Iron deficiency and intestinal malabsorption in HIV disease

Association of myocardial iron deficiency based on T2* CMR with the risk of mild left ventricular dysfunction in HIV-1-infected patients

Objectives

This study sought to noninvasively determine myocardial iron levels in HIV-1-infected patients using CMR and explore the association between T2* values and mild left ventricular systolic dysfunction (LVSD).

Methods

This prospective study was conducted from June 2019 to July 2021. HIV-1-infected adults and healthy controls were consecutively enrolled for CMR exam. CMR exam included the assessment of myocardium iron content (T2*), cardiac function (cine), inflammation (T2), and fibrosis (through extracellular volume fraction [ECV] and late gadolinium enhancement [LGE]) measurements. Mild LVSD is defined as a left ventricular ejection fraction (LVEF) between 40% and 49%.

Results

Of 47 HIV-1-infected patients enrolled, 12 were diagnosed with mild LVSD (HIV-1+/LEVF+) and 35 were diagnosed with preserved LV function (HIV-1+/LEVF-). Compared with healthy controls, HIV-1-infected patients displayed higher T2*, T1, T2, ECV values and lower global circumferential strain (GCS) and global radial strain (GRS) (all P < 0.05). However, between patients with and without mild LVSD, only the T2* values and ECV (all P <0.05) were different. The association between increased T2* values (>26 ms) and mild LVSD remained significant after adjusting for the established univariate predictors (ECV >32.9%, T1 values >1336 ms) of mild LVSD (odds ratio [OR], 10.153; 95% confidence interval [CI] 1.565-65.878, P = 0.015).

Conclusions

Myocardial T2* values were elevated in HIV-1-infected patients, supporting the notion that ID was associated with mild LVSD. Our findings highlight the potential for ID in HIV-1-infected patients as an auxiliary biomarker to monitor the course of LVSD.

Fecal Metabolome Signature in the HIV-1 Elite Control Phenotype: Enrichment of Dipeptides Acts as an HIV-1 Antagonist but a Prevotella Agonist

HIV-1 elite controllers (EC) are a rare group among HIV-1-infected individuals who can naturally control viral replication for a prolonged period. Due to their heterogeneous nature, no universal mechanism could be attributed to the EC status; instead, several host and viral factors have been discussed as playing a role. In this study, we investigated the fecal metabolome and microbiome in a Swedish cohort of EC (n = 14), treatment-naive viremic progressors (VP; n = 16), and HIV-negative individuals (HC; n = 12). Fecal untargeted metabolomics was performed by four ultra-high-performance liquid chromatography tandem mass spectrometry (UHPLC-MS/MS). Molecular docking and biochemical microscale thermophoresis (MST) were used to describe the peptide-metabolite interactions. Single-cycle infectivity assays were performed in TZM-Bl cell lines using CCR5- and CXCR4-tropic HIV-1 strains. The microbiome analysis was performed using 16S rRNA sequencing. Th effects of metabolites on bacterial species viability were determined using several clinical isolates. We observed an enrichment of dipeptides in EC compared to VP and HC (adjusted P < 0.05). In silico analysis by molecular docking, in vitro biochemical assays, and ex vivo infection assays identified anti-HIV-1 properties for two dipeptides (WG and VQ) that could bind to the HIV-1 gp120, of which WG was more potent. The microbiome analysis identified enrichment of the genus Prevotella in EC, and these dipeptides supported bacterial growth of the genus Prevotella in vitro. The enrichments of the dipeptides and higher abundance of Prevotella have a distinct mechanism of elite control status in HIV-1 infection that influences host metabolism. IMPORTANCE HIV-1 elite controllers (EC) are a rare group among HIV-1-infected individuals who can naturally control viral replication for a prolonged period. Due to their heterogeneous nature, no universal mechanism could be attributed to the EC status; instead, several host and viral factors have been discussed as playing a role. In this study, we investigated the fecal metabolome and microbiome in a Swedish cohort of EC, treatment-naive viremic progressors (VP), and HIV-negative individuals (HC). We observed an enrichment of dipeptides in EC compared to the other two study groups. In silico and in vitro analyses identified anti-HIV-1 properties for two dipeptides that could bind to the HIV-1 gp120 and act as an HIV-1 antagonist. Furthermore, these dipeptides supported bacterial growth of the genus Prevotella in vitro that was enriched in EC, which influences host metabolism. Thus, increased levels of both dipeptides and Prevotella could provide beneficial effects for EC.

