezabih²","email":"","orcid":"","institution":"University of Alabama","correspondingAuthor":false,"prefix":"","firstName":"Yihienew","middleName":"M.","lastName":"Bezabih²","suffix":""},{"id":477229308,"identity":"a5038c5a-c6b8-42bf-a0e3-3fea9e08a48e","order_by":2,"name":"Addisu A. Negatu³","email":"","orcid":"","institution":"Dr. Addisu Medium Clinic","correspondingAuthor":false,"prefix":"","firstName":"Addisu","middleName":"A.","lastName":"Negatu³","suffix":""},{"id":477229310,"identity":"ce63f661-a8bd-477e-aa6b-0855f3a4597b","order_by":3,"name":"Ergoye Melese⁴","email":"","orcid":"","institution":"Bahir Dar University","correspondingAuthor":false,"prefix":"","firstName":"Ergoye","middleName":"","lastName":"Melese⁴","suffix":""},{"id":477229313,"identity":"3542c9fa-b9a3-441d-b4e9-acd9603fd0b7","order_by":4,"name":"Yirga Mengistie¹","email":"","orcid":"","institution":"Bahir Dar University","correspondingAuthor":false,"prefix":"","firstName":"Yirga","middleName":"","lastName":"Mengistie¹","suffix":""},{"id":477229315,"identity":"3ffdcec8-bee2-4158-9b0a-0b1bd66406ca","order_by":5,"name":"Woldesellassie M. Bezabhe⁵","email":"","orcid":"","institution":"University of Tasmania","correspondingAuthor":false,"prefix":"","firstName":"Woldesellassie","middleName":"M.","lastName":"Bezabhe⁵","suffix":""}],"badges":[],"createdAt":"2025-06-17 09:08:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6912450/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6912450/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86662600,"identity":"757984ee-932e-4cef-b699-65d59e7dc06f","added_by":"auto","created_at":"2025-07-14 10:44:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":8399,"visible":true,"origin":"","legend":"\u003cp\u003eBar graph showing the proportion of patients who had mild, moderate and severe anemia.\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6912450/v1/677cf62e2f7935c2aa382d37.png"},{"id":86665130,"identity":"e0d3bdb1-b07d-4bcf-9961-327e74ef9ea3","added_by":"auto","created_at":"2025-07-14 11:00:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1095033,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6912450/v1/cbae6946-2e50-4615-a158-45da516a065c.pdf"},{"id":86662603,"identity":"12985069-5430-4f28-a594-015de916c4b0","added_by":"auto","created_at":"2025-07-14 10:44:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":293699,"visible":true,"origin":"","legend":"","description":"","filename":"QuestionaireSupplementaryfile1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6912450/v1/114f3c86c42d5e86907869a5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Anemia prevalence and associated factors in patients with HIV at Ethiopian Hospitals","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eAccording to the World Health Organization (WHO), anemia is defined as a hemoglobin (Hb) level of \u0026lt;\u0026thinsp;12.0 g/dL in women and \u0026lt;\u0026thinsp;13.0 g/dL in men (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). It is a significant public health problem affecting people in developing countries (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Approximately one-third of the global population (32.9%) was estimated to suffer from anemia in 2010 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), which decreased to 22.8% (95% CI: 22.6%-23.1%) by 2019(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). People with HIV are among the most vulnerable to anemia(with even higher prevalence rates of 66.7% in Nepal in 2020, 42.03% in Kenya in 2024, and 39.8% at Mizan-Tepi University Hospital, Southwest Ethiopia in 2021 (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)).\u003c/p\u003e\u003cp\u003eEthiopia remains a high-burden country for HIV/AIDS, with an adult prevalence of 0.9%. Approximately 669,000 people are living with HIV, and 14,842 new infections were reported in 2019 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Anemia is one of the most common hematologic complications of HIV/AIDS, affecting up to 95% of patients at some point during their disease course (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Its multifactorial etiology includes direct viral suppression of the bone marrow, chronic inflammation due to opportunistic infections, and toxicity related to antiretroviral therapy(ART) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The occurrence of anemia independently predicts faster disease progression, poorer treatment response, and increased mortality in patients with HIV/AIDS. It also contributes to reduced quality of life and complicates ART by reducing adherence and immune recovery (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn 2015, the WHO introduced the \u0026ldquo;Treat All\u0026rdquo; policy, which initiates ART regardless of CD4 count or clinical stage and has been associated with reduced morbidity and mortality, improved quality of life, and overall health (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). However, its impact on anemia prevalence remains inadequately documented. The replacement of zidovudine (AZT) with tenofovir disoproxil fumarate (TDF) as the first-line antiretroviral regimen in 2013 and the introduction of dolutegravir (DTG) in 2019 have been associated with a decreased prevalence of anemia among people living with HIV (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Data are limited about the prevalence of anemia following the policy change and the availability of safer antiretroviral agents. Therefore, this study aimed to determine the prevalence of anemia and its associated risk factors among people living with HIV.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Study design, area and period\u003c/h2\u003e\u003cp\u003eThis institution-based, descriptive cross-sectional study was conducted between 1 January and 1 February, 2025, at two hospitals - Tibebe Ghion Specialized Hospital and Felege Hiwot Comprehensive Specialized Hospital in Bahir Dar, Ethiopia. The ART care was a multidisciplinary care led by nurses.\u003c/p\u003e\u003cp\u003eTibebe Ghion Specialized Hospital is located approximately 10 km south of Bahir Dar city. It is a tertiary-level university teaching hospital with a 450-bed capacity, providing inpatient and outpatient services across all major medical departments. The hospital also operates ART clinics that offer free diagnostic and therapeutic services to over 3500 clients annually, with 165 of them receiving chronic follow-up care.\u003c/p\u003e\u003cp\u003eFelege Hiwot Comprehensive Specialized Hospital is situated within Bahir Dar city and has a capacity of 350 beds. Nurses and physicians led the ART clinic, providing care for approximately 7,000 patients.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2. Study Population, inclusion and exclusion criteria\u003c/h2\u003e\u003cp\u003e The study population consisted of patients with HIV aged 15 years and older who were receiving follow-up care at the ART clinics of Tibebe Ghion Specialized Hospital and Felege Hiwot Comprehensive Specialized Hospital in Bahir Dar. Patients were excluded if they were under 15 years of age, had a known hematologic disorder or bleeding tendency, had received a blood transfusion within the past three months, were pregnant or lactating, or had grossly incomplete data.