Dietary micronutrient intake and risk of progression to acquired immunodeficiency syndrome (AIDS) in human immunodeficiency virus type 1 (HIV-1)-infected homosexual men

The cardiometabolic profile and related dietary intake of Ugandans living with HIV and AIDS

Introduction

Suboptimal diet and physical inactivity downgrade the putative benefits of Antiretroviral Therapy (ART) among People Living with HIV (PLWH). However, there is paucity of literature on dietary intake and cardiometabolic profiles of PLWH in Uganda.

Methods

A cross-sectional study among PLWH in Uganda was conducted. Dietary intake was assessed using a 24h recall method of 2 non-consecutive days. The short International Physical Activity Questionnaire assessed participants' physical activity. Fasted blood samples were analyzed for Fasting Blood Glucose (FBG), total cholesterol, LDL-c, HDL-c and triglycerides. Blood pressure and anthropometric measurements were performed following step 2 of the WHO STEPS.

Results

253 patients completed in this study. A high prevalence of low HDL-c (31.9%), abdominal obesity (44.5%), high BMI (51.6%), raised FBG (45.3%), high SBP (31.5%), elevated triglycerides (26.4%) and metabolic syndrome (28%) was found. More women were identified with metabolic syndrome (31.5%) than men (19.2%). Low prevalence of high LDL-c (4.7%) and total cholesterol (9.8%) was found. Diets had a high carbohydrate (65.8 ± 10.4) E% and fiber intake (30.1 ± 12.7) g with minimal PUFA (6.1 ± 2.3) E%, fruits and vegetables (1.4 servings). High proportions were found of unmet intake for vitamin A (38.2%), B₁(48.8%), B₂ (29.6%), B₁₂ (29%), folate (61.4%), Ca (76%), Zn (53.1%) and Mg (41.7%). Mean MET min was 6,700 ± 5,509 and over 68% of the participants had >3,000 MET min.

Conclusion

Our findings reveal a high prevalence of metabolic disturbances among PLWH in Uganda and further highlight that their diets are suboptimal with low fruits and vegetable intake

Levels of Zinc Transporters mRNA Depending on Zinc Status and HIV-1 Tat Induced Inflammation in Muscle (Rhabdomyosarcoma) and Monocyte (THP-1) Cell Lines

Monocytes and muscles demonstrate functionally contrasting behavior under conditions of zinc deficiency with relation to zinc storage system (muscle retain zinc in contrast to monocytes). We aimed to understand the effects of zinc status and HIV-1 Tat mediated inflammation on expression of zinc transporters in these types of cells. Expression of zinc transporters [ZnTs, ZIPs, and metallothionein (MT)] was quantified by qRT-PCR in RD, THP-1 cells separately and in co-cultured THP-1-RD cells. ZnT1 protein expression levels were confirmed by Western blot. Significant increase of MT and ZnT1 mRNA in response to zinc supplementation and decrease during zinc deficiency indicates significance of the genes encoding transporters in maintaining zinc homeostasis in these tissues. In the RD cells ZIP10 exhibited inverse relation to zinc status whereas no correlation was found in the THP-1 cells. Tat-induced inflammation resulted in the significant elevation of MT, IL6, ZIP7, ZIP8, ZIP9 transcripts in the co-cultured RD cells, whereas THP-1 cells demonstrated increased IL-1β levels and reduced levels of ZIP7 and ZIP14. Zinc status and HIV-1Tat induced inflammation appear to influence differential expression of MT, ZnTs, and ZIPs in the muscle and monocyte cells.

The effect of selenium and zinc on CD4(+) count and opportunistic infections in HIV/AIDS patients: a randomized double blind trial

Objectives: We assessed the effect of selenium and zinc supplementation on CD4 cell count and the risk of developing opportunistic infections.Methods: In a double blind clinical trial, 146 HIV(+) patients receiving combination antiretroviral therapy with CD4(+) >200/cubic millimeter were screened for comorbidities and opportunistic infections, and randomized to receive daily selenium (200 µg), zinc (50 mg) or placebo for 6 months, before a 3-month follow-up period. CD4 cell counts were measured in the 3^th, 6^th and 9^th months. The serum selenium and zinc were measured in the 6^th month. The incidence of opportunistic infection was assessed monthly for 6 months and at the end of the 9^th month.Results: The final incidence of supplement deficiency for placebo, zinc and selenium were 46.7%, 44.7% and 50.0%, respectively. Overall compliance with supplementation was 99.42%. Although the changes from baseline were not statistically significant, zinc supplementation was significantly associated with reduced risk of opportunistic infections.Conclusion: Development of the opportunistic infections after zinc supplementation significantly decreased; however, significant improvement in CD4 count was not observed in this group.

Pan-retroviral Nucleocapsid-Mediated Phase Separation Regulates Genomic RNA Positioning and Trafficking

The duality of liquid-liquid phase separation (LLPS) of cellular components into membraneless organelles defines the nucleation of both normal and disease processes including stress granule (SG) assembly. From mounting evidence of LLPS utility by viruses, we discover that HIV-1 nucleocapsid (NC) protein condenses into zinc-finger (ZnF)-dependent LLPSs that are dynamically influenced by cytosolic factors. ZnF-dependent and Zinc (Zn²⁺)-chelation-sensitive NC-LLPS are formed in live cells. NC-Zn²⁺ ejection reverses the HIV-1 blockade on SG assembly, inhibits NC-SG assembly, disrupts NC/Gag-genomic RNA (vRNA) ribonucleoprotein complexes, and causes nuclear sequestration of NC and the vRNA, inhibiting Gag expression and virus release. NC ZnF mutagenesis eliminates the HIV-1 blockade of SG assembly and repositions vRNA to SGs. We find that NC-mediated, Zn²⁺-coordinated phase separation is conserved among diverse retrovirus subfamilies, illustrating that this exquisitely evolved Zn²⁺-dependent feature of virus replication represents a critical target for pan-antiretroviral therapies.

Monette et al. discover a high degree of conservation of zinc-finger embedded, intrinsically disordered prion-like domains across retrovirus Gag proteins. These domains within the Gag Nucleocapsid regulate the formation of zinc-dependent liquid-liquid phase condensates and stress granules in HIV-1-expressing cells to induce repositioning of the viral genomic RNA.

Dietary Micronutrients and Gender, Body Mass Index and Viral Suppression Among HIV-Infected Patients in Kampala, Uganda

BACKGROUND

HIV/AIDS is a hallmark of immune suppression. Micronutrient deficiencies in diet and recurrent opportunistic infections play major roles in the lives of people living with HIV. Although benefits of providing adequate diet to HIV positive persons are well documented, the demand for key elements still remain unclear in particular settings, especially in low and middle-income countries.

METHODS

This was a cross sectional analysis of baseline data collected from HIV-infected adults initiating antiretroviral therapy, and who were enrolled in a multivitamin supplementation trial. A food frequency questionnaire was used and intake were obtained as a product of quantities consumed. Adequacy was calculated as the proportion of Recommended Dietary Allowances (RDA). A chi square test and logistic regression analysis were used at p-value 0.05 to show significant associations.

RESULTS

Mean intakes were above minimum requirements for analyzed micronutrients with the exception of Calcium and Iron. Participants who met RDA intakes were as follows: highest (≥ 80%) for Magnesium, Selenium, Zinc and Vitamins B2, B6, B9, C and E; moderate (50% to <80%) for Vitamins B3, and A; and lowest (≤50%) for Iron (30%), Calcium (14.9%), Vitamins B12 and B1. Gender differences in met RDA were observed for Iron, Selenium, Zinc, Vitamins A, B1, B3 and E. In multivariable analyses, nutritional status and CD4 count had no influence on meeting RDA for majority of micronutrients such as magnesium, Selenium, B class vitamins (B1, B2, B3, B6, B9, B12), vitamin (A, C, and E), Zinc and Calcium, but not including iron.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Diets consumed by the study participants were low in most protective nutrients (Iron, Calcium, Zinc, Vitamin A, B1, B3, and B12). This deficiency was more common among females than males, and irrespective of BMI or CD 4 count. Findings warrant further investigation on the impact and cost implications for suplementation interventions that target the elements lacking in the diets of people living with HIV in similar low-resourced settings.

Zinc and selenium indicators and their relation to immunologic and metabolic parameters in male patients with human immunodeficiency virus

OBJECTIVES

Micronutrient deficiencies are common among people living with HIV (PLWHIV). The clinical and immunologic consequences of micronutrient deficiencies have been poorly explored in the context of human immunodeficiency virus (HIV) infection. The aim of this study was to determine the prevalence of zinc and selenium deficiency (dietary intake and serum concentrations) and analyze their associations with absolute CD4+ T-cell counts, inflammation markers, and metabolic disorders in a cohort of antiretroviral-experienced HIV-infected individuals.