Effect of Human Immunodeficiency Virus on Trace Elements in the Brain

Comorbidities of human immunodeficiency virus (HIV) include HIV-associated neurocognitive disorder (HAND). Changes in the brain due to HIV include atrophy, hyperintensities, and diffusion changes. However, no research has focused on trace elements concentration changes in the brain due to HIV, as seen in other neurodegenerative diseases. Therefore, the aim of this study was to determine the concentration of several trace elements in the brains of individuals with and without HIV infection. Prior to formalin embalming, blood was drawn and tested in triplicate with Determine HIV-1/2 rapid tests and confirmed with a SD HIV Device 1/2 3.0 rapid HIV Kit. After embalming, tissue was sampled from the caudate nucleus and analyzed using inductively coupled plasma mass spectrometry. A Kruskal-Wallis test was used to determine statistically significant differences between the two groups (p < 0.05). Fifteen HIV-positive and 14 HIV-negative male cadavers were included (mean age 44, range 22 to 61). Cadmium was marginally decreased, possibly due to malnutrition or utilization by the HIV nucleocapsid. Nickel was marginally increased, perhaps due to a reduced capability to remove metals from the body. In conclusion, this article provides the first information on trace element levels in the brains from HIV-infected individuals and postulates that cadmium and nickel may play a role in the pathophysiology of HAND. This information can contribute to finding a treatment for HAND, other than the use of antiretroviral drugs. Future studies should asses the levels of cadmium and nickel in a larger cohort of HIV-infected individuals.

Anemia, diet and therapeutic iron among children living with HIV: a prospective cohort study

BACKGROUND

Children living with HIV have higher-than-normal prevalence of anemia. The beneficial effect of therapeutic iron has been questioned in the setting of high prevalence of infections. This study examines anemia prevalence and effect of standard therapeutic iron on HIV disease progression among children.

METHODS

Perinatally-infected children aged 2-12 years were enrolled at three sites in southern India, and were followed for 1 year with clinical assessments, dietary recall and anthropometry. Laboratory parameters included iron markers (ferritin, soluble transferrin receptor) and other micronutrient levels (vitamin A, B12, folate). Iron was given to anemic children based on WHO guidelines. Statistical analyses including frequency distributions, chi square tests and multivariate logistic regression were performed using Stata v13.0.

RESULTS

Among 240 children enrolled (mean age 7.7 years, 54.6% males), median CD4 was 25%, 19.2% had advanced disease, 45.5% had malnutrition, and 43.3% were on antiretroviral treatment (ART) at baseline. Anemia was prevalent in 47.1% (113/240) children. Iron deficiency was present in 65.5%; vitamin A and vitamin B12 deficiency in 26.6% and 8.0% respectively; and anemia of inflammation in 58.4%. Independent risk factors for anemia were stunting, CD4 < 25%, detectable viral load ≥ 400 copies/ml and vitamin A deficiency. Inadequate dietary iron was prominent; 77.9% obtained less than two-thirds of recommended daily iron. Among clinically anemic children who took iron, overall adherence to iron therapy was good, and only minor self-limiting adverse events were reported. Median hemoglobin rose from 10.4 g/dl to 10.9 mg/dl among those who took iron for 3 months, and peaked at 11.3 mg/dl with iron taken for up to 6 months. Iron was also associated with a greater fall in clinical severity of HIV stage; however when adjusted for use of ART, was not associated with improvement in growth, inflammatory and CD4 parameters.

CONCLUSIONS

Children living with HIV in India have a high prevalence of anemia mediated by iron deficiency, vitamin A deficiency and chronic inflammation. The use of therapeutic iron for durations up to 6 months appears to be safe in this setting, and is associated with beneficial effects on anemia, iron deficiency and HIV disease progression.