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Study variables and operational definition\u003c/h2\u003e\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\u003ch2\u003e2.3.1\u003c/b\u003e Dependent variable\u003c/b\u003e\u003c/h2\u003e\u003cp\u003eThe primary outcome was the prevalence of anemia, defined according to WHO criteria as a haemoglobin level\u0026thinsp;\u0026lt;\u0026thinsp;12 g/dL in women and \u0026lt;\u0026thinsp;13 g/dL in men. Anemia was further stratified by severity into mild (11\u0026ndash;12.9 g/dL in men and 11\u0026ndash;11.9 g/dL in women), moderate (8\u0026ndash;10.9 g/dL), and severe (\u0026lt;\u0026thinsp;8 g/dL).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\u003ch2\u003e2.3.2 Independent variables\u003c/h2\u003e\u003cp\u003eIndependent variables were broadly categorized into socio-demographic characteristics, clinical parameters, laboratory findings, and medication-related factors. Socio-demographic variables included age, sex, marital status, religion, place of residence, and educational status. Clinical parameters encompassed WHO clinical stage, presence of opportunistic infections (OIs), nutritional status, duration since HIV diagnosis, functional status, and ART adherence. Nutritional status was assessed using BMI, with BMI\u0026thinsp;\u0026lt;\u0026thinsp;18.5 kg/m\u0026sup2; classified as underweight, 18.5\u0026ndash;24.9 kg/m\u0026sup2; as normal, and \u0026ge;\u0026thinsp;25 kg/m\u0026sup2; as overweight. ART adherence was categorized based on doses missed in the last month as good (missed\u0026thinsp;\u0026lt;\u0026thinsp;2 doses out of 30 doses or \u0026lt;\u0026thinsp;3 out of 60 doses), fair (missed 2\u0026ndash;4 out of 30 doses or 4\u0026ndash;9 out of 60 doses), or poor (missed\u0026thinsp;\u0026ge;\u0026thinsp;5 out of 30 doses or \u0026ge;\u0026thinsp;10 out of 60 doses). Laboratory variables included the most recent CD4 cell count, viral load, Liver function tests (LFT), renal function tests (RFT), hemoglobin level, white blood cell (WBC) count, and platelet (PLT) count. Medication-related variables included the type of ART regimen (AZT-based vs. non-AZT-based), cotrimoxazole preventive therapy, and isoniazid preventive therapy.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.4. Sample size determination and sampling technique\u003c/h2\u003e\u003cp\u003eThe sample size was determined using a single population proportion formula, with the following assumptions: the prevalence of anemia among patients with HIV was estimated to be 31% based on a meta-analysis involving 20 studies(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), a 5% margin of error, and a 95% confidence interval using online calculator.\u003c/p\u003e\u003cp\u003eThe calculated sample size was 329; taking into account 10% non-response or data incompleteness rate (approximately 33 participants), the final sample size was adjusted to 362. Additional sample size calculations for selected secondary outcome variables (associated risk factors) using a double population proportion formula yielded smaller required sample sizes; therefore, the final sample size for the study remained 362.\u003c/p\u003e\u003cp\u003eWe used the ART clinic registries as the sampling frame and applied systematic random sampling to select study participants. From Tibebe Ghion Specialized Hospital, one data collector collected data from 32 patients by selecting every 5th patient record. At Felege Hiwot Comprehensive Specialized Hospital, five data collectors extracted data from a total of 330 patients by selecting every 10th patient they evaluated.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e2.5. Data collection and quality assurance\u003c/h2\u003e\u003cp\u003e After reviewing relevant literature and guidelines from the WHO and the Ministry of Health, a data extraction questionnaire was developed based on the study objectives (see supplementary file 1). Data collection was supplemented by patient interviews during follow-up evaluations. The clarity and completeness of the checklist were pretested on 5% of patient charts before the main data collection. Based on this pilot test and a review of previous studies, necessary corrections and modifications were made to the data collection format. Research nurses working in ART clinics received appropriate training and collected the data using KoBocollect app, which was installed on their smartphones. The principal investigator regularly reviewed submitted data for completeness and consistency.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e2.6. Data management and analysis\u003c/h2\u003e\u003cp\u003eAfter data collection, the data was exported to SPSS version 29 for analysis. The data were carefully cleaned and checked for completeness before analysis. Categorical variables were summarised using proportions and frequencies and continuous variables with means and standard deviations. The findings were presented in tables and bar graphs. A binary logistic regression model was used to identify factors associated with anemia incidence. We selected variables with p\u0026thinsp;\u0026lt;\u0026thinsp;0.25 in the univariable logistic model to be included in the final multivariable logistic regression based on clinical relevance, statistical significance (p\u0026thinsp;\u0026le;\u0026thinsp;0.05), and number of events per variable (\u0026ge;\u0026thinsp;10) as suggested by Peduzzi et al (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In the final model, variables with a p\u0026thinsp;\u0026le;\u0026thinsp;0.05 were considered statistically associated with anemia. Model adequacy was evaluated using the Hosmer-Lemeshow goodness-of-fit test, with a p-value greater than 0.05 indicating a good fit. Multicollinearity among independent variables was assessed using the variance inflation factor, with values less than 10 considered acceptable.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1. Socio-demographic factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, 362 patient charts were reviewed. Their ages range from 15 to 70 years with mean \u0026plusmn; SD of 41.2 \u0026plusmn; 11.5 years. The most common age groups were 40-59 years (50.8%) and 20-39 years (42%), accounting for 92.8% of the study population. Of the total, 214 (59.1%) were female. Most were married (57.5%) and lived in urban areas (80.7%). Most participants identified as Ethiopian Orthodox Christian (95.3%) and had completed primary or secondary education (60.3%) (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2. Clinical factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinically, 92.8% of patients were classified as WHO clinical stage I or II, indicating asymptomatic or mildly symptomatic disease. Additionally, 87.8% were not experiencing opportunistic infections or cancers at the time of assessment. Around 97.2% demonstrated good adherence to ART, missing fewer than 2 doses out of 30 doses (within 1 month) or 3 doses out of 60 doses (within 2 months).\u003c/p\u003e\n\u003cp\u003eThe duration of ART among participants ranged from 1 month to 22 years, with a median (interquartile range (IQR) of 10.1 (4-15) years. More than two-thirds of the patients (68.5%) had been on ART for over five years, while 31.5% had been on ART for less than five years. Based on BMI, 85.1% of patients had a normal nutritional status (BMI 18.5\u0026ndash;24.9), 6.1% were overweight, and 8.5% were underweight. Functionally, 94.75% of participants worked at the workplace or at home to support their families.