METHODS

The zinc and selenium intakes of 124 HIV-infected men were estimated using 3-d food records. In a subcohort of 45 individuals, serum zinc and selenium concentrations and proinflammatory cytokines were determined. Body composition, bone mineral density (BMD), CD4+ T-cell counts, lipid profile, glucose, and blood pressure were determined and were associated with zinc and selenium dietary intake and serum concentrations.

RESULTS

Of the PLWHIV studied, 58% had suboptimal intake of zinc and 8% demonstrated suboptimal intake of selenium. Serum deficiencies for zinc and selenium were 23.9% and 65.9%, respectively. Zinc and selenium intake were correlated with increased muscle mass. Selenium intake was associated with increased BMD of the lumbar region. An inverse correlation between serum selenium concentration and several proinflammatory cytokines (interleukin-1β, interleukin-6, and tumor necrosis factor-α) was found.

CONCLUSION

Suboptimal zinc and selenium intake and serum concentration deficiencies are highly prevalent in treated HIV-positive individuals and are associated with body composition, BMD, and inflammation. Clinical trials should be designed to explore the effect of zinc and selenium supplementation on metabolic, inflammatory, and immunologic parameters on the HIV-positive population.

Food elimination, food substitution, and nutrient supplementation among ARV-exposed HIV-positive persons in southern Ghana

BACKGROUND

Optimal nutrition is a determinant of health in all persons. In persons living with HIV (PLHIV), nutrition is particularly important. Various factors, including dietary practices, play a role in guaranteeing nutritional health.

OBJECTIVES

We investigated multiple non-prescription drugs use among HIV-positive persons receiving antiretroviral therapy (ART) from four treatment centers in southern Ghana. This paper, however, focuses on nutrient supplement use, food elimination, and food substitution practices by the PLHIV.

METHODS

Using quantitative and qualitative methods, we collected data from 540 HIV-positive persons at the health facility level. This paper focuses on only the quantitative data. Individual study participants were selected using a systematic random sampling procedure. Participants were interviewed after informed consent. We used univariate analysis to generate descriptive tabulations for key variables. Multivariable logistic regression modeling identified predictors of three practices (nutrient supplementation, food elimination, and food substitution). P value less than 0.05 or 95% confidence intervals facilitated determination of statistical significance. All analyses were performed using IBM SPSS Statistics for Windows, version 20.0.

RESULTS

The use of nutrient supplements was a popular practice; 72% of the PLHIV used various kinds. The primary motive for the practice was to boost appetite and to gain weight. A little over 20% of the participants reportedly eliminated certain foods and beverages, while 17% introduced new foods since their initial HIV diagnosis. All the three practices were largely driven by the quest for improved health status. We determined predictors of nutrient supplementation to be ART clinic location and having an ART adherence monitor. Having an ART adherence monitor was significantly associated with reduced odds of nutrient supplementation (AOR = 0.34; 95% CI 0.12-0.95). The only predictor for food elimination was education level (AOR = 0.29; 95% CI 0.30-0.92); predictors of food substitution were ART clinic location (AOR = 0.11; 95% CI 0.02-0.69) and anemia (defined as hemoglobin concentration less than 11.0 g/dl) (AOR = 0.21; 95% CI 0.12-0.85).

CONCLUSIONS

The practice of supplementation is popular among this group of PLHIV. Food elimination and substitution are practiced, albeit in moderation. The predictors identified may prove helpful in provider-client encounters as well as local HIV programming.

Malaria, Epstein-Barr virus infection and the pathogenesis of Burkitt's lymphoma

A geographical and causal connection has long been recognized between malaria, Epstein-Barr virus (EBV) infection and Burkitt's lymphoma (BL), but the underlying mechanisms remain obscure. Potential clues are that the malaria parasite Plasmodium falciparum selectively absorbs vitamin A from the host and depends on it for its biological activities; secondly, alterations in vitamin A (retinoid) metabolism have been implicated in many forms of cancer, including BL. The first author has proposed that the merozoite-stage malaria parasite, emerging from the liver, uses its absorbed vitamin A as a cell membrane destabilizer to invade the red blood cells, causing anemia and other signs and symptoms of the disease as manifestations of an endogenous form of hypervitaminosis A (Mawson AR, Path Global Health 2013;107(3):122-9). Repeated episodes of malaria would therefore be expected to expose the tissues of affected individuals to potentially toxic doses of vitamin A. It is proposed that such episodes activate latent EBV infection, which in turn activates retinoid-responsive genes. Expression of these genes enhances viral replication and induces germinal center (GC) B cell expansion, activation-induced cytidine deaminase (AID) expression, and c-myc translocation, which in turn predisposes to BL. Thus, an endogenous form of retinoid toxicity related to malaria infection may be the common factor linking frequent malaria, EBV infection and BL, whereby prolonged exposure of lymphatic tissues to high concentrations of retinoids may combine to induce B-cell translocation and increase the risk of Burkitt's lymphoma.

The Relationship between Vitamin A Deficiency and Hiv Infection: Review of Scientific Studies

Review of the literature shows that in adults there are variations in the association of hyporetinemia with disease progression as well as variations in the response to supplementation. Populations that are likely to be deficient in vitamin A show the biggest responses. Additional vitamin A supplementation may not be necessary, and may even be harmful, in adults who already have a good dietary intake of vitamin A and who take many other vitamin supplements. Vitamin A supplementation does not appear to have any impact on mother-to-child transmission of HIV; nevertheless, vitamin A supplementation of pregnant women in the third trimester may be useful to reduce the incidence of low-birthweight and premature infants. the impact of vitamin A on mother-to-child transmission of HIV in preterm infants is awaiting further investigation. Vitamin A supplementation of HIV-infected children appears to be beneficial to reduce the incidence and severity of diarrhea in particular. Randomized, placebo-controlled trials in pregnant women and adults have shown that the association between vitamin A and HIV is probably an association of reverse causality.

Serum Zinc Concentration and C-Reactive Protein in Individuals with Human Immunodeficiency Virus Infection: the Positive Living with HIV (POLH) Study

Low zinc levels and chronic inflammation are common in individuals infected with human immunodeficiency virus (HIV). Zinc deficiency may promote systemic inflammation, but research on the role of zinc in inflammation among HIV-positive individuals taking account of anti-retroviral therapy is lacking. We assessed the association between serum zinc and C-reactive protein (CRP) concentration in a cohort of HIV-positive individuals. A cross-sectional survey was conducted among 311 HIV-positive individuals (177 men and 134 women) aged 18-60 years residing in Kathmandu, Nepal. High-sensitive or regular serum CRP concentrations were measured by the latex agglutination nephelometry or turbidimetric method, and zinc concentrations were measured by the atomic absorption method. Relationships were assessed using multiple linear regression analysis. The geometric means of zinc in men and women were 73.83 and 71.93 ug/dL, respectively, and of CRP were 1.64 and 0.96 mg/L, respectively. Mean serum CRP concentration was significantly decreased with increasing serum zinc concentration across zinc tertiles (P for trend = 0.010), with mean serum CRP concentration in the highest tertile of serum zinc concentration was 44.2 % lower than that in the lowest tertile. The mean serum CRP concentrations in men and women in the highest tertile of serum zinc concentrations were 30 and 35.9 % lower, respectively, than that in the lowest tertile (P for trend = 0.263 and 0.162, respectively). We found a significant inverse relation between log zinc and log CRP concentrations (beta for 1 unit change in log zinc; β = -1.79, p = 0.0003). Serum zinc concentration may be inversely associated with serum CRP concentration in HIV-positive individuals.

Vitamin-D deficiency impairs CD4+T-cell count recovery rate in HIV-positive adults on highly active antiretroviral therapy: A longitudinal study

BACKGROUND & AIMS

We implemented a prospective study among human immunodeficiency virus (HIV)-positive adults to examine the association between vitamin-D deficiency (VDD) and insufficiency (VDI) vs sufficiency (VDS) and CD4+T-cell improvement over 18 months of highly active antiretroviral therapy (HAART).

METHODS

We used data from a randomized placebo-controlled micronutrient trial with 25-hydroxy vitamin-D (25(OH)D) measured at enrollment in 398 adults. CD4+T-cell count was measured repeatedly at months 0, 3, 6, 12 and 18. Linear mixed models quantified the vitamin-D-related differences in CD4+T-cell count and associated 99% confidence intervals at baseline and respective follow-up intervals.

RESULTS

At baseline 23%, 60% and 17% of participants were VDS, VDI and VDD, respectively. Absolute CD4+T- cell counts recovered during follow-up were persistently lower for baseline VDD and VDI relative to VDS participants. The greatest deficit in absolute CD4+T-cells recovered occurred in VDD vs VDS participants with estimates ranging from a minimum deficit of 26 cells/μl (99% CI: -77, 26) to a maximum deficit of 65 cells/μl (99% CI: -125, -5.5) during follow-up. This VDD-associated lower absolute CD4+T-cell gain was strongest among patients 35 years old or younger and among participants with a baseline body mass index of less than 25 kg/m(2).