The importance of nutritional care in HIV-infected children in resource-limited settings

Renewed efforts to provide proper nutritional care are essential for appropriate pediatric HIV management. Current studies support the use of vitamin A and macronutrients that increase caloric and protein intake. With additional research on key issues such as the needed composition and timing for nutritional supplementation, we can determine the best strategies to support the growth and development of HIV-infected children in resource-limited settings. Malnutrition among children is common in the resource-limited settings where HIV infection is most prevalent. While malnutrition is associated with higher morbidity and mortality for HIV-infected children, there is only limited evidence to guide the use of nutritional support for HIV-infected children. The best studied is vitamin A, which is associated with improved mortality and clinical outcomes. Zinc and multivitamin supplementation have not consistently been associated with clinical benefits. Limited research suggests macronutrient supplementation, which typically uses enriched formulas or foods, improves key anthropometrics for HIV-infected children, but the optimal composition of nutrients for supplementation has not been determined. More research is needed to understand the most efficient and sustainable ways to ensure adequate nutrition in this vulnerable population.

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).

Effect of body mass index reduction on serum hepcidin levels and iron status in obese children

Iron deficiency has been linked to obesity. Hepcidin is the main regulator of iron homeostasis and is higher in obese children compared to controls. To gain insight into the link between obesity and hepcidin, we performed an intervention study in 15 obese children. These children were subjected to a 6-month weight loss program and underwent physical examination and iron status and absorption as well as hepcidin, interleukin-6 and leptin serum levels evaluation at baseline and after the weight loss program. After the program all children reduced their body mass index standard deviation score (BMI SDS) of at least 0.5. We observed a significant decrease in hepcidin (P=0.003) and leptin levels (P=0.005), and a significant increase in iron absorption (P=0.02). A direct correlation between the measure of hepcidin and leptin reduction was observed and this correlation appeared significant (r²=0.33, P=0.003) when adjusted for interleukin-6 and BMI SDS variations. In conclusion, we have shown that, in obese children, BMI reduction is associated with hepcidin reduction, potentially improving iron status and absorption. Implications of these findings could be considered in the management of obese children with poor iron status.

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.

Hepcidin in obese children as a potential mediator of the association between obesity and iron deficiency

CONTEXT

Obesity and iron deficiency are two of the most common nutritional disorders worldwide. Several studies found higher rates of iron deficiency in obese than in normal-weight children. Hepcidin represents the main inhibitor of intestinal iron absorption, and its expression is increased in adipose tissue of obese patients. Leptin is able, in vitro, to raise hepcidin expression.

OBJECTIVES

Aims of this work were 1) to assess the association between poor iron status and obesity, 2) to investigate whether iron homeostasis of obese children may be modulated by serum hepcidin variations, and 3) to assess the potential correlation between leptin and serum hepcidin variations.

METHODS

Iron status and absorption as well as hepcidin, leptin, and IL-6 levels were studied in 60 obese children and in 50 controls.

RESULTS

Obese children showed lower iron and transferrin saturation (both P < 0.05) and higher hepcidin levels (P = 0.004) compared with controls. A direct correlation between hepcidin and obesity degree (P = 0.0015), and inverse correlations between hepcidin and iron (P = 0.04), hepcidin and transferrin saturation (P = 0.005), and hepcidin and iron absorption (P = 0.003) were observed. A correlation between leptin and hepcidin (P = 0.006) has been found. The correlation remained significant when adjusted for body mass index, sex, pubertal stage, and IL-6 values.

CONCLUSIONS

We propose that in obese patients, increased hepcidin production, at least partly leptin mediated, represents the missing link between obesity and disrupted iron metabolism.

Altered iron metabolism in children with human immunodeficiency virus disease

BACKGROUND

Despite the high prevalence of altered iron metabolism in children with human immunodeficiency virus (HIV) disease, these alterations have not been well studied.

PROCEDURES

Twenty-six children with HIV disease underwent laboratory evaluation to determine the presence of anemia, and to classify the anemia as iron-deficiency anemia or anemia of chronic disease.