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3. Laboratory and medication factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe CD4 count among patients ranged from zero to 1852 cells/mm\u003csup\u003e3\u003c/sup\u003e.\u0026nbsp;The median (IQR) CD4 count was 460 (322-635) cells/mm\u0026sup3;.\u0026nbsp;Around 72.6% of patients had CD4 count more than 350 cells/mm\u003csup\u003e3\u003c/sup\u003e, 15.2% had a count between 200 and 350 cells/mm\u0026sup3;, and 11.6% had a count of less than 200 cells/mm\u0026sup3;. Regarding viral load, 89.8% of patients had a suppressed viral load (\u0026lt;50 copies/mL), while 8% had detectable viremia (\u0026ge;50 copies/mL), including both low-level (50\u0026ndash;1000 copies/mL) and high-level (\u0026gt;1000 copies/mL) viremia. Additionally, 1.1% (4/362) of patients had liver function test results above the laboratory-specific upper limit of normal (ULN), and 1.4% (5/362) had elevated renal function test results exceeding the ULN. Around 97.5% (353/362) were on a non-AZT-based regimen and only 2.5 %( 9/362), were on an AZT-based regimen. Moreover, 19.3% (70/362) were on Cotrimoxazole Preventive Therapy, and 1.1% (4/362) were on Isoniazid Preventive Therapy (Table 1).\u003c/p\u003e\n\u003cp\u003eTable 1: Sociodemographic and clinical characteristics of patients included in this study\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"627\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eCount (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eAnemia Status\u003c/p\u003e\n \u003cp\u003eYes \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eCOR (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026le;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e7 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e20-39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e152 (42.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.95(0.17-5.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e40-59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e184 (50.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.52(0.09-2.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026ge;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e19 (5.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1.45(0.22-9.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e148 (40.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e109\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1.38(0.84-2.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eMarital Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eNever Married\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e61 (16.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e208 (57.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.86(0.44-1.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e66 (18.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1.11(0.49-2.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e27 (7.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.89(0.30-2.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eReligion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eOrthodox\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e345 (95.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e268\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eMuslim\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e17 (4.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.52(0.18-1.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eLevel of Education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e87 (24.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e108 (29.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1.69(0.78-3.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e110 (30.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e3.04(1.46-6.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eNo Education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e56 (15.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1.70(0.70-4.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eResidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e292 (80.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e223\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e70 (19.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1.23(0.64-2.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eFunctional Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eWorking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e343 (94.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e271\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eAmbulatory/Bed-ridden\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e17 (4.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e6.90(2.46-19.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eBMI (kg/m\u0026sup2;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eNormal (18.5-24.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e308 (85.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e245\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eUnderweight (\u0026lt;18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e31 (8.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e4.72(2.20-10.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eOverweight (25-29.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e22 (6.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.61(0.17-2.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eART duration (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026le;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e114 (31.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e2.94 (1.77-4.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026gt;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e248 (68.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e207\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eWHO Clinical Stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eStage 1/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e336 (92.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e269\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eStage 3/4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e26 (7.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e6.42(2.78-14.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eOpportunistic Infections\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e44 (12.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e3.77(1.96-7.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eART Adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e352 (97.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e274\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eFair/Poor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e10 (2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e3.51(0.99-12.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eCD4 Category (cells/mm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026lt;200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e42 (11.