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Mutivitamins and HIV+

Introduction

Prior to the introduction of highly active antiretroviral therapy (HAART), the prevalence of malnutrition among HIV-infected persons at all stages of immune deficiency was common. [1] Micronutrient deficiencies are still common among HIV+ patients who do not have access to these drugs.  Their occurrence is due to malabsorption, altered metabolism, gut infection, and altered gut barrier function [2].  In early observational studies, supplementation with a combination of multiple micronutrients (some at levels > RDA) was associated with slower disease progression in HIV-infected persons and reduced risk of mortality, while no benefit was observed with a greater increase in intake<[3, 4]. 

In North America, supplementation with multiple vitamins and trace elements is common among the HIV infected population (63-73%).  Even with supplementation, however, 29% of HIV infected persons were reported to have deficient levels of one or more micronutrients in a study conducted prior to the introduction of HAART5.  Tang et al., [1] have summarized and reviewed the data generated on micronutrients and their impact on HIV infection prior to and following the introduction of HAART. 

Multivitamin trials

Supplementation trials with multiple micronutrient combinations have been conducted in HIV-infected patients in Africa and Thailand.  The most recent clinical trials conducted by Fawzi et al. [6], Villamor et al. [7], and Jiamton et al [8] support a protective effect of multivitamin supplementation in susceptible HIV-infected populations.  

In a randomized, placebo controlled trial of 1078 pregnant Tanzanian women infected with HIV, Fawzi et al observed a significant protective effect of a multiple vitamin supplement on progression of HIV disease.  This regimen also reduced the relative risk of death from AIDS-related causes.  However, adding 5000 IU of preformed vitamin A plus 30 mg beta-carotene to this multivitamin formulation reduced the benefits.

Villamor et al. followed the infants born to HIV-infected mothers who were supplemented with the same multivitamin beginning at 12-27 wk gestation through 2 y post natal and observed significant benefits on child growth.  Compared to the placebo group, the infants whose mothers were supplemented achieved a higher attained weight at 2 y, and had higher z scores on both weight-for- age and weight-for-length parameters.  The infant growth benefits seen with multivitamin supplementation were attenuated in the group of mothers given 5000 IU preformed vitamin A and 30 mg beta-carotene in addition to the multivitamin. 

In a randomized placebo controlled trial of HIV infected men and women living in Bangkok, Jiamton et al examined the impact of a higher dose multiple vitamin and mineral supplement on survival and disease progression after 48 wk.  Supplementation significantly enhanced survival among those with CD4 counts < 200 x 106 cells/L.

Critical Thinking Questions:

• Is there a potential role for multivitamins in HIV+ patients residing in industrialized countries?
• Are multivitamins appropriate for HIV+ patients without access to HAART?
• Why does the addition of vitamin A appear to attenuate the effectiveness of the multivitamin supplement used in the trials conducted in Tanzania?
• How do the multivitamins used in the intervention trials above compare to standard multivitamins available in the U.S.?
• Do antiretroviral therapies (HAART) affect micronutrient levels?
• Are micronutrient needs higher among HIV+ patients?  If so, why?
• Would a standard daily multivitamin supplement interfere with any of the drugs commonly prescribed for HIV+ patients?
• Are common biochemical assays for micronutrient status reliable in HIV+ patients
• Are standard multivitamin supplements safe for HIV+ patients?

Websites:

• World Health Organization (WHO) – http://www.who.int/3by5/mediacentre/fsFood/en/
• Tufts University School of Medicine – http://www.tufts.edu/med/nutrition-infection/hiv/health_high_quality_diet.html
• TheBody.com - http://www.thebody.com/dietnut/multivitamins.html