RESULTS

Half of the children had an alteration in iron metabolism: 6 were iron deficient, 4 had hyperferritinemia, and 3 demonstrated hyperferritinemia with iron deficiency.

CONCLUSIONS

These data indicate that alterations in iron metabolism are common even in the HAART era and warrant further study to identify individuals at risk for these alterations.

HIV-associated anemia in children: a systematic review from a global perspective

OBJECTIVES

To assess the importance of anemia in HIV-infected children in western and tropical settings.

DESIGN

A systematic review with a descriptive component.

METHODS

: Four databases were searched and reference lists of pertinent articles were checked. Studies that reported data on anemia or hemoglobin levels in HIV-infected children were selected and grouped according to the location and the definition of anemia.

RESULTS

Thirty-six studies met the inclusion criteria. Mild (hemoglobin <11 g/dl) and moderate (hemoglobin <9 g/dl) anemia were more prevalent with HIV infection (odds ratio 4.5; 95% confidence interval 2.5-8.3 and odds ratio 4.5; 95% confidence interval 2.0-10.3, respectively). Mean hemoglobin levels were lower (standardized mean difference; 0.79; 95% confidence interval 0.47-1.10). These differences were observed in both western and tropical settings. Anemia incidence ranged from 0.41 to 0.44 per person-year. There was limited data on more severe anemia (hemoglobin <7 or <5 g/dl). As anemia was frequently identified as an independent risk factor for disease progression and death, we next reviewed the limited data to formulate better strategies. Failure of erythropoiesis was the most important mechanism for anemia in HIV-infected children. Therapeutic options include highly active antiretroviral therapy and prevention or treatment of secondary infections. Erythropoietin can improve anemia in children, but it has not been evaluated in developing countries. Micronutrient supplementation may be helpful in individual children. The potential benefits or risks of iron supplementation in HIV-infected children require evaluation.

CONCLUSION

Anemia is a very common complication of pediatric HIV infection, associated with a poor prognosis. With the increasing global availability of highly active antiretroviral therapy, more data on the safety and efficacy of possible interventions in children are urgently needed.

MRN-100, an Iron-based Compound, Possesses Anti-HIV Activity In Vitro

We examined the in vitro anti-human immunodeficiency virus (HIV) activity of MRN-100, an iron-based compound derived from bivalent and tervalent ferrates. MRN-100 action against HIV-1 (SF strain) was tested in primary cultures of peripheral blood mononuclear cells (MNC) by analyzing p24 antigen production and percent survival of MNC infected with HIV. MRN-100 at a concentration of 10% (v/v) inhibited HIV-1 replication in 11 out of 14 samples (79%). The percentage of suppression of p24 antigen was −12.3 to 100% at 10 days post-treatment. MRN-100 also exhibited a significant protective effect in the survival of HIV-1-infected MNC. MNC survival post-treatment was dose dependent, 70.4% ± 8.4, 83.6% ± 10.7 and 90% ± 11.4, at concentrations 2.5, 5 and 10% (v/v), respectively, as compared with 53% ± 4 for HIV-1-infected MNC without treatment. The effect was detected as early as 4 days and continued up to 11 days. Treatment with MRN-100 caused no significant change in proliferative response of MNC alone or cocultured with different mitogens: PHA and Con-A (activators of T cell function) and PWM (activator of CD4⁺ T cell-dependent B cells). We concluded that MRN-100 possesses anti-HIV activity in vitro and without an increase in lymphocyte proliferation, MRN-100 may be a useful agent for treating patients with acquired immunodeficiency syndrome.

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.

Alterations in serum levels of trace elements in tuberculosis and HIV infections

OBJECTIVE

To evaluate serum concentrations of trace elements in tuberculosis (TB) patients with or with out human immunodeficiency virus (HIV) coinfection before and after anti-TB chemotherapy.

SUBJECTS

A total of 155 TB patients, 74 of which were coinfected with HIV, and 31 healthy controls from Gondar, Ethiopia.

METHODS

Serum levels of copper, zinc, selenium and iron were determined using an inductively coupled plasma mass spectrometer from all subjects at baseline and from 44 TB patients (22 with HIV coinfection) at the end of an intensive phase of anti-TB chemotherapy.