CONCLUSIONS

VDD is associated with lower absolute CD4+T-cell count recovery in HIV-positive patients on HAART. Vitamin-D supplementation may improve CD4+T-cell recovery during HAART. However, future intervention studies are needed to definitively evaluate the effectiveness of this vitamin as an adjunct therapy during HAART.

Effect of selenium supplementation on CD4+ T-cell recovery, viral suppression and morbidity of HIV-infected patients in Rwanda: a randomized controlled trial

OBJECTIVE

To examine the effect of selenium supplementation on CD4 T-cell counts, viral suppression, and time to antiretroviral therapy (ART) initiation in ART-naive HIV-infected patients in Rwanda.

METHODS

A multicenter, double-blinded, placebo-controlled, randomized clinical trial was conducted. Eligible patients were HIV-infected adults (≥21 years) who had a CD4 cell count between 400 and 650 cells/μl (ART eligibility was ≤350 cells/μl throughout the trial), and were willing to practice barrier methods of birth control. Patients were randomized to receive once-daily 200 μg selenium tablets or identical placebo. They were followed for 24 months with assessments every 6 months. Declines in CD4 cell counts were modeled using linear regressions with generalized estimating equations and effect modification, and the composite outcome (ART eligible or ART initiation) using Cox proportional-hazards regression, both conducted with intention to treat.

RESULTS

Of the 300 participants, 149 received selenium, 202 (67%) were women, and median age was 33.5 years. The rate of CD4 depletion was reduced by 43.8% [95% confidence interval (CI) 7.8-79.8% decrease] in the treatment arm - from mean 3.97 cells/μl per month to mean 2.23 cells/μl per month. We observed 96 composite outcome events - 45 (47%) in the treatment arm. We found no treatment effect for the composite outcome (hazard ratio 1.00, 95% CI 0.66-1.54) or viral suppression (odds ratio 1.18, 95% CI 0.71-1.94). The trial was underpowered for the composite outcome due to a lower-than-anticipated event rate. Adverse events were comparable throughout.

CONCLUSIONS

This randomized clinical trial demonstrated that 24-month selenium supplementation significantly reduces the rate of CD4 cell count decline among ART-naive patients.

HIV and schistosomiasis in rural Zimbabwe: the association of retinol-binding protein with disease progression, inflammation and mortality

BACKGROUND

Vitamin A has widespread effects on immune function and is therefore interesting in HIV-infection. Retinol-binding protein (RBP or RBP4) is a negative acute-phase protein and a marker of vitamin A status. Our aim was to investigate the association of RBP with HIV progression, infection with schistosomiasis, inflammatory cytokines, and mortality.

METHODS

The study included 192 HIV-infected and 177 HIV-uninfected individuals from Mupfure in rural Zimbabwe. Of these, 208 were infected with Schistosoma haematobium, 27 with S. mansoni and 48 with both. Plasma RBP, HIV-RNA, CD4 cell count, haemoglobin, cytokines, clinical staging (CDC category), self-reported level of function (Karnoffsky Performance Score, KPS) and schistosomiasis status were assessed at baseline. Participants were followed up for survival 3-4 years post-enrolment.

RESULTS

RBP levels were lower in HIV-infected individuals(p<0.0001). Among HIV-infected individuals, multivariable analysis showed RBP to be positively correlated with CD4 cell count(p=0.050), KPS(p=0.003), and haemoglobin(p<0.0001) and negatively correlated with HIV-RNA(p<0.0001), CDC category(p<0.0001), tumor necrosis factor-receptor II(p<0.0001) and interleukin(IL)-6(p=0.004), as well as with IL-8(p=0.005) and IL-10(p=0.003) for HIV-infected men. Furthermore, among HIV-infected individuals RBP correlated negatively with schistosomiasis(p=0.038) and intensity of infection: circulating anodic antigen(p=0.014), circulating cathodic antigen(p<0.0001) and faecal egg output(p=0.004).

CONCLUSIONS

In HIV-infected individuals, RBP was negatively associated with levels of inflammatory markers, markers of HIV progression, infection with schistosomiasis and markers of schistosomal intensity.

Selected micronutrient levels and response to highly active antiretroviral therapy (HAART) among HIV/AIDS patients attending a teaching Hospital in Addis Ababa, Ethiopia

Poor micronutrient levels are associated with an increased risk of progression to AIDS and are also suggested to influence outcome of highly active antiretroviral therapy (HAART), though existing data are inconclusive to support the latter. Few published data are available on micronutrient levels in Ethiopian HIV/AIDS patients taking HAART. The objective of the study was to determine the association of micronutrient levels and response to HAART (CD4(+) T cell count) among adult HIV/AIDS patients attending a teaching Hospital in Addis Ababa. CD4(+) T cell counts and micronutrient (retinol, zinc, and iron) levels for 171 subjects were determined using standard procedures. Some proportions of the study participants were found deficient for retinol (14.03 %), zinc (47.3 %), and iron (2.8 %). Patients who were deficient in retinol had a significantly lower median CD4(+) T cell counts (P = 0.002) compared to non-deficient subjects. Association of micronutrient quartiles with CD4+ T cell count was assessed using adjusted multivariate regression by taking quartile 4 as a reference category. Accordingly, patients who had retinol levels in quartile 4 had a significantly lower mean CD4(+) T cell count compared to quartile 3 (P = 0.02). The significantly higher CD4(+) T cell counts in patients who were non-deficient in retinol imply the role of retinol in improving the production of CD4(+) T cells. However, both lower and higher retinol levels were associated with suppressed immunity (CD4 < 200 cells/mm(3)), suggesting an adverse effect of higher retinol levels. Thus, retinol may be potentially harmful depending on the dose, emphasizing the need for optimized level of retinol in nutrient supplements in patients taking HAART.

Habitual nutrient intake in HIV-infected youth and associations with HIV-related factors

Few studies have evaluated habitual nutrient intake among HIV-infected youth in the United States, even though diet may influence disease progression and risk of comorbidities. This study determined habitual micronutrient and macronutrient intake in HIV-infected youth. HIV-infected subjects and healthy controls 1-25 years old were prospectively enrolled. Nutrient intake was assessed via 24-h dietary recalls performed every 3 months for 1 year and compared to recommended intake from the U.S. Dietary Reference Intakes (DRIs) and Acceptable Macronutrient Distribution Ranges (AMDRs). Subjects with two or more food recalls were analyzed (175 HIV(+) and 43 healthy controls). Groups were similar in age, race, sex, body mass index, and kilocalorie intake. In both groups, intake of several micronutrients was below the DRI. In addition, HIV(+) subjects had a lower percentage DRI than controls for vitamins A, D, E, pantothenic acid, magnesium, calcium, folate, and potassium. HIV(+) subjects' percentage caloric intake from fat was above the AMDR and was higher than controls. Caloric intake was negatively correlated with current and nadir CD4 count. Zinc, riboflavin, and magnesium percentage DRI were positively associated with current CD4 count. In HIV(+) subjects not on antiretroviral therapy, HIV-1 RNA levels were negatively correlated with protein intake. HIV(+) youth have an inadequate dietary intake of several essential nutrients and poorer dietary intake compared to controls. Intake of some nutrients was associated with important HIV-related factors. Further investigation is warranted to determine the impact of dietary intake of specific nutrients on HIV progression and chronic complication risk in this population.

Effect of coadministration of neurovite and Lamivudine on the histomorphology of the cerebellum of wistar rats

Introduction. Lamivudine is a nucleoside reverse transcriptase inhibitor antiretroviral agent used in the treatment of human immunodeficiency virus type 1 infection. This study was to investigate the effects of coadministration of neurovite and lamivudine on the histomorphology of the cerebellum of Wistar rats. Materials and Methods. Twenty Wistar rats were divided equally into four groups. Group A animals were the control treated with distilled water. Groups B, C, and D animals were treated, respectively, with therapeutic dose of lamivudine (4.28 mg/kg), a combination of lamivudine (4.28 mg/kg) and neurovite (7.05 mg/kg), and neurovite (7.05 mg/kg) alone, daily. The rats were sacrificed using chloroform inhalation, processed, and stained using H&E method. Results. There was severe cellular degeneration with dystrophic changes, vacuolization in the molecular and granular layers, and aggregation of swollen Purkinje cells in group B animals compared with group C animals which showed only slight cellular dystrophy and inflammation. The mean cellular population was significantly (P < 0.05) higher in the treatment groups compared with the control. Conclusion. There was amelioration of damage of the cerebellum in the animals treated with neurovite and lamivudine combination compared to animals treated with only lamivudine. Therefore, there is need to give neurovite to patients on lamivudine therapy.