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e4.17(2.11-8.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e200-350\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e55 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1.72(0.88-3.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026gt;350\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e263 (72.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e216\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eViral Load (copies/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026lt;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e325 (89.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e258\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026ge;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e29 (8.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e2.71(1.23-5.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eAbnormal LFT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e4 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e10.42(1.07-101.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eRenal Impairment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e5 (1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e5.19(0.85-31.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eHAART Regimen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eAZT-Based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e9 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.36(0.09-1.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eCotrimoxazole preventive therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e70 (19.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e3.38(1.93-5.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eIsoniazid preventive therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e4 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1.10(0.11-10.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e ART: Antiretroviral Therapy; AZT: Zidovudine; BMI: Body Mass Index; CD4: Cluster of Differentiation 4; COR: Crude Odds Ratio; HAART: Highly Active Antiretroviral Therapy; LFT: Liver Function Test; WHO: World Health Organization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4. The magnitude of anemia\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe prevalence of anemia in our study was 22.9% (83/362, 95% CI: 18.7-27.6). In terms of severity, the majority of anemia cases were mild (14.6% (53/362), 6.9% (25/362) moderate anemia, and 1.4 %( 5/362) severe anemia (Figure 1). The mean hemoglobin level \u0026plusmn; SD was 13.24 \u0026plusmn; 1.78 g/dL. In addition to anemia, 13.0% (47/362) of patients had leukopenia, and 6.1% (22/362) had thrombocytopenia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.5. Associated factors of anemia\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the univariable logistic model, several factors demonstrated significant associations with anemia. These included being underweight (BMI \u0026lt;18.5 kg/m\u0026sup2;), having advanced HIV disease (WHO clinical stage 3/4 or CD4 count \u0026lt;200 cells/mm\u003csup\u003e3\u003c/sup\u003e), and experiencing opportunistic infections or cancers. Additional risk factors were elevated LFTs, detectable viral load (\u0026ge;50 copies/mL), and the use of cotrimoxazole preventive therapy. Functional impairment (ambulatory/bedridden status), ART duration less than 5 years and completion of primary education also showed a significant association.\u003c/p\u003e\n\u003cp\u003eHowever, after adjusting for potential confounders in the multivariable logistic regression, completion of primary education, being underweight, increased viral load and ART duration of less than 5 years remained independently associated with anemia.\u003c/p\u003e\n\u003cp\u003ePatients with a primary level of education had significantly higher odds of anemia compared to those with tertiary education (AOR: 3.35; 95% CI: 1.48\u0026ndash;7.55). Underweight patients were also more likely to be anemic, with nearly three times higher odds than those with a normal BMI (AOR: 2.92; 95% CI: 1.10-7.75). Additionally, patients with an elevated viral load (\u0026gt;50 copies/mL) had a significantly increased risk of anemia compared to those with fully suppressed viral loads (\u0026lt;50 copies/mL) (AOR: 2.48; 95% CI: 1.03-6.00). Lastly, a shorter duration of ART, less than 5 years, was associated with nearly twice increased likelihood of anemia compared to durations of more than 5 years (AOR: 1.96; 95% CI: 1.03-3.71) (Table 2).\u003c/p\u003e\n\u003cp\u003eTable 2: Unadjusted and adjusted odds of developing anemia using a logistic regression model.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eCOR (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eAOR (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eAge Category (in years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026le;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e20-39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0.95 (0.17-5.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e2.04 (0.12-34.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e40-59\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0.52 (0.09-2.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1.78 (0.10-30.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026ge;60\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1.45 (0.22-9.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e5.02 (0.25-99.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eEducation Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1.69(0.78-3.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1.73(0.72-4.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e3.04(1.46-6.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e3.35(1.48-7.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eNo education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1.70 (0.70-4.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1.93 (0.70-5.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eBMI(in Kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eNormal (18.5-24.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eUnderweight (\u0026lt;18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e4.72 (2.20-10.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e2.92 (1.10-7.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eOverweight (25-29.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0.61 (0.17-2.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e0.56 (0.14-2.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eFunctional Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eWorking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eAmbulatory and \u0026nbsp; \u0026nbsp;Bedridden\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e6.90 (2.46-19.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e0.97 (0.22-4.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eWHO clinical Stages\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eStages 1 and 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eStages 3 and 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e6.42 (2.78-14.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1.52 (0.45-5.