RESULTS

Compared with the control group, the concentrations of iron, zinc and selenium were significantly lower (P<0.05) while that of copper and copper/zinc ratio was significantly higher (P<0.05) in the serum of TB patients. TB patients with HIV coinfection had significantly lower serum zinc and selenium concentrations and significantly higher copper/zinc ratio compared to that in TB patients without HIV coinfection (P<0.05). The serum concentration of zinc had significantly increased at the end of intensive phase of anti-TB chemotherapy in patients without HIV coinfection (P<0.05). An increase in serum selenium level was observed in TB patients with or without HIV coinfection after therapy. On the contrary, serum copper concentration and copper/zinc ratio declined significantly after anti-TB chemotherapy irrespective of HIV serostatus (P<0.05).

CONCLUSIONS

The results indicate that TB patients have altered profile of trace elements in their sera. This warrants the need for further investigations so that strategies for trace elements supplementation can be planned in addition to their potential as diagnostic parameters in monitoring responses to anti-TB chemotherapy.

Nutritional and metabolic abnormalities in pre-AIDS HIV infection

Since the earliest reports of human immunodeficiency virus (HIV) disease, undernutrition has been associated with HIV infection, typically with the late stages of the disease (namely acquired immunodeficiency syndrome), and may advance to severe wasting and cachexia. Specific micronutrient deficiencies are also recognized to occur with HIV infection, but their actual effect on the clinical course of the disease is hard to assess. The studies reviewed provide more insight into the complex interface between undernutrition and, in some cases, obesity and HIV/acquired immunodeficiency syndrome and highlight the possibility of alleviating or curing undernutrition by means of simple and comparatively inexpensive dietary adjustments.

Management of gastrointestinal disorders in children with HIV infection

A double scenario characterizes the epidemiology of HIV infection in children. In countries where highly active antiretroviral therapy (HAART) is available, the pattern of HIV infection is evolving into that of a chronic disease, for which control strictly depends on patients' adherence to treatment. In developing countries with no or limited access to HAART, AIDS is rapidly expanding and is loaded with a high fatality ratio, due to the combined effects of malnutrition and opportunistic infections. The digestive tract is a target of the disease in both settings. Opportunistic infections play a major role in children with severe immune impairment, with Cryptosporidium parvum being the leading agent of severe diarrhea. Several therapeutic approaches are effective in reducing fecal output, but the eradication of the parasite is rarely obtained. Other opportunistic infections may induce severe and protracted diarrhea, including atypical mycobacteria and cytomegalovirus. Diagnosis of diarrhea should be individually tailored based on presenting symptoms and risk factors. A stepwise approach is effective in limiting patient discomfort and minimizing the costs of investigations, starting with microbiologic investigation and proceeding with endoscopy and histology. Aggressive treatment of infectious diarrhea is required in severely immunocompromised children. However, antiretroviral therapy prevents the development of severe cryptosporidiosis. The liver and pancreas are also target organs in HIV infection, although functional failure is rare. The digestive-absorptive functions are impaired, with steatorrhea, nutrient malabsorption, and increased permeability occurring in 20-70% of children. Intestinal dysfunction contributes to growth failure and further immune derangement, leading to wasting, the terminal stage of AIDS. Nutritional management is crucial in HIV-infected children and is based on aggressive nutritional rehabilitation through enteral or parenteral routes and micronutrient supplementation.HIV may play a direct enteropathogenic role and is implicated in both diarrhea and intestinal dysfunction. This explains the efficacy of antiretroviral therapy in inducing remission of diarrhea and restoring intestinal function. Gastrointestinal side effects of antiretroviral drugs are increasingly observed; they are often mild and transient. Severe reactions are rare but require the withdrawal of drugs. In conclusion, severe enteric infections and intestinal dysfunction characterize the intestinal involvement of HIV infection. This is more common in, but not limited to, children who do not receive effective antiretroviral therapy. Diagnostic approaches include microbiologic and morphologic examinations and assessment of digestive processes, but immunologic and virologic data should be also carefully considered. Treatment is based upon specific anti-infectious drugs, antiretroviral therapy, and nutritional rehabilitation.