Plant-based diets are traditional in developing countries: 21st century challenges for better nutrition and health

The chronic degenerative diseases were virtually unknown in original hunter-gatherer societies. At the dawn of the 21st century, however, they represent the most important public health challenge to populations of both the industrialized, affluent nations of the temperate zones and the low-income developing countries of the tropics. The developing countries most closely reflect the legacy of our traditional foreparents while constituting threequarters of the world's populace and public health interest. For economic, traditional, religious and cultural reasons, the majority of the dietary fares in the developing world are largely plant based. This is associated with high prevalences of deficiency states in vitamin A, iron, zinc, riboflavin and vitamin B12. Poor linear growth and chronic energy deficiency are concomitant conditions. Conversely, the major chronic diseases have low prevalences among the rural peasantry and tribal groups, with the exception of gastro-esophageal cancer, osteoarthritis and cataract. As a site for intensive research in food and nutritional sciences, Guatemala provides important lessons about the origin and evolvement of a congruent plant-based diet within a food system and which factors of demographic expansion, urbanization, environmental stress and food technology will carry it through the 21st century. We can conclude that, whatever was the 'original' dietary pattern of pre-agricultural humankind, a plant-based diet regimen provides the lowest content of promoters and the highest content of inhibitors of metabolic dysregulation that lead to the major causes of disease and debility in adults over 40 years of age. For developing countries, the challenge is to maintain and reinforce the traditional eating patterns while improving their delivery of micronutrients and obviating any adverse environmental consequences in their traditional preparation patterns. For developed countries, there is an opportunity to find a 'road map' of guidelines to allow correction of current, pathogenic dietary and lifestyle patterns by examining the food-ways of traditional developing societies' cuisines.

Dietary intake and nutritional status of HIV-1-infected children and adolescents in Florianopolis, Brazil

This cross-sectional study aimed to investigate the nutritional status and dietary intake of HIV-infected children and adolescents and the relationship between nutritional status and dietary intake and CD4(+) T-cell count and viral load. The sample was composed of 49 subjects aged 7-17 years and living in Florianópolis, Brazil. Nutritional status was assessed by height-for-age and body mass index-for-age. Dietary intake was assessed by a food frequency questionnaire. Spearman correlations and multiple linear regressions were used to determine the relationship between energy, nutrient intake and body mass index-for-age and CD4(+) T-cell count and viral load. The mean body mass index-for-age and height-for-age values were -0.26 ± 0.86 and -0.56 ± 0.92, respectively. The energy intake was 50.8% above the estimated energy requirement and inadequate intake of polyunsaturated fat, cholesterol, fibre, calcium and vitamin C was present in 100%, 57.1%, 40.8%, 61.2% and 26.5% of the sample, respectively. Multiple linear regression analyses revealed that energy intake was correlated with CD4+ T-cell count (r = 0.33; p = 0.028) and viral load (r = -0.35; p = 0.019). These data showed low body mass index-for-age and height-for-age z-scores, high energy intake and inadequate intake of important nutrients for immune function, growth and control of chronic diseases. A lower energy intake was correlated with viral suppression and immune preservation.

Multivitamin supplements have no effect on growth of Tanzanian children born to HIV-infected mothers

Growth faltering and micronutrient deficiencies commonly coexist in HIV-exposed children in sub-Saharan Africa, and correcting deficiencies, such as those of vitamins B-complex, C, and E, may improve HIV-related endpoints and child growth. We therefore examined the effect of daily oral supplementation of vitamins B-complex, C, and E on growth among 2341 children born to HIV-infected mothers in Tanzania. HIV-infected women pregnant at ≤32 wk of gestation were enrolled in the study. Children were randomized at age 6 wk to receive multivitamins or placebo until age 104 wk. All women received the same types of vitamins pre- and postnatally. At 6 wk, 256 children (11.1%) were HIV infected and the mean (SD) Z-scores for length for age (LAZ), weight for length (WLZ), and weight for age (WAZ) were -0.39 ± 1.20, -0.21 ± 1.23, and -0.52 ± 1.11, respectively. There was no overall treatment effect on LAZ, WLZ, or WAZ profiles during the follow-up (P ≥ 0.15). There was no treatment effect from 6 to 104 wk on LAZ [(95% CI: -0.14, 0.13); P = 0.94], WLZ [(95% CI: -0.17, 0.13); P = 0.78], or WAZ [(95% CI: -0.15, 0.16); P = 0.97] or on the incidence of growth failure, defined as respective Z-scores < -2 (P ≥ 0.29). Among the subgroup of HIV-uninfected children, there was no treatment effect from 6 to 104 wk on LAZ, WLZ, and WAZ (P ≥ 0.71) or on the incidence of growth failure (P ≥ 0.16). Multivitamin supplements had no effect on growth among children born to HIV-infected women who were themselves receiving multivitamins.

The role of thiamine in HIV infection

Patients infected with HIV have a high prevalence of thiamine deficiency. Genetic studies have provided the opportunity to determine which proteins link thiamine to HIV pathology, i.e., renin-angiotensin system, poly(ADP-ribosyl) polymerase 1, Sp1 promoter gene, transcription factor p53, apoptotic factor caspase 3, and glycogen synthetase kinase 3β. Thiamine also affects HIV through non-genomic factors, i.e., matrix metalloproteinase, vascular endothelial growth factor, heme oxygenase 1, the prostaglandins, cyclooxygenase 2, reactive oxygen species, and nitric oxide. In conclusion, thiamine may benefit HIV patients, but further investigation of the role of thiamine in HIV infection is needed.

Assessing Nutrient Intake and Nutrient Status of HIV Seropositive Patients Attending Clinic at Chulaimbo Sub-District Hospital, Kenya

Background. Nutritional status is an important determinant of HIV outcomes. Objective. To assess the nutrient intake and nutrient status of HIV seropositive patients attending an AIDS outpatient clinic, to improve the nutritional management of HIV-infected patients. Design. Prospective cohort study. Setting. Comprehensive care clinic in Chulaimbo Sub-District Hospital, Kenya. Subjects. 497 HIV sero-positive adults attending the clinic. Main Outcome Measures. Evaluation of nutrient intake using 24-hour recall, food frequency checklist, and nutrient status using biochemical assessment indicators (haemoglobin, creatinine, serum glutamate pyruvate (SGPT) and mean corpuscular volume (MCV)). Results. Among the 497 patients recruited (M : F sex ratio: 1.4, mean age: 39 years ± 10.5 y), Generally there was inadequate nutrient intake reported among the HIV patients, except iron (10.49 ± 3.49 mg). All the biochemical assessment indicators were within normal range except for haemoglobin 11.2 g/dL (11.4 ± 2.60 male and 11.2 ± 4.25 female). Conclusions. Given its high frequency, malnutrition should be prevented, detected, monitored, and treated from the early stages of HIV infection among patients attending AIDS clinics in order to improve survival and quality of life.

Review of metabolic, immunologic, and virologic consequences of suboptimal vitamin D levels in HIV infection

Low 25-hydroxyvitamin D levels are common in the general and HIV-infected populations alike. Defined as levels less than 30 ng/mL, suboptimal vitamin D is known to afflict over 70% of representative samples from each group in resource-rich countries with even greater prevalence in resource-poor regions of the world. In both those with and without HIV, dark skin, low vitamin D intake, exiguous exposure to sunlight, and season act as risk factors for suboptimal vitamin D levels. In those infected with HIV, antiretroviral therapy, particularly non-nucleoside reverse transcriptase inhibitors (NNRTIs), increase risk for low vitamin D as well. Furthermore, metabolic aberrations, including obesity and hyperlipidemia, and miscellaneous risk factors, such as advanced AIDS and substance abuse, have been linked to suboptimal vitamin D in those with HIV. While the skeletal and cardiovascular systems of HIV patients may be adversely impacted as a result of low levels, recent data have also linked low vitamin D to decreased CD4 counts, higher viral loads, and to critical end points including progression to AIDS events and death. More research is needed to confirm these potential consequences of low vitamin D in those with HIV and to discern the benefits of routine screening for and treatment of low vitamin D in this population.

HIV-1, reactive oxygen species, and vascular complications

Over 1 million people in the United States and 33 million individuals worldwide suffer from HIV/AIDS. Since its discovery, HIV/AIDS has been associated with an increased susceptibility to opportunistic infection due to immune dysfunction. Highly active antiretroviral therapies restore immune function and, as a result, people infected with HIV-1 are living longer. This improved survival of HIV-1 patients has revealed a previously unrecognized risk of developing vascular complications, such as atherosclerosis and pulmonary hypertension. The mechanisms underlying these HIV-associated vascular disorders are poorly understood. However, HIV-induced elevations in reactive oxygen species (ROS), including superoxide and hydrogen peroxide, may contribute to vascular disease development and progression by altering cell function and redox-sensitive signaling pathways. In this review, we summarize the clinical and experimental evidence demonstrating HIV- and HIV antiretroviral therapy-induced alterations in reactive oxygen species and how these effects are likely to contribute to vascular dysfunction and disease.