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eOpportunistic Infections/CAs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e3.77 (1.96-7.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1.46 (0.54-3.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eCD4 Count (cells/mm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026gt;350\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e200-350\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1.72(0.88-3.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1.32 (0.55-3.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026lt;200\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e4.17(2.11-8.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1.54 (0.56-4.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eViral Load (copies/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026lt;50\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026ge;50\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e2.71 (1.23-5.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e2.48 (1.03-6.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eART Duration (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026le;5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e2.94 (1.77-4.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1.96 (1.03-3.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026gt;5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eCotrimoxazole preventive therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e3.38 (1.93-5.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1.52 (0.63-3.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e AOR: Adjusted Odds Ratio; ART: Antiretroviral Therapy; BMI: Body Mass Index; COR: Crude Odds Ratio; \u003cstrong\u003eCD4\u003c/strong\u003e: Cluster of differentiation 4; WHO: World Health Organization\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis multisite study assessed the prevalence of anemia among people with HIV following the full implementation of the WHO \u0026ldquo;Treat All\u0026rdquo; policy. The findings indicate a decline in anemia prevalence compared to earlier reports. This finding aligns with international studies showing a declining trend in the overall prevalence of anemia among people with HIV, from approximately 33% in 2007 to 20% in 2017 (19). This reduction has been largely attributed to the implementation of the WHO\u0026rsquo;s \u0026ldquo;Treat All\u0026rdquo; policy in Sept 2015 and the subsequent optimization of ART regimens (20). A similar trend has been observed in Ethiopia. Prior to the full implementation of the WHO \u0026ldquo;Treat All\u0026rdquo; policy, which occurred between 2017 and 2018, studies reported anemia prevalence among people with HIV ranging from 32.9% to 36.5% (21\u0026ndash;23). Following broader adoption, later studies documented a decline to 23\u0026ndash;26% (24\u0026ndash;26), suggesting a positive impact of expanded access to and optimization of ART.\u003c/p\u003e\n\u003cp\u003eThe lower anemia prevalence in our study and recent reports(27,28), compared to earlier higher rates(29,30), may reflect improvements in several contributing factors. The WHO replaced AZT with TDF as the preferred first-line ART regimen in 2013(31) due to AZT\u0026apos;s strong association with long-term toxicities such as anemia and neutropenia, as well as its potential to induce resistance mutations that compromise the efficacy of second- and third-line treatment options (32,33). This is evident from our study, where only 2.5% of patients were on AZT, compared to 48.8% to 62.5% in previous studies (21,24,34), where AZT-associated anemia may have contributed to the higher prevalence. DTG, which became the first-line ART regimen in 2019, has also been associated with increased serum iron levels after six months of treatment (35). Furthermore, DTG has been shown to improve hemoglobin concentration, white blood cell count, and platelet levels within three months of initiation (16).\u003c/p\u003e\n\u003cp\u003eAnemia tends to decline in ART-na\u0026iuml;ve patients after initiating treatment, with noticeable improvements in hemoglobin levels observed at 6 months, and 12 months from the baseline (21,36). Since the majority of our patients (94%) had been on ART for over 12 months, it is likely that their disease course had stabilised, contributing to the lower prevalence of anemia. Lastly, improved HIV care and better drug adherence, leading to enhanced viral load suppression, likely contributed to the lower anemia prevalence observed in our study by reducing the burden of opportunistic infections. This is further supported by previous studies reporting higher proportions of participants with CD4 counts below 200 cells/mm\u0026sup3; (23%\u0026ndash;83%) and WHO stage III or IV conditions (40%\u0026ndash;72.6%) (20, 35, 38) compared to our study (11.9% and 6.3%, respectively), both of which are well-established risk factors for anemia.\u003c/p\u003e\n\u003cp\u003eThis study identified several factors significantly associated with anemia. Completing primary education, being underweight, increased viral load (more than 50 copies/ml) and ART duration of less than 5 years were found to increase the risk of anemia. Lower educational status was associated with a higher risk of anemia among HIV+ patients, as shown in studies from Debre Tabor, Ethiopia (AOR: 3.2; 95% CI: 1.24\u0026ndash;8.40) and Buenos Aires, Argentina (65.4% vs. 34.6% anemia prevalence compared to those with higher education)(38,39). Similarly, our study found that individuals with primary education were 3.35 times more likely to develop anemia than those with tertiary education. Those with no education also lean toward having increased risk of anemia although not significant (AOR: 1.93; 95% CI (0.7-5.29). This association may be attributed to unmeasured factors such as better economic status, improved nutritional intake, and healthier lifestyle behaviours, including greater access to healthcare and contraceptive use, among those with higher education levels (40)\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBeing underweight has been consistently linked to a significantly increased risk of anemia, with studies reporting odds ratios ranging from 1.98 to 6.6(15,22,41,42). In our study, underweight patients were \u003cstrong\u003e2.92(1.10-7.75) times\u003c/strong\u003e more likely to develop anemia; due to \u003cstrong\u003enutritional deficiencies, impaired nutrient absorption, inflammation-related suppression of red blood cell production, and increased susceptibility to infections\u0026nbsp;\u003c/strong\u003e(43)\u003cstrong\u003e.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAdditionally, an increased viral load of more than 50 copies/mL was also found to increase the chance of anemia by nearly 2.5(1.03-6.0) times in our study. Our findings are in line with studies that assessed the prevalence and correlates of anemia at the University of Southern California (44) and another multisite study in the USA (AOR-1.43(1.23-1.64)) (45). This is due to heightened immune activation and chronic inflammation, which lead to bone marrow suppression and increased vulnerability to opportunistic infections(19).