Potential Mechanisms for Altered Iron Metabolism in Human Immunodeficiency Virus Disease

Recently, anemia associated with human immunodeficiency virus (HIV) disease has received more attention as our understanding of the significance of anemia in this population has grown and more emphasis is placed on the quality of life of people living with HIV/AIDS. Although the diagnosis and treatment of anemia in HIV disease has been discussed in great detail, the prevalence and pathophysiology of the two most common forms of anemia, iron deficiency anemia (IDA) and the anemia of chronic disease (ACD), have not received much attention despite the difficulty and importance of differentiating between these two anemias. In addition, little attention has been given to iron overload, which has serious implications in individuals with HIV disease. This article proposes a model of altered iron metabolism in HIV disease as a basis for explaining the pathophysiology and implications of IDA, ACD, and iron overload in this population. Implications for clinical practice and recommendations for future research are discussed.

Effects of nutritional rehabilitation on intestinal function and on CD4 cell number in children with HIV

BACKGROUND

A complex interplay of malnutrition, intestinal dysfunction, and immune impairment increases the progression of human immunodeficiency virus (HIV) disease in children. The authors tested the hypothesis that nutritional support improves intestinal and immune functions in children infected with human immunodeficiency virus (HIV).

METHODS

A questionnaire was circulated through reference centers for pediatric HIV infection to evaluate the effects of nutritional rehabilitation, total parenteral nutrition (TPN) and enteral nutrition (EN), in children. Information included changes in body weight, CD4 cell numbers, and intestinal absorption-as judged by the xylose load-before and after clinical nutritional support and the outcome of children.

RESULTS

Sixty-two children underwent nutritional support: 46 received TPN and 16 received EN. All but three had full-blown acquired immunodeficiency syndrome, and all were severely malnourished. Baseline clinical conditions were worse in children receiving TPN than in those receiving EN. Intestinal dysfunction was detected in all children who received xylose oral load. A significant increase in CD4 cell count, xylose levels, and body weight followed EN. A similar pattern was observed after TPN, but none of the parameters significantly changed. Twenty-seven children who received TPN and three who received EN eventually died. Fourteen who received TPN and eight who received EN were shifted to oral feeding, and five who received TPN and five who received EN continued with clinical nutritional support at the end of the observation period.

CONCLUSIONS

Nutritional intervention may restore intestinal absorption and increase CD4 cell numbers. The efficacy of nutritional intervention is enhanced if provided before a terminal stage of HIV infection. These data provide evidence of a close association among nutritional condition, intestinal absorption, and immune impairment.

Iron deficiency anemia is highly prevalent among human immunodeficiency virus-infected and uninfected infants in Uganda

Although anemia is a common finding among human immunodeficiency (HIV)-infected infants in sub-Saharan Africa, the factors contributing to the pathogenesis of anemia have not been well characterized. We sought to characterize the relative contribution of iron deficiency and chronic disease to the anemia among infants. Hemoglobin, ferritin, erythropoietin, tumor necrosis factor-alpha (TNF-alpha), neopterin, CD4(+) lymphocyte count and plasma HIV load were measured in 165 HIV-infected and 39 uninfected 9-mo-old infants seen in an outpatient pediatric clinic in Kampala, Uganda. Among HIV-infected and uninfected infants, the prevalence of anemia (hemoglobin < 110 g/L) was 90.9 and 76.9%, respectively (P = 0.015), and the prevalence of iron deficiency anemia (hemoglobin < 110 g/L and ferritin < 12 microg/L) was 44.3 and 45.4%, respectively (P = 0.92). The relatively higher prevalence of anemia among HIV-infected infants was attributed to the anemia of chronic disease. Among infants with and without iron deficiency, the fitted regression line was log(10) plasma erythropoietin = 2.86 - 0.016.hemoglobin, and log(10) plasma erythropoietin = 4.11 - 0.028.hemoglobin, respectively, with a difference in the slope of the regression lines between log(10) erythropoietin and hemoglobin among infants with and without iron deficiency (P = 0.049). Infants in Uganda have an extremely high prevalence of anemia, and nearly half of the anemia is due to iron deficiency. The erythropoietin response to anemia appears to be upregulated among infants with iron deficiency.