Vitamin A and carotenoids during pregnancy and maternal, neonatal and infant health outcomes: a systematic review and meta-analysis

Vitamin A (VA) deficiency during pregnancy is common in low-income countries and a growing number of intervention trials have examined the effects of supplementation during pregnancy on maternal, perinatal and infant health outcomes. We systematically reviewed the literature to identify trials isolating the effects of VA or carotenoid supplementation during pregnancy on maternal, fetal, neonatal and early infant health outcomes. Meta-analysis was used to pool effect estimates for outcomes with more than one comparable study. We used GRADE criteria to assess the quality of individual studies and the level of evidence available for each outcome. We identified 23 eligible trials of which 17 had suitable quality for inclusion in meta-analyses. VA or beta-carotene (βC) supplementation during pregnancy did not have a significant overall effect on birthweight indicators, preterm birth, stillbirth, miscarriage or fetal loss. Among HIV-positive women, supplementation was protective against low birthweight (<2.5 kg) [risk ratio (RR) = 0.79 [95% confidence interval (CI) 0.64, 0.99]], but no significant effects on preterm delivery or small-for-gestational age were observed. Pooled analysis of the results of three large randomised trials found no effects of VA supplementation on neonatal/infant mortality, or pregnancy-related maternal mortality (random-effects RR = 0.86 [0.60, 1.24]) although high heterogeneity was observed in the maternal mortality estimate (I(2) = 74%, P = 0.02). VA supplementation during pregnancy was found to improve haemoglobin levels and reduce anaemia risk (<11.0 g/dL) during pregnancy (random-effects RR = 0.81 [0.69, 0.94]), also with high heterogeneity (I(2) = 52%, P = 0.04). We found no effect of VA/βC supplementation on mother-to-child HIV transmission in pooled analysis, although some evidence suggests that it may increase transmission. There is little consistent evidence of benefit of maternal supplementation with VA or βC during pregnancy on maternal or infant mortality. While there may be beneficial effects for certain outcomes, there may also be potential for harm through increased HIV transmission in some populations.

Aflatoxin levels, plasma vitamins A and E concentrations, and their association with HIV and hepatitis B virus infections in Ghanaians: a cross-sectional study

BACKGROUND

Micronutrient deficiencies occur commonly in people infected with the human immunodeficiency virus. Since aflatoxin exposure also results in reduced levels of several micronutrients, HIV and aflatoxin may work synergistically to increase micronutrient deficiencies. However, there has been no report on the association between aflatoxin exposure and micronutrient deficiencies in HIV-infected people. We measured aflatoxin B1 albumin (AF-ALB) adduct levels and vitamins A and E concentrations in the plasma of HIV-positive and HIV-negative Ghanaians and examined the association of vitamins A and E with HIV status, aflatoxin levels and hepatitis B virus (HBV) infection.

METHODS

A cross-sectional study was conducted in which participants completed a demographic survey and gave a 20 mL blood sample for analysis of AF-ALB levels, vitamins A and E concentrations, CD4 counts, HIV viral load and HBV infection.

RESULTS

HIV-infected participants had significantly higher AF-ALB levels (median for HIV-positive and HIV-negative participants was 0.93 and 0.80 pmol/mg albumin, respectively; p <0.01) and significantly lower levels of vitamin A (-16.94 μg/dL; p <0.0001) and vitamin E (-0.22 mg/dL; p <0.001). For the total study group, higher AF-ALB was associated with significantly lower vitamin A (-4.83 μg/dL for every 0.1 pmol/mg increase in AF-ALB). HBV-infected people had significantly lower vitamin A (-5.66 μg/dL; p = 0.01). Vitamins A and E levels were inversely associated with HIV viral load (p = 0.02 for each), and low vitamin E was associated with lower CD4 counts (p = 0.004).

CONCLUSIONS

Our finding of the significant decrease in vitamin A associated with AF-ALB suggests that aflatoxin exposure significantly compromises the micronutrient status of people who are already facing overwhelming health problems, including HIV infection.

Effect of selenium supplementation on CD4 T-cell recovery, viral suppression, morbidity and quality of life of HIV-infected patients in Rwanda: study protocol for a randomized controlled trial

Background

Low levels of serum selenium are associated with increased risk of mortality among HIV+ patients in East Africa. We aim to assess the effect of selenium supplementation on CD4 cell count, HIV viral load, opportunistic infections, and quality of life in HIV-infected patients in Rwanda.

Methods and Design

A 24-month, multi-centre, patient and provider-blinded, randomized, placebo-controlled clinical trial involving 300 pre-antiretroviral therapy (ART) HIV-infected patients will be carried out at two sites in Rwanda. Patients ≥ 21 years of age with documented HIV infection, CD4 cell count of 400-650 cells/mm³, and not yet on ART will be recruited. Patients will be randomized at each study site using a randomized block design to receive either the selenium micronutrient supplement or an identically appearing placebo taken once daily. The primary outcome is a composite of time from baseline to reduction of CD4 T lymphocyte count below 350 cells/mm³ (confirmed by two measures at least one week apart), or start of ART, or the emergence of a documented CDC-defined AIDS-defining illness. An intention-to-treat analysis will be conducted using stepwise regression and structural equation modeling.

Discussion

Micronutrient interventions that aim to improve CD4 cell count, decrease opportunistic infections, decrease HIV viral load, and ultimately delay initiation of more costly ART may be beneficial, particularly in resource-constrained settings, such as sub-Saharan Africa. Additional trials are needed to determine if micro-supplementation can delay the need for more costly ART among HIV-infected patients. If shown to be effective, selenium supplementation may be of public health importance to HIV-infected populations, particularly in sub-Saharan Africa and other resource-constrained settings.

Trial Registration

NCT01327755

Coinfection with hepatitis C virus, oxidative stress and antioxidant status in HIV-positive drug users in Miami

BACKGROUND

The pathogenesis of HIV/hepatitis C virus (HCV) coinfection is poorly understood. We examined markers of oxidative stress, plasma antioxidants and liver disease in HIV/HCV-coinfected and HIV-monoinfected adults.

METHODS

Demographics, medical history, and proof of infection with HIV, hepatitis A virus (HAV), hepatitis B virus (HBV) and HCV were obtained. HIV viral load, CD4 cell count, complete blood count (CBC), complete metabolic panel, lipid profile, and plasma concentrations of zinc, selenium, and vitamins A and E were determined. Malondialdehyde (MDA) and glutathione peroxidase concentrations were obtained as measures of oxidative stress. Aminotransferase to platelet ratio index (APRI) and fibrosis index (FIB-4) markers were calculated.

RESULTS

Significant differences were found between HIV/HCV-coinfected and HIV-monoinfected participants in levels of alanine aminotransferase (ALT) (mean±standard deviation: 51.4±50.6 vs. 31.9±43.1 U/L, respectively; P=0.014), aspartate aminotransferase (AST) (56.2±40.9 vs. 34.4±30.2 U/L; P<0.001), APRI (0.52±0.37 vs. 0.255±0.145; P=0.0001), FIB-4 (1.64±.0.91 vs. 1.03±0.11; P=0.0015) and plasma albumin (3.74±0.65 vs. 3.94±0.52 g/dL; P=0.038). There were no significant differences in CD4 cell count, HIV viral load or antiretroviral therapy (ART) between groups. Mean MDA was significantly higher (1.897±0.835 vs. 1.344± 0.223 nmol/mL, respectively; P=0.006) and plasma antioxidant concentrations were significantly lower [vitamin A, 39.5 ± 14.1 vs. 52.4±16.2 μg/dL, respectively (P=0.0004); vitamin E, 8.29±2.1 vs. 9.89±4.5 μg/mL (P=0.043); zinc, 0.61±0.14 vs. 0.67±0.15 mg/L (P=0.016)] in the HIV/HCV-coinfected participants than in the HIV-monoinfected participants, and these differences remained significant after adjusting for age, gender, CD4 cell count, HIV viral load, injecting drug use and race. There were no significant differences in glutathione peroxidase concentration, selenium concentration, body mass index (BMI), alcohol use or tobacco use between groups. Glutathione peroxidase concentration significantly increased as liver disease advanced, as measured by APRI (β=0.00118; P=0.0082) and FIB-4 (β=0.0029; P=0.0177). Vitamin A concentration significantly decreased (β=-0.00581; P=0.0417) as APRI increased.

CONCLUSION

HIV/HCV coinfection is associated with increased oxidative stress and decreased plasma antioxidant concentrations compared with HIV monoinfection. Research is needed to determine whether antioxidant supplementation delays liver disease in HIV/HCV coinfection.

Role of Nutrition in HIV Infection: Review of Evidence for more Effective Programming in Resource-Limited Settings

Background

HIV infection and malnutrition negatively reinforce each other.

Objective

For program guidance, to review evidence on the relationship of HIV infection and malnutrition in adults in resource-limited settings.