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe final finding of our study indicated that a shorter duration of ART was associated with a higher likelihood of anemia. Specifically, being on ART for less than five years increased the risk of anemia by two fold. This finding is supported by a retrospective cohort study in which the prevalence of anemia significantly declined from 32.9% at baseline to 14.4% at six months and 9.4% at 12 months following ART initiation(21). Similarly, a study conducted in Malawi in 2016 reported that being on ART for more than ten years was associated with a significantly lower risk of anemia (AOR: 0.4; 95% CI: 0.2\u0026ndash;0.9) (46). The observed protective effect of long-term ART may be attributed to improved viral suppression, immune reconstitution, and overall health status over time.\u003c/p\u003e\n\u003cp\u003eThis study was well-powered, with a sufficient sample size, and employed \u003cstrong\u003esystematic random sampling\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003efrom a registration frame, ensuring representativeness. \u003cstrong\u003eResearch nurses were trained to collect data using KoBocollect, a tool that minimises errors.\u0026nbsp;\u003c/strong\u003eThe study met key \u003cstrong\u003eassumptions of logistic regression, including a binary outcome, linearity, and absence of\u003c/strong\u003e multicollinearity. However, its \u003cstrong\u003ecross-sectional design\u003c/strong\u003e limits causal inference, and the use of CBC\u003cstrong\u003e\u0026nbsp;results from the past six months\u003c/strong\u003e may not fully reflect the current anemia status. Additionally, some independent variables \u003cstrong\u003e(\u003cstrong\u003eviral load, CD4\u003c/strong\u003e)\u003c/strong\u003e contained outliers, which could impact the accuracy of the results.\u003c/p\u003e\n\u003cp\u003eAnemia remains a significant issue, contributing to increased morbidity and mortality in HIV/AIDS patients (17). Therefore, we recommend routine CBC testing at regular intervals, particularly for patients at higher risk. Given the strong association between being underweight and anemia, it is crucial to provide continuous nutritional counselling during follow-ups. Hospitals or local health offices could support this by developing educational brochures. Moreover, targeted health education efforts should be prioritized for patients with lower educational attainment, as limited education was associated with increased anemia occurrence. Additionally, optimizing overall management, especially at the initiation of therapy, can help achieve early viral load suppression. As patients stabilize on their regimen, the likelihood of anemia decreases, reinforcing the importance of early intervention.\u0026nbsp;\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eAnemia is common in people with HIV, especially in those who are underweight, completed primary education, are on ART for less than 5 years, and have increased viral load. These findings underscore the importance of routine anemia screening and targeted interventions in those high risk patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eART\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAntiretroviral Therapy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAZT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eZidovudine\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBody Mass Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCD4\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCluster of Differentiation 4\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCOR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCrude Odds Ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHAART\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHighly Active Antiretroviral Therapy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLFT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLiver Function Test\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from the Bahir Dar University Ethics Review Committee (Institutional Review Board Reference Number: 004/2024). Permission letters were obtained from Bahir Dar University, and the Amhara National Regional State Laboratory Center. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. An informed consent was obtained from each patient before data collection. No patient identifiers were collected to ensure confidentiality, and all electronic data were stored securely on a password-protected computer. Access to patient data was restricted to the research team only.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: not applicable\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u003c/h2\u003e\n\u003cp\u003e\u003cem\u003eA.M.B. (First Author)\u003c/em\u003e conceived and designed the study, collected data, wrote the initial manuscript draft, and coordinated revisions. \u003cem\u003eW.M.B. (Last Author)\u003c/em\u003e supervised the research, validated results, co-led the thesis-to-manuscript conversion, and provided critical revisions. \u003cem\u003eY.M.B.\u003c/em\u003e performed data analysis and editing. \u003cem\u003eA.A.N.\u003c/em\u003e contributed to data collection and methodological design. \u003cem\u003eY.M.\u003c/em\u003e and \u003cem\u003eE.M.\u003c/em\u003e provided expert commentary on methodology and manuscript content. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKhusun H, Yip R, Schultink W, Dillon DHS. World Health Organization Hemoglobin Cut-Off Points for the Detection of Anemia Are Valid for an Indonesian Population. J Nutr. 1999;129(9):1669\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePe\u0026ntilde;a-Rosas JP, WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. Geneva, World Health Organization, 2011 (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eWHO/NMH/NHD/MNM/11.1\u003c/span\u003e\u003cspan address=\"http://WHO/NMH/NHD/MNM/11.1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). [cited 2022 May 12]; Available from: https://www.academia.edu/4215770/WHO_Haemoglobin_concentrations_for_the_diagnosis_of_anaemia_and_assessment_ of_severity_Vitamin_and_Mineral_Nutrition_Information_System_Geneva_ World_Health_Organization_2011_WHO_NMH_NHD_MNM_11_1_\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChaparro CM, Suchdev PS. Anemia epidemiology, pathophysiology, and etiology in low- and middle-income countries. Ann N Y Acad Sci. 2019;1450(1):15\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGardner W, Kassebaum N. Global, Regional, and National Prevalence of Anemia and Its Causes in 204 Countries and Territories, 1990\u0026ndash;2019. Curr Dev Nutr. 2020;4:nzaa053035.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDuguma TA, Bambo GM, Kebede SS. Prevalence of anemia and associated factors among patients living with HIV/AIDS at Mizan-Tepi University Teaching Hospital, Southwest Ethiopia. HIV AIDS Rev. 2024;23(1):58\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSah SK, Dahal P, Tamang GB, Mandal DK, Shah R, Pun SB. Prevalence and Predictors of Anemia in HIV-Infected Persons in Nepal. HIVAIDS Auckl NZ. 2020;12:193\u0026ndash;200.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKamau DM, Kangethe S, Essuman S. Prevalence and Underlying Factors of Anemia Among Adult HIV Patients Undergoing Highly Active Antiretroviral Therapy at Murang\u0026rsquo;a Level 5 Hospital, Kenya. J Med Biomed Lab Sci Res [Internet]. 2024 Jun 27 [cited 2025 May 26];4(1). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://jmblsr.com/index.php/JMBLSR/article/view/31\u003c/span\u003e\u003cspan address=\"http://jmblsr.com/index.php/JMBLSR/article/view/31\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHIV AIDS National Strategic Plan For Ethiopia. 2021\u0026ndash;2025 Final Printed | PDF [Internet]. [cited 2025 Apr 28]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.scribd.com/document/568428232/HIV-AIDS-National-Strategic-Plan-for-Ethiopia-2021-2025-Final-Printed\u003c/span\u003e\u003cspan address=\"https://www.scribd.com/document/568428232/HIV-AIDS-National-Strategic-Plan-for-Ethiopia-2021-2025-Final-Printed\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOpie J. Haematological complications of HIV Infection. S Afr Med J. 2012;102(6):465.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBain BJ. Pathogenesis and pathophysiology of anemia in HIV infection. Curr Opin Hematol. 1999;6(2):89\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDepartment of Medical Laboratory Science, University KI, Obeagu U, Obeagu EI, Alum GU et al. EU, Department of Biochemistry, Ebonyi State, Abakaliki, Ebonyi State, Nigeria,. Anemia as a Prognostic Marker for Disease Progression in HIV Infection. IAA J Biol Sci. 2023;11(1):33\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVolberding PA, Levine AM, Dieterich D, Mildvan D, Mitsuyasu R, Saag M, et al. Anemia in HIV Infection: Clinical Impact and Evidence-Based Management Strategies. Clin Infect Dis. 2004;38(10):1454\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThe impact of anemia on quality of life and healthcare resource utilization in patients with HIV/AIDS receiving antiretroviral therapy*. Current Medical Research and Opinion: Vol 23, No 4 [Internet]. [cited 2025 Apr 29]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.tandfonline.com/doi/abs/\u003c/span\u003e\u003cspan address=\"https://www.tandfonline.com/doi/abs/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1185/030079907X178775\u003c/span\u003e\u003cspan address=\"10.1185/030079907X178775\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFord N, Vitoria M, Doherty M. Providing antiretroviral therapy to all who are HIV positive: the clinical, public health and programmatic benefits of Treat All. J Int AIDS Soc. 2018;21(2):e25078.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBerhane Y, Haile D, Tolessa T. Anemia in HIV/AIDS Patients on Antiretroviral Treatment at Ayder Specialized Hospital, Mekele, Ethiopia: A Case-Control Study. J Blood Med. 2020;11:379\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGudina A, Wordofa M, Urgessa F. Immuno-hematological parameters among adult HIV patients before and after initiation of Dolutegravir based antiretroviral therapy, Addis Ababa, Ethiopia. PLoS ONE. 2024;19(10):e0310239.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNegesse A, Getaneh T, Temesgen H, Taddege T, Jara D, Abebaw Z. Prevalence of anemia and its associated factors in human immuno deficiency virus infected adult individuals in Ethiopia. A systematic review and meta-analysis. BMC Hematol. 2018;18:32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePeduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol. 1996;49(12):1373\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLang R, Gill MJ, Coburn SB, Grossman J, Gebo KA, Horberg MA, et al. The changing prevalence of anemia and risk factors in people with HIV in North America who have initiated ART, 2007\u0026ndash;2017. AIDS Lond Engl. 2023;37(2):287\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWei L, Zhao Y, Gan X, Zhao D, Wu Y, Dou Z, et al. The burden of anemia among Chinese HIV-infected patients following the initiation of antiretroviral therapy in the treat-all era: a nationwide cohort study. BMC Infect Dis. 2023;23(1):704.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYesuf T, Muhie OA, Shibru H. Prevalence and predictors of anemia among adult HIV infected patients at the University of Gondar Hospital, Northwest Ethiopia. HIVAIDS - Res Palliat Care. 2019;11211\u0026ndash;7.\u0026lt;\\/p\u0026gt;\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAgeru TA, Koyra MM, Gidebo KD, Abiso TL. Anemia and its associated factors among adult people living with human immunodeficiency virus at Wolaita Sodo University teaching referral hospital. PLoS ONE. 2019;14:(10):e0221853.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDeressa T, Damtie D, Workineh M, Genetu M, Melku M. Anemia and thrombocytopenia in the cohort of HIV-infected adults in northwest Ethiopia: a facility-based cross-sectional study. EJIFCC. 2018;29(1):36\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGebreweld A, Fiseha T, Girma N, Haileslasie H, Gebretsadik D. Prevalence of cytopenia and its associated factors among HIV infected adults on highly active antiretroviral therapy at Mehal Meda Hospital, North Shewa Zone, Ethiopia. PLoS ONE. 2020;15(9):e0239215.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMengistu A, Egata G, Hawulte B, Markos M, Lolaso T. Anemia and Associated Factors Among Adults with Human Immune Deficiency Virus on Antiretroviral Therapy in Public Health Facilities of Kembata Tembaro Zone, Southern Ethiopia: A Cross-Sectional Study. HIVAIDS Auckl NZ. 2020;12:341\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAynalem YA, Shibabaw Shiferaw W, Woldiye Z. Prevalence of Anemia and Its Associated Factors in Antiretroviral-Treated HIV/AIDS-Positive Adults from 2013 to 2018 at Debre Berhan Referral Hospital, Ethiopia. Adv Hematol. 2020;2020:2513578.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXie B, Huang W, Hu Y, Dou Y, Xie L, Zhang Y, et al. Anemia and opportunistic infections in hospitalized people living with HIV: a retrospective study. BMC Infect Dis. 2022;22(1):912.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaudha R, Amanya,Richard K et al. Demiano, Muhumuza Atwooki, Roggers, Mutebi Muyoozi, Ronald, Wagubi, Robert,. Anemia in HIV Patients Attending Highly Active Antiretroviral Therapy Clinic at Hoima Regional Referral Hospital: Prevalence, Morphological Classification, and Associated Factors. HIVAIDS - Res Palliat Care. 2023;15:621\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShen Y, Wang Z, Lu H, Wang J, Chen J, Liu L, et al. Prevalence of Anemia among Adults with Newly Diagnosed HIV/AIDS in China. PLoS ONE. 2013;8(9):e73807.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOmoregie R, Omokaro EU, Palmer O, Ogefere HO, Egbeobauwaye A, Adegue JE et al. Prevalence of anaemia among HIV-infected patients in Benin City, Nigeria. Tanzan J Health Res [Internet]. 2009 [cited 2025 Jun 14];11(1). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ajol.info/index.php/thrb/article/view/43242\u003c/span\u003e\u003cspan address=\"https://www.ajol.info/index.php/thrb/article/view/43242\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThe 2013 WHO Guidelines For Antiretroviral. 3 | PDF | Management Of Hiv/Aids | Hiv/Aids [Internet]. [cited 2025 Jun 15]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.scribd.com/document/338177865/The-2013-WHO-Guidelines-for-Antiretroviral-3\u003c/span\u003e\u003cspan address=\"https://www.scribd.com/document/338177865/The-2013-WHO-Guidelines-for-Antiretroviral-3\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePatel DM, Moyo C, Bositis CM. A Review of the 2010 WHO Adult Antiretroviral Therapy Guidelines: Implications and Realities of These Changes for Zambia. Med J Zambia. 