A prospective, cross-sectional study of anaemia and peripheral iron status in antiretroviral naïve, HIV-1 infected children in Cape Town, South Africa

BACKGROUND

Anaemia is a common manifestation of paediatric HIV infection. Although there are many causes, anaemia of chronic diseases is the most frequent type. In poor countries iron deficiency is widespread. It is probable that many HIV-infected children in these countries are also iron deficient. This study describes the relationship between paediatric HIV infection and anaemia, and documents the peripheral iron status of antiretroviral naive, HIV-infected children.

METHODS

Sixty children were evaluated prospectively. Investigations included CD4+ count, haemoglobin concentration (Hb), red blood cell (RBC) morphology, and iron studies.

RESULTS

Anaemia was present in 73% of children. Compared to mild HIV infection, median Hb was lower in children with moderate clinical infection (104 g/L v 112 g/L, p = 0.04) and severe clinical infection (96 g/L v 112 g/L, p = 0.006), and more children with severe infection were anaemic (92% v 58%, 0.04). There was a significant relationship between immunological status and Hb. 68% had abnormal RBC morphology. Significantly more children with moderate and severe disease, and severe immunosuppression had abnormal RBC morphology. 52% were iron-depleted, 20% had iron-deficient erythropoiesis and 18% iron deficiency anaemia (IDA). 16% (7/44) of anaemic children had microcytosis and hypochromia. Median soluble transferrin receptor concentration was significantly higher in those with microcytic hypochromic anaemia (42.0 nmol/L v 30.0 nmol/L, p = 0.008).

CONCLUSIONS

Both the proportion of anaemic children and the median Hb were associated with disease status. Iron depletion and IDA are major problems in HIV-infected children in South Africa.

HIV and other predictors of serum folate, serum ferritin, and hemoglobin in pregnancy: a cross-sectional study in Zimbabwe

BACKGROUND

Folate and iron status and hemoglobin concentrations are important to maternal and infant health.

OBJECTIVE

Our goal was to identify predictors of serum folate, serum ferritin, and hemoglobin.

DESIGN

This was a cross-sectional study of 1669 pregnant women (22-35 wk of gestation) in Harare, Zimbabwe, who were receiving prenatal care. The statistical effects of age, season, gestational age, gravidity, HIV-1 infection, malaria parasitemia, and serum alpha1-antichymotrypsin (ACT) on serum folate, serum ferritin (log10 transformed), and hemoglobin were estimated by using multiple linear regression analyses.

RESULTS

Serum folate (x: 11.4 micromol/L) was 0.52-nmol/L (95% CI: 0.04, 1.0) lower in HIV-infected women than in uninfected women and 0.65-nmol/L (0.014, 1.28) lower in weeks 25-35 than in weeks 22-25. Serum ferritin (geometric x: 11.6 microg/L) was 0.93 times (0.86, 0.99) lower in HIV-infected women and 2.25 times (1.41, 3.61) higher in women with malaria parasitemia than in uninfected women. Similarly, serum ferritin was 0.71 times (0.63, 0.79) higher in weeks 32-35 than in weeks 22-25 and 1.21 times (1.12, 1.29) higher in gravida > or =3 than in gravida 1. Elevated serum ACT was a strong predictor of serum folate, serum ferritin, and hemoglobin. HIV infection was associated with a 12.9-g/L (8.9, 16.8) lower hemoglobin concentration in women with nondepleted iron stores but low serum retinol and a 7-8-g/L lower hemoglobin concentration in women with other combinations of serum ferritin and retinol (P for interaction = 0.038). Season, age, gestational age, and gravidity were not significant predictors of hemoglobin. Low serum folate, ferritin, and retinol were associated with low hemoglobin.