Results and conclusions

Adequate nutritional status supports immunity and physical performance. Weight loss, caused by low dietary intake (loss of appetite, mouth ulcers, food insecurity), malabsorption, and altered metabolism, is common in HIV infection. Regaining weight, particularly muscle mass, requires antiretroviral therapy (ART), treatment of opportunistic infections, consumption of a balanced diet, physical activity, mitigation of side effects, and perhaps appetite stimulants and growth hormone. Correcting nutritional status becomes more difficult as infection progresses. Studies document widespread micronutrient deficiencies among HIV-infected people. However, supplement composition, patient characteristics, and treatments vary widely across intervention studies. Therefore, the World Health Organization (WHO) recommends ensuring intake of 1 Recommended Nutrient Intake (RNI) of each required micronutrient, which may require taking micronutrient supplements. Few studies have assessed the impact of food supplements. Because the mortality risk in patients receiving ART increases with lower body mass index (BMI), improving the BMI seems important. Whether this requires provision of food supplements depends on the patient's diet and food security. It appears that starting ART improves BMI and that ready-to-use fortified spreads and fortified-blended foods further increase BMI (the effect is somewhat less with fortified-blended foods). The studies are too small to assess effects on mortality. Once ART has been established and malnutrition treated, the nutritional quality of the diet remains important, also because of ART's long-term metabolic effects (dyslipidemia, insulin resistance, obesity). Food insecurity should also be addressed if it prevents adequate energy intake and reduces treatment initiation and adherence (due to the opportunity costs of obtaining treatment and mitigating side effects).

Micronutrient supplementation in children and adults with HIV infection

BACKGROUND

Micronutrient deficiencies are widespread and compound the effects of HIV disease; micronutrient supplements may be effective and safe in reducing this burden.

OBJECTIVES

To assess whether micronutrient supplements are effective and safe in reducing mortality and morbidity in adults and children with HIV infection.

SEARCH STRATEGY

The CENTRAL, EMBASE, PubMed, and GATEWAY databases were searched for randomised controlled trials of micronutrient supplements using the search methods of the Cochrane HIV/AIDS Group.

SELECTION CRITERIA

Randomised controlled trials were selected that compared the effects of micronutrient supplements (vitamins, trace elements, and combinations of these) with other supplements, placebo or no treatment on mortality, morbidity, pregnancy outcomes, immunologic indicators, and anthropometric measures in HIV-infected adults and children. Any adverse effects of supplementation were recorded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials, appraised trial quality for risk of bias using standardised criteria, and extracted data using standardised forms.

MAIN RESULTS

Sixteen additional trials are included in this update to the original Cochrane review (Irlam 2005). Overall, 30 trials involving 22 120 participants are reviewed: 20 trials of single supplements (vitamin A, vitamin D, zinc, selenium) and 10 of multiple micronutrients. Eight trials were undertaken in child populations.None of the six trials of vitamin A or beta-carotene supplementation in adults demonstrated any significant reduction in HIV disease progression. Vitamin A halved all-cause mortality in a meta-analysis of three trials in African children, had inconsistent impacts on diarrhoeal and respiratory morbidity, and improved short-term growth in one trial. No significant adverse effects of vitamin A in adults or children have been reported.Zinc supplements reduced diarrhoeal morbidity and had no adverse effects on disease progression in a single safety trial in South African children. No significant clinical benefits were found from zinc supplementation of pregnant Tanzanian women or Peruvian adults with persistent diarrhoea.Selenium reduced diarrhoeal morbidity in pregnant women in Tanzania, and reduced viral load in two separate small trials in American adults.Single trials of vitamin D supplements in adults, and in adolescents and children, demonstrated safety but no clinical benefits.Multiple micronutrient supplements conferred multiple clinical benefits to pregnant women and their offspring in a large Tanzanian trial. Supplementation in another Tanzanian trial reduced the recurrence of pulmonary TB and increased weight gain in co-infected patients. No significant adverse effects were reported.

AUTHORS' CONCLUSIONS

Multiple micronutrient supplements reduced morbidity and mortality in HIV-infected pregnant women and their offspring and also improved early child growth in one large randomised controlled trial in Africa. Additional research is needed to determine if these are generalisable findings. Vitamin A supplementation is beneficial and safe in HIV-infected children, but further evidence is needed to establish if supplementation confers similar benefits in HIV-infected adults. Zinc is safe in HIV-infected adults and children. It may have similar benefits in HIV-infected children and adults, and uninfected children with diarrhoea, as it does in HIV-uninfected children.Further trials of single supplements (vitamin D, zinc, and selenium) are required to build the evidence base. The long-term clinical benefits, adverse effects, and optimal formulation of multiple micronutrient supplements require further investigation in individuals with diverse disease status. 

Randomized, controlled clinical trial of zinc supplementation to prevent immunological failure in HIV-infected adults

BACKGROUND

Adequate zinc is critical for immune function; however, zinc deficiency occurs in >50% of human immunodeficiency virus (HIV)-infected adults. We examined the safety and efficacy of long-term zinc supplementation in relation to HIV disease progression.

METHODS

A prospective, randomized, controlled clinical trial was conducted involving 231 HIV-infected adults with low plasma zinc levels (<0.75 mg/L), who were randomly assigned to receive zinc (12 mg of elemental zinc for women and 15 mg for men) or placebo for 18 months. The primary end point was immunological failure. HIV viral load and CD4(+) cell count were determined every 6 months. Questionnaires, pill counts, and plasma zinc and C-reactive protein levels were used to monitor adherence to study supplements and antiretroviral therapy. Intent-to-treat analysis used multiple-event analysis, treating CD4(+) cell count <200 cells/mm(3) as a recurrent immunological failure event. Cox proportional hazard models and the general-linear model were used to analyze morbidity and mortality data.

RESULTS

Zinc supplementation for 18 months reduced 4-fold the likelihood of immunological failure, controlling for age, sex, food insecurity, baseline CD4(+) cell count, viral load, and antiretroviral therapy (relative rate, 0.24; 95% confidence interval, 0.10-0.56; P<.002). Viral load indicated poor control with antiretroviral therapy but was not affected by zinc supplementation. Zinc supplementation also reduced the rate of diarrhea by more than half (odds ratio, 0.4; 95% confidence interval, 0.183-0.981; P=.019), compared with placebo. There was no significant difference in mortality between the 2 groups.

CONCLUSIONS

This study demonstrated that long-term (18-month) zinc supplementation at nutritional levels delayed immunological failure and decreased diarrhea over time. This evidence supports the use of zinc supplementation as an adjunct therapy for HIV-infected adult cohorts with poor viral control. Trial registration. ClinicalTrials.gov identifier: NCT00149552.

Micronutrients and HIV infection

The immune system requires several essential micronutrients to maintain an effective immune response. HIV infection destroys the immune system and promotes nutritional deficiencies, which further impair immunity. This article reviews the role of several micronutrients (vitamins A, C, E and D, the B vitamins, and minerals, selenium, iron and zinc) that are relevant for maintaining immune function. In addition, the deficiencies of these micronutrients have been associated with faster progression of HIV-1 disease. This review examines the evidence from observational studies of an association between micronutrient status and HIV disease, as well as the effectiveness of micronutrient supplementation on HIV-disease progression, pregnancy outcomes and nutritional status, among others, utilizing randomized clinical trials. Each micronutrient is introduced with a summary of its functions in human physiology, followed by the presentation of studies conducted in HIV-infected patients in relation to this specific micronutrient. Overall findings and recommendations are then summarized.

Prevention of diarrhoea in children with HIV infection or exposure to maternal HIV infection

BACKGROUND

Diarrhoea is a major cause of morbidity and mortality among infants and children worldwide, especially in low- and middle-income countries. Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is a condition that similarly disproportionately affects low- and middle-income countries; of the nearly 2.1 million children under age 15 years living with HIV/AIDS, the large majority reside in sub-Saharan Africa. Infants and children with HIV infection have more frequent and more severe diarrhoea than children without HIV. Interventions including vitamin A, zinc and cotrimoxazole may contribute substantially to preventing diarrhoea in children with HIV infection or exposure to HIV.

OBJECTIVES

We perform a systematic review of randomised controlled trials and nonrandomised studies that examine the effectiveness of vitamin A, zinc and cotrimoxazole on mortality and morbidity from diarrhoea in HIV-infected and -exposed infants and children.

SEARCH STRATEGY

Electronic databases including Pubmed, Central and EMBASE were searched without limits to language from 1980 to April 2010. Conference database searches were performed, experts were contacted and bibliographies were handsearched.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and nonrandomised studies (NRSs) that examined the effectiveness of the three interventions were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed citations for eligibility and double-extracted included studies. Assessment of bias of individual studies was performed independently by both reviewers. Only two summary estimates were performed due to heterogeneity in study design and interventions.

MAIN RESULTS

Four RCTs were identified for vitamin A. One RCT was identified for zinc. One RCT and two NRSs were identified for cotrimoxazole. Vitamin A reduced mortality overall in children with HIV infection (four studies). A pooled estimate of three studies for reduction in mortality from vitamin A compared to placebo had a relative risk (DerSimonian and Laird method, random effects) of 0.50 (95% confidence interval (CI): 0.31 to 0.79) in 267 patients. Diarrheoa-specific mortality did not reach statistical significance and diarrhoeal morbidity outcomes were variable in three trials. Zinc supplementation reduced the number of physician visits for watery diarrhoea in one trial. Cotrimoxazole reduced mortality and hospitalisations compared to placebo in one RCT, although diarrhoea-specific morbidities were not significant.