2010;37(2):118\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUpdated recommendations on first-. line and second-line antiretroviral regimens and post-exposure prophylaxis and recommendations on early infant diagnosis of HIV [Internet]. [cited 2025 May 20]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/WHO-CDS-HIV-18.51?utm_source=chatgpt.com\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/WHO-CDS-HIV-18.51?utm_source=chatgpt.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGebremedhin KB, Haye TB. Factors Associated with Anemia among People Living with HIV/AIDS Taking ART in Ethiopia. Adv Hematol. 2019;2019:9614205.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKamurai B, Chikwati RP, Vhanda D, Nyamayaro T, Manasa J, Kouamou V. Effect of dolutegravir on ferritin, iron, and C-reactive protein among people living with HIV and co-infections. South Afr J HIV Med 25(1):1543.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKerkhoff AD, Wood R, Cobelens FG, Gupta-Wright A, Bekker LG, Lawn SD. Resolution of anaemia in a cohort of HIV-infected patients with a high prevalence and incidence of tuberculosis receiving antiretroviral therapy in South Africa. BMC Infect Dis. 2014;14(1):1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZenebe WA, Anbese AT, Tesfaye TS. Anemia And Associated Factors Among Adult People Living With HIV/AIDS Receiving Anti-Retroviral Therapy At Gedeo Zone, SNNPR, Ethiopia, 2018. HIVAIDS - Res Palliat Care. 2019;11351\u0026ndash;6.\u0026lt;\\/p\u0026gt;\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGonzalez L, Seley C, Martorano J, Garcia-Moreno I, Troncoso A. Infections and inequalities: anemia in AIDS, the disadvantages of poverty. Asian Pac J Trop Biomed. 2012;2:(6):485\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZerihun KW, Bikis GA, Muhammad EA. Prevalence and associated factors of anemia among adult human immune deficiency virus positive patients on anti-retroviral therapy at Debre tabor Hospital, Northwest Ethiopia. BMC Res Notes. 2019;12:168.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTilahun WM, Gebreegziabher ZA, Geremew H, Simegn MB. Prevalence and factors associated with anemia among HIV-infected women in sub-saharan Africa: a multilevel analysis of 18 countries. BMC Public Health. 2024;24(1):2236.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMengistu A, Egata G, Hawulte B, Markos M, Lolaso T. Anemia and Associated Factors Among Adults with Human Immune Deficiency Virus on Antiretroviral Therapy in Public Health Facilities of Kembata Tembaro Zone, Southern Ethiopia: A Cross-Sectional Study. HIVAIDS Auckl NZ. 2020;12:341\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAynalem YA, Shibabaw Shiferaw W, Woldiye Z. Prevalence of Anemia and Its Associated Factors in Antiretroviral-Treated HIV/AIDS-Positive Adults from 2013 to 2018 at Debre Berhan Referral Hospital, Ethiopia. Adv Hematol. 2020;2020:2513578.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKreuzer KA, Rockstroh JK. Pathogenesis and pathophysiology of anemia in HIV infection. Ann Hematol. 1997;75(5\u0026ndash;6):179\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLevine AM, Berhane K, Masri-Lavine L, Sanchez ML, Young M, Augenbraun M, et al. Prevalence and Correlates of Anemia in a Large Cohort of HIV-Infected Women: Women\u0026rsquo;s Interagency HIV Study. JAIDS J Acquir Immune Defic Syndr. 2001;26(1):28.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHarding BN, Whitney BM, Nance RM, Ruderman SA, Crane HM, Burkholder G, et al. Anemia risk factors among people living with HIV across the United States in the current treatment era: a clinical cohort study. BMC Infect Dis. 2020;20(1):238.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNgongondo M, Rosenberg NE, Stanley CC, Lim R, Ongubo D, Broadhurst R, et al. Anemia in people on second line antiretroviral treatment in Lilongwe, Malawi: a cross-sectional study. BMC Infect Dis. 2018;18(1):39.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Prevalence, Anemia, HIV, AIDS, Risk facto","lastPublishedDoi":"10.21203/rs.3.rs-6912450/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6912450/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAnemia is the most common hematologic complication in people with HIV and significantly impacts disease progression and quality of life. This study aims to determine anemia prevalence and associated factors in patients with HIV.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA cross-sectional study was conducted among 362 patients aged 15 years or older with HIV. Data on socio-demographics, clinical parameters, laboratory results, and medication history were collected using a pretested questionnaire. A logistic regression model was used to identify factors associated with anemia.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePatients\u0026rsquo; mean age\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation was 41.2\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5 years, and 59.1% were female. The prevalence of anemia in people with HIV was 22.9% (95% CI: 18.7\u0026ndash;27.6), of which 14.6% was mild anemia, 6.9% moderate anemia, and 1.4% severe anemia. Only completing primary level education (adjusted odds ratio (AOR): 3.35; 95% CI: 1.48\u0026ndash;7.55), being underweight (AOR: 2.92; 95% CI: 1.10\u0026ndash;7.75), increased viral load (AOR: 2.48; 95% CI: 1.03-6.00), and antiretroviral therapy (ART) duration of less than 5 years (AOR: 1.96; 95% CI: 1.03\u0026ndash;3.71) were significantly associated with anemia.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAnemia remains a prevalent condition in people with HIV and warrants regular monitoring through routine complete blood counts (CBC), especially for those who only completed primary education, were underweight and had high viral load.\u003c/p\u003e","manuscriptTitle":"Anemia prevalence and associated factors in patients with HIV at Ethiopian Hospitals","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-14 10:44:29","doi":"10.21203/rs.3.rs-6912450/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"335529367686609720740525873356269505468","date":"2025-07-30T12:43:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-22T22:38:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"23594892385398461803353347067216891152","date":"2025-07-20T17:51:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-20T16:54:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-16T12:10:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-25T07:05:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-24T14:36:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2025-06-24T07:14:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"64f81e94-0a81-458c-bff8-9a5da2067413","owner":[],"postedDate":"July 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-20T17:08:07+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-14 10:44:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6912450","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6912450","identity":"rs-6912450","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}