CONCLUSIONS

HIV was associated with lower serum folate, serum ferritin, and hemoglobin. HIV infection was also associated with lower hemoglobin, particularly in women with stored iron and low serum retinol. Low serum folate, ferritin, and retinol were associated with low hemoglobin.

Ritonavir combination therapy restores intestinal function in children with advanced HIV disease

OBJECTIVES

To investigate the intestinal absorptive processes in children with HIV infection before and after treatment with combination therapy that includes ritonavir. To test the hypothesis that combination therapy improves intestinal function.

DESIGN

Intestinal function tests were performed in 10 children with advanced HIV disease at the enrollment and after 3 and 6 months of therapy with ritonavir combined with two HIV reverse transcriptase inhibitors. HIV viral load and CD4 cell counts were also determined; body weight was monitored.

METHODS

The D-xylose absorption test, the steatocrit and the determination of fecal alpha1-antitrypsin concentration were used to evaluate carbohydrate and fat absorption, as well as fecal protein loss. Serum iron levels were measured to indirectly evaluate iron absorption. HIV-1 RNA-polymerase chain reaction (PCR) and immunofluorescence imaging were used to evaluate virologic and immunologic responses.

RESULTS

In all, 9 children had carbohydrate malabsorption, 3 steatorrhea, 2 protein loss, and 7 iron deficiency. Most tests produced normal results after 3 months of therapy, and all abnormalities were abolished 6 months after institution of combination therapy. Mean results of each of four absorption tests were significantly changed on combination therapy. Viral load was progressively reduced and CD4 count was increased, with an inverse relationship. An evident shift of body weight pattern toward catch-up growth was observed in all children.

CONCLUSIONS

Ritonavir combination therapy results in prompt and sustained restoration of intestinal function, which is associated with reduction in viral load, increase in CD4 counts, and gain in body weight.

Exocrine pancreatic function and fat malabsorption in human immunodeficiency virus-infected patients

BACKGROUND

Nutrients malabsorption frequently occurs in human immunodeficiency virus (HIV)-infected patients, but very few studies have investigated exocrine pancreatic digestive capacity in these patients. We therefore evaluated the frequency of exocrine pancreatic impairment and its eventual relation with fat malabsorption in HIV-infected patients.

METHODS

Thirty-five HIV-infected patients (30 male, 5 female: mean age +/- standard deviation, 33.6 +/- 7.2 years) and 51 sex- and age-matched controls without gastroenterologic diseases were studied. In all subjects fecal elastase 1 (EL-1) was assayed, and fecal fat excretion was evaluated with the steatocrit test.

RESULTS

Nineteen of 35 (54%) HIV-infected patients showed subnormal EL-1 values, whereas all the controls had normal values; furthermore, EL-1 values were significantly lower in patients than in controls: mean (95% confidence intervals), 207 ( 164-251 ) microg/g versus 312 (291-332) microg/g (P < 0.0001). Increased fecal fat excretion was observed in almost all (25 of 35) HIV-infected patients, and an inverse but not significant correlation was found between fecal EL-1 and steatocrit values. No association was found between reduced fecal EL-1 and the severity of HIV disease or nutritional and immunologic status. Opportunistic infections and drug administration had no influence on EL-1 concentrations in stools.

CONCLUSIONS

Reduced exopancreatic function is frequent in HIV-infected patients but does not seem to be a major factor contributing to fat malabsorption.

Micronutrients and the pathogenesis of human immunodeficiency virus infection

Micronutrient deficiencies may be common during human immunodeficiency virus (HIV) infection. Insufficient dietary intake, malabsorption, diarrhoea, and impaired storage and altered metabolism of micronutrients can contribute to the development of micronutrient deficiencies. Low plasma or serum levels of vitamins A, E, B6, B12 and C, carotenoids, Se, and Zn are common in many HIV-infected populations. Micronutrient deficiencies may contribute to the pathogenesis of HIV infection through increased oxidative stress and compromised immunity. Low levels or intakes of micronutrients such as vitamins A, E, B6 and B12, Zn and Se have been associated with adverse clinical outcomes during HIV infection, and new studies are emerging which suggest that micronutrient supplementation may help reduce morbidity and mortality during HIV infection.