AUTHORS' CONCLUSIONS

Vitamin A shows benefits in reduction of mortality in HIV-infected children. The effect of vitamin A on children with HIV exposure is not clear and needs further review. Zinc and combination vitamin A, zinc and micronutrient supplementation did not show an effect compared to vitamin A alone in children with HIV infection. Cotrimoxazole reduced mortality and some morbidity in children with HIV infection. Further research may clarify the effects of these interventions on morbidity from diarrhoea and in the population of children with HIV exposure.

Vitamin A deficiency and behavioral and motor deficits in the human immunodeficiency virus type 1 transgenic rat

The human immunodeficiency virus type 1 (HIV-1) transgenic (Tg) rat model incorporates a noninfectious viral genome that is under similar regulatory control mechanisms in vivo as those that exist with natural infection in humans. Vitamin A (VA) deficiency in humans has been associated with progressive systemic HIV disease and with impaired cognition in rodent models. The effects on of VA deficiency on the development of behavioral abnormalities with HIV infection have not been previously described. In these studies, wild-type (Wt) and Tg rats maintained on either a normal (VA+) or a VA-deficient (VA-) diet were examined for activity in an open field (horizontal activity, total distance, vertical activity, and rearing) and on rotarod testing. On both open field and rotarod testing, the Tg rats performed worse than the Wt rats, with the most severe deficits noted in the TgVA- animals. Analysis of the specific effects of the presence of the HIV transgene and the diet on the performance on the open field tests showed a dominant effect from the transgene on all of the tests, with an effect from the diet on only the number of rearings. On rotarod testing, effects form both the diet and the transgene were observed at lower speeds, at the highest speeds, and on the accelerating rotarod. These studies therefore demonstrate that behavioral and motor abnormalities can be detected in this model and are likely due to similar mechanisms by which humans infected with HIV might develop cognitive-motor impairment in association with VA deficiency.

Micronutrient concentrations and subclinical atherosclerosis in adults with HIV

BACKGROUND

Extremes in micronutrient intakes are common in HIV-infected patients in developed countries and may affect the progression of atherosclerosis in this population.

OBJECTIVE

We completed a cross-sectional study examining the association between serum micronutrient concentrations and surrogate markers of atherosclerosis in a cohort of HIV-infected adults.

DESIGN

We measured serum selenium, zinc, vitamin A, and vitamin E concentrations as well as carotid intima-media thickness (c-IMT) and coronary artery calcium (CAC) in 298 Nutrition for Healthy Living participants. We assessed cardiovascular disease risk factors, c-IMT, and CAC for each micronutrient tertile by using a chi-square test for binary variables and analysis of variance for continuous variables. We performed multivariate regression of c-IMT and CAC with each micronutrient with adjustment for HIV-related and cardiovascular disease risk factors.

RESULTS

In the multivariate analysis, the highest tertile of serum vitamin E concentration was associated with higher common and internal c-IMT and CAC scores (P < 0.05 for c-IMT and CAC). Participants with higher vitamin E concentrations were more likely to have detectable CAC (50% compared with 44% compared with 67% for tertiles 1, 2, and 3, respectively; P = 0.004) and common c-IMT >0.8 mm (5% compared with 4% compared with 17% for tertiles 1, 2, and 3, respectively; P = 0.002). Other than vitamin E, micronutrients had no association with markers of atherosclerosis.

CONCLUSIONS

Our study showed that elevated serum vitamin E concentrations are associated with abnormal markers of atherosclerosis and may increase the risk of cardiovascular complications in HIV-infected adults.

Nutritional aspects of HIV-associated wasting in sub-Saharan Africa

The twin global epidemics of HIV infection and food scarcity disproportionately affect sub-Saharan Africa, and a significant proportion of patients who require antiretroviral therapy (ART) are malnourished because of a combination of HIV-associated wasting and inadequate nutrient intake. Protein-calorie malnutrition, the most common form of adult malnutrition in the region, is associated with significant morbidity and compounds the immunosuppressive effects of HIV. A low body mass index (BMI), a sign of advanced malnutrition, is an independent predictor of early mortality (<6 mo) after ART initiation in several analyses, and recent studies show an association between early weight gain when receiving ART and improved treatment outcomes. The cause of the observed increase in mortality is uncertain, but it is likely due in part to malnutrition-induced immune system dysfunction, a higher burden of opportunistic infections, and metabolic derangements. In this article, we describe the epidemiology of HIV infection and malnutrition in sub-Saharan Africa, potential causes of increased mortality after ART initiation among patients with a low BMI, recent studies on post-ART weight gain and treatment outcome, and trials of macronutrient supplementation from the region. We close by highlighting priority areas for future research.

A randomized trial to determine the optimal dosage of multivitamin supplements to reduce adverse pregnancy outcomes among HIV-infected women in Tanzania

BACKGROUND

We previously reported that supplementation with multivitamins (vitamin B complex, vitamin C, and vitamin E) at multiples of the Recommended Dietary Allowance (RDA) significantly decreased the risk of adverse pregnancy outcomes among HIV-infected women. The minimum dosage of multivitamins necessary for optimal benefits is unknown.

OBJECTIVE

We investigated the efficacy of multivitamin supplements at single compared with multiple RDAs on decreasing the risk of adverse pregnancy outcomes among HIV-infected women.

DESIGN

We conducted a double-blind, randomized controlled trial among 1129 HIV-infected pregnant women in Tanzania. Eligible women between 12 and 27 gestational weeks were randomly assigned to receive daily oral supplements of either single or multiple RDA multivitamins from enrollment until 6 wk after delivery.

RESULTS

Multivitamins at multiple and single doses of the RDA had similar effects on the risk of low birth weight (11.6% and 10.2%, respectively; P = 0.75). We found no difference between the 2 groups in the risk of preterm birth (19.3% and 18.4%, respectively; P = 0.73) or small-for-gestational-age (14.8% and 12.0%, respectively; P = 0.18). The mean birth weights were similar in the multiple RDA (3045 + or - 549 g) and single RDA multivitamins group (3052 + or - 534 g; P = 0.83). There were no significant differences between the 2 groups in the risk of fetal death (P = 0.99) or early infant death (P = 0.19).

CONCLUSION

Multivitamin supplements at a single dose of the RDA may be as efficacious as multiple doses of the RDA in decreasing the risk of adverse pregnancy outcomes among HIV-infected women. This trial was registered at clinicaltrials.gov as NCT00197678.

The oxidative stress-induced niacin sink (OSINS) model for HIV pathogenesis

Although several specific micronutrient deficiencies are associated with disease progression and increased mortality risk in HIV/AIDS, and even a simple multivitamin/mineral supplement can prolong survival, this is typically viewed merely as nutritional support of the immune system, and only necessary if there are deficiencies to be rectified. However, the reality is more complex. Several striking nutrient-related metabolic abnormalities have been consistently documented in HIV infection. One is chronic oxidative stress, including a drastic depletion of cysteine from the glutathione pool, and a progressive decline of serum selenium that is correlated with disease progression and mortality. Another is decreased blood levels of tryptophan, with an associated intracellular niacin deficiency. Tryptophan depletion or "deletion" by induction of indoleamine-2,3-dioxygenase (IDO), the first step in oxidative tryptophan metabolism, is a known mechanism for immune suppression that is of critical importance in cancer and pregnancy, and, potentially, in HIV/AIDS. Existing evidence supports the hypothesis that these nutrient-related metabolic abnormalities in HIV infection regarding antioxidants, selenium, sulfur, tryptophan and niacin are interrelated, because HIV-associated oxidative stress can induce niacin/NAD+ depletion via activation of poly(ADP-ribose) polymerase (PARP), which could lead to tryptophan oxidation for compensatory de novo niacin synthesis, thereby contributing to immune tolerance and T-cell loss via tryptophan deletion and PARP-induced cell death. This "oxidative stress-induced niacin sink" (OSINS) model provides a mechanism whereby the oxidative stress associated with HIV infection can contribute to immunosuppression via tryptophan deletion. This model is directly supported by evidence that antioxidants can counteract indoleamine-2,3-dioxygenase (IDO), providing the critical link between oxidative stress and tryptophan metabolism proposed here. The OSINS model can be used to guide the design of nutraceutical regimens that can effectively complement antiretroviral therapy for HIV/AIDS.

Micronutrients and T-cell subsets: a comparison between HIV-infected and uninfected, severely malnourished Rwandan children

OBJECTIVE

To determine the levels of CD4+ cells and micronutrients in HIV-infected and uninfected severely malnourished children.

DESIGN

Cross-sectional study in two centres.

SETTING

Children admitted to the malnutrition units in Kigali and Butare, Rwanda.

PATIENTS

A total of 112 children aged 2 months to 5 years presenting with severe malnutrition (weight for height Z- score -3 SD +/- oedema). Fifty-two (46.4%) were HIV-infected.

