Assessing the Need for Improved Methods of Anemia Detection in Antiretroviral Therapy Programs in Developing Countries and Considerations for Future Research
Creators: name: Simmers, Erin M.
Publisher: name: The University of North Carolina at Chapel Hill University Libraries
Year: 2006

description: The high prevalence and rapid spread of human immunodeficiency virus (HIV) across sub-Saharan Africa is a public health problem of unprecedented scale. Acquired lmmtmodeficiency Syndrome (AIDS) related morbidity and mortality predominantly affects young adults in the prime of their working and reproductive years. As a result, the HIV I AIDS pandemic in sub-Saharan Africa has had a detrimental impact on societal and family structures as well as economic growth and development. In order to counter these effects, an initiative introduced in 2003 by the World Health Organization sought to make highly active antiretroviral therapy (HAART) available to poor populations living in underdeveloped countries. Patients must remain on HAART for life if the treatment is to be effective. One of the problems faced with implementing antiretroviral therapy (ART) in resource-limited settings is that care is often based on hematologic parameters, necessitating a reliable and modem laboratory infrastructure. The WHO has determined that a lack oflaboratory infrastructure should not preclude the implementation of ART programs and, in the absence of such infrastructure, has made available alternate methodologies on which to base care. Anemia is a common condition found in HIV positive individuals, and certain antiretroviral drugs may cause or exacerbate this condition. Use of a low-tech Hemoglobin Color Scale to estimate anemia is suggested in areas, such as developing cotmtries in Africa, where automated hematology equipment is unavailable. However, few studies have been done to assess the appropriateness of its use in antiretroviral programs. For this reason, further research should be undertaken to assess the performance ofthe Hemoglobin Color Scale. Given the uncertainty of the effectiveness of the Hemoglobin Color Scale, alternative diagnostic methods should also be investigated. This paper reviews what it known about the performance of the Hemoglobin Color Scale. The primary benefits of this method of anemia detection include low cost and low infrastructure requirements. The main limitation to this method is that few studies have been published to assess its accuracy and no studies have been published to directly assess the impact that use has on clinical care. Diagnostic tests may perform differently depending on the patient population and prevalence of the disease of interest. These factors should be taken into account when assessing the performance of a diagnostic test. For this reason, studies that evaluate the Hemoglobin Color Scale should provide information not only about test performance, but also about background parameters and clinical interventions. This paper provides suggestions for future study into low-tech methods of anemia diagnosis and describes how some of these considerations may be addressed. Additionally, preliminary evidence is presented that supports the study of a centrifuged hematocrit as an alternative method of anemia diagnosis. An example is given of prospective study design that could be carried out in an antiretroviral therapy program in Lusaka, Zambia to assess the performance of both the hemoglobin color scale and a manual hematocrit in a clinical setting. The goal of identifying reliable low-tech diagnostics is to allow for easier expansion of public health interventions and higher quality of care for the patients involved. These benefits would have an immediate impact on antiretroviral programs, but could also be extended to other areas of primary care in developing countries.