Anemia Prevalence Higher in Females than Males Living with HIV

A new cross-sectional investigation evaluating sex differences in the risk profile for anemia revealed a greater prevalence of the hematologic blood disorder in female patients living with HIV, compared with males.1

At an urban tertiary care center in Zambia, investigators evaluated ≥600 adult patients living with HIV who had been treated with antiretroviral therapy (ART) for ≥6 months, collecting data from standardized questionnaires and medical records. World Health Organization (WHO) criteria defined anemia as hemoglobin <3 g/dL for males and <12 g/dL for females.

“The study’s findings emphasize the necessity for sex-specific interventions to manage anemia among people living with HIV,” wrote the investigative team, led by Kingsley Kamvuma, department of pathology and microbiology, HAND research group, school of medicine and health sciences at Mulungush University. “For females, interventions should focus on addressing nutritional support.”

Estimates suggest anemia’s prevalence in people living with HIV is disproportionately higher in sub-Saharan Africa, particularly Southern Africa (58–70%), despite advancements in combinational ART.2 Anemia can worsen HIV-related complications, including immunosuppression and infection, and can be a marker of underlying comorbidities, such as chronic inflammation and nutritional deficiencies.3

Sex-specific differences point to a greater risk of anemia in women in the general population, due to biological factors, however little is known about sex differences among people living with HIV.2 Kamvuma and colleagues noted that biological, hormonal, and social factors each play a distinct role in influencing anemia risk in this population.1

They added that a clearer understanding of this link is critical for gender-specific intervention, optimization of anemia management strategies, and confronting sex-specific disparities in health outcomes among people living with HIV.

Adult participants were recruited between August and December 2023. Pregnant women, those with excessive menstrual bleeding, and disorders, including sickle cell anemia, were excluded from the study. Children were not evaluated as anemia risk factors and management significantly differed among adult populations.

Administered questionnaires covered information on demographics (age, sex, marital status, and education level), HIV-related specifics (ART duration, regimen, and viral load), presence of comorbidities (hypertension and Hepatitis B), lifestyle factors (exercise), and anthropometric measures (body mass index [BMI] and waist circumference [WC].

A total of 631 people living with HIV were enrolled in the study, with a median age of 44 years, and comprised 63.2% females. Anemia was prevalent in 36% of patients, with a significantly higher rate in females compared with males (41.1% vs 27.2%; P <.001).

Notably, Kamvuma and colleagues noted male patients living with HIV on non-nucleoside reverse transcriptase inhibitors (NNRTI) regimens were more likely to experience anemia, compared with those on integrase strand transfer inhibitors (INSTI) or protease inhibitors (PI) (P =.03). Female patients living with HIV on NNRTI were additionally more likely to be anemia (P =.008).

Adjusted analysis identified further factors associated with anemia in females living with HIV. Lower waist circumference (adjusted odds ratio [aOR], 0.97 [95% CI, 0.95–0.99]; P =.018), higher albumin levels (aOR, 0.96 [95% CI, 0.92–0.99]; P = .047), NNRTI regimens (aOR, 2.78 [95% CI, 1.34–5.78]; P = .006), microcytosis (aOR, 3.18 [95% CI, 1.26–8.03]; P = .014), and hypertension (aOR, 0.34 [95% CI, 0.13–0.87]; P = .024) were each linked to the risk of anemia.

Among males living with HIV, several factors, including a higher BMI, lower waist circumference, NNRTI regimen, and high creatinine and albumin levels were significantly associated with anemia in unadjusted analyses. In the adjusted analysis, Kamvuma and colleagues noted that none of these variables remained statistically significant in men.

“Regular monitoring of hemoglobin levels, waist circumference, and albumin levels in women, along with comprehensive reproductive health services, will help alleviate anemia and improve overall health outcomes,” they added.

References

1. Kamvuma K, Hamooya BM, Chiyenu KOR, et al. Sex differences in the risk profiles for anemia in people living with HIV, A cross sectional study. PLoS One. 2025;20(3):e0319611. Published 2025 Mar 10. doi:10.1371/journal.pone.0319611

2. Ezeamama AE, Sikorskii A, Bajwa RK, et al. Evolution of Anemia Types During Antiretroviral Therapy-Implications for Treatment Outcomes and Quality of Life Among HIV-Infected Adults. Nutrients. 2019;11(4):755. Published 2019 Mar 31. doi:10.3390/nu11040755

3. Demitto FO, Araújo-Pereira M, Schmaltz CA, et al. Impact of Persistent Anemia on Systemic Inflammation and Tuberculosis Outcomes in Persons Living With HIV. Front Immunol. 2020;11:588405. Published 2020 Sep 24. doi:10.3389/fimmu.2020.588405