METHODS

CD4+ counts, selenium, zinc and copper levels were measured. The percentage of CD4 cells was calculated as a proportion of total lymphocyte count.

RESULTS

The mean age of the 52 HIV-infected children (18 months) was lower than of the 60 uninfected children (26 months) (p=0.01). Six (11.5%) of the HIV-infected had oedematous malnutrition compared with 50% of the uninfected group. The mean (SD) CD4+ count was 1054 (780) in the HIV-infected and 1579 (721) in the uninfected group (p=0.001). The CD4+ count was also significantly lower in the HIV-infected group than in the uninfected group for the ages <12 mths (p=0.09), 12-24 mths (p=0.045) and >36 mths (p=0.001). In HIV-infected children, 17% had severe immunosuppression (<15% CD4+ cells), 33% moderate (15-24%) and 50% had none (>25%) compared with 9%, 12% and 80% in the HIV-uninfected group, respectively (p<0.001). Approximately one-third in both groups had low levels of selenium and zinc and 77% had raised levels of copper. In multivariate analysis there was significant correlation between selenium and CD4+ (r=0.36, p<0.001) in HIV-infected children and no correlation of zinc and copper to CD4+ %. In HIV uninfected children, CD4+ % was related to selenium (r=0.282, p=0.03) and to zinc (r=0.264, p=0.047) but not to copper.

CONCLUSIONS

In severely malnourished children with HIV infection, low CD4+ levels are associated mainly with HIV infection. There was no significant difference in levels of selenium, zinc and copper between HIV-infected and uninfected children.

Undernutrition, infection and immune function

Undernutrition and infection are the major causes of morbidity and mortality in the developing world. These two problems are interrelated. Undernutrition compromises barrier function, allowing easier access by pathogens, and compromises immune function, decreasing the ability of the host to eliminate pathogens once they enter the body. Thus, malnutrition predisposes to infections. Infections can alter nutritional status mediated by changes in dietary intake, absorption and nutrient requirements and losses of endogenous nutrients. Thus, the presence of infections can contribute to the malnourished state. The global burden of malnutrition and infectious disease is immense, especially amongst children. Childhood infections impair growth and development. There is a role for breast-feeding in protection against infections. Key nutrients required for an efficient immune response include vitamin A, Fe, Zn and Cu. There is some evidence that provision of the first three of these nutrients does improve immune function in undernourished children and can reduce the morbidity and mortality of some infectious diseases including measles, diarrhoeal disease and upper and lower respiratory tract infections. Not all studies, however, show benefit of single nutrient supplementation and this might be because the subjects studied have multiple nutrient deficiencies. The situation regarding Fe supplementation is particularly complex. In addition to immunization programmes and improvement of nutrient status, there are important roles for maternal education, improved hygiene and sanitation and increased supply of quality water in the eradication of infectious diseases.

Zinc supplementation for the treatment or prevention of disease: current status and future perspectives

Zinc is a nutritionally essential trace element, and thus zinc deficiency may severely affect human health. Many studies were published in which the effect of nutritional zinc supplementation on the incidence or severity of a certain disease was investigated. This review summarizes the main observations and aims to evaluate the use of nutritional zinc supplementation for prevention and treatment of human disease.

The effect of multi-vitamin/mineral supplementation on mortality during treatment of pulmonary tuberculosis: a randomised two-by-two factorial trial in Mwanza, Tanzania

Malnutrition is common in pulmonary tuberculosis (TB), and may impair survival. The objective of this study was to assess effects of multi-vitamin/mineral (MVM) and zinc (Zn) supplementation during TB treatment on mortality. Patients diagnosed with sputum-positive pulmonary TB in Mwanza, Tanzania, were randomised, using a two-by-two factorial design, to Zn (45mg) or placebo, and MVM (vitamins A, B, C, D, E, and selenium and copper) or placebo. Survival status was ascertained at the end of the 8-month TB treatment and supplementation period. Of 499 TB patients, 213 (43%) had HIV. The mean weight gain at 7 months was 6·88kg (95% CI 6·36, 7·41). Zn and MVM combined, but neither alone (interaction, p=0·03), increased weight gain by 2·37kg (95% CI 0·91, 3·83), irrespective of HIV status. Survival status at 8 months was determined for 422 patients (84·6%), of which fifty-two (12·3%) had died. Among fifty-two deaths, there were no effects of MVM (relative risk (RR) 0·73; 95% CI 0·43, 1·23) and Zn (RR 0·76; 95% CI 0·46, 1·28). However, among HIV co-infected patients, marginally significant effects of both MVM (RR 0·60; 95% CI 0·34, 1·05) and Zn (RR 0·63, 95% CI 0·37, 1·08) were seen, and MVM and Zn combined reduced mortality (RR 0·29; 95% CI 0·10, 0·80; interaction ratio 0·52). In conclusion, supplementation with MVM, including Zn, during treatment of pulmonary TB may reduce mortality in those co-infected with HIV. A randomised trial of the effect of the combined intervention used in this study should be conducted in a different setting to confirm the finding.

Micronutrients in HIV-positive persons receiving highly active antiretroviral therapy

In HIV-infected persons, low serum concentrations of vitamins and minerals, termed micronutrients, are associated with an increased risk of HIV disease progression and mortality. Micronutrient supplements can delay HIV disease progression and reduce mortality in HIV-positive persons not receiving highly active antiretroviral therapy (HAART). With the transition to more universal access to HAART, a better understanding of micronutrient deficiencies and the role of micronutrient supplements in HIV-positive persons receiving HAART has become a priority. The provision of simple, inexpensive micronutrient supplements as an adjunct to HAART may have several cellular and clinical benefits, such as a reduction in mitochondrial toxicity and oxidative stress and an improvement in immune reconstitution. We reviewed observational and trial evidence on micronutrients in HIV-positive persons receiving HAART to summarize the current literature and suggest future research priorities. A small number of observational studies have suggested that some, but not all, micronutrients may become replete after HAART initiation, and few intervention studies have found that certain micronutrients may be a beneficial adjunct to HAART. However, most of these studies had some major limitations, including a small sample size, a short duration of follow-up, a lack of adjustment for inflammatory markers, and an inadequate assessment of HIV-related outcomes. Therefore, few data are available to determine whether HAART ameliorates micronutrient deficiencies or to recommend or refute the benefit of providing micronutrient supplements to HIV-positive persons receiving HAART. Because micronutrient supplementation may cause harm, randomized placebo-controlled trials are needed. Future research should determine whether HAART initiation restores micronutrient concentrations, independent of inflammatory markers, and whether micronutrient supplements affect HIV-related outcomes in HIV-positive persons receiving HAART.

Micronutrient levels and HIV disease status in HIV-infected patients on highly active antiretroviral therapy in the Nutrition for Healthy Living cohort

BACKGROUND

Low serum micronutrient levels were common before widespread use of highly active antiretroviral therapy (HAART) and were associated with adverse outcomes. Few data are available on micronutrient levels in subjects taking HAART.

OBJECTIVE

To determine the prevalence of low serum retinol, alpha-tocopherol, zinc, and selenium in HIV-infected subjects taking HAART and to assess the association of micronutrient levels with HIV disease status.

DESIGN

Cross-sectional.

SETTING

Nutrition for Healthy Living (NFHL) study.

PARTICIPANTS

HIV-infected subjects on HAART.

METHODS

Retinol, alpha-tocopherol, zinc, and selenium were determined in frozen serum samples from 171 men and 117 women. Low serum levels were defined as retinol <30 microg/dL, selenium <85 microg/L, alpha-tocopherol <500 microg/dL, and zinc <670 microg/L. Association of micronutrient quartiles with CD4 cell count, CD4 count <200 cells/mm, HIV viral load (VL), and undetectable VL was assessed using adjusted multivariate regression.

RESULTS

Five percent of men and 14% of women had low retinol, 8% of men and 3% of women had low selenium, and 7% of men and no women had low alpha-tocopherol. Forty percent of men and 36% of women had low zinc, however. Subjects in the upper quartiles of zinc had lower log VL levels than those in the lowest quartile (significant for women). Subjects in the upper quartiles of selenium also tended to have lower VL levels compared with those in the lowest quartile. Surprisingly, women in the upper quartiles of retinol had higher log VLs than those in the lowest quartile. There was no significant association of any micronutrient with CD4 cell count or likelihood of CD4 count <200 cells/mm. The level of CD4 cell count influenced the association of retinol with log VL in men, however. In men with CD4 counts >350 cells/mm, those with higher retinol had higher log VLs compared with the lowest quartile, whereas in men with CD4 counts <350, those with higher retinol levels had lower log VLs compared with the lowest quartile.

CONCLUSIONS

Low retinol, alpha-tocopherol, and selenium are uncommon in HIV-infected subjects on HAART. Zinc deficiency remains common, however. Decreased retinol levels in women and in men with CD4 counts >350 cells/mm and increased zinc and selenium levels in both genders may be associated with improved virologic control.