Micronutrient supplementation in the AIDS diarrhoea-wasting syndrome in Zambia: a randomized controlled trial

Selenium Status of Southern Africa

Selenium is an essential trace element that exists in inorganic forms (selenite and selenates) and organic forms (selenoamino acids, seleno peptides, and selenoproteins). Selenium is known to aid in the function of the immune system for populations where human immunodeficiency virus (HIV) is endemic, as studies suggest that a lack of selenium is associated with a higher risk of mortality among those with HIV. In a recent study conducted in Zambia, adults had a median plasma selenium concentration of 0.27 μmol/L (IQR 0.14-0.43). Concentrations consistent with deficiency (<0.63 μmol/L) were found in 83% of adults. With these results, it can be clearly seen that selenium levels in Southern Africa should be investigated to ensure the good health of both livestock and humans. The recommended selenium dietary requirement of most domesticated livestock is 0.3 mg Se/kg, and in humans above 19 years, anRDA (recommended daily allowance) of 55 mcg Se/per dayisis recommended, but most of the research findings of Southern African countries have recorded low levels. With research findings showing alarming low levels of selenium in soils, humans, and raw feed materials in Southern Africa, further research will be vital in answering questions on how best to improve the selenium status of Southern African soils and plants for livestock and humans to attain sufficient quantities.

Adverse outcome pathway for aminoglycoside ototoxicity in drug-resistant tuberculosis treatment

Individuals treated for multidrug-resistant tuberculosis (MDR-TB) with aminoglycosides (AGs) in resource-limited settings often experience permanent hearing loss. However, AG ototoxicity has never been conceptually integrated or causally linked to MDR-TB patients' pre-treatment health condition. We sought to develop a framework that examines the relationships between pre-treatment conditions and AG-induced hearing loss among MDR-TB-infected individuals in sub-Saharan Africa. The adverse outcome pathway (AOP) approach was used to develop a framework linking key events (KEs) within a biological pathway that results in adverse outcomes (AO), which are associated with chemical perturbation of a molecular initiating event (MIE). This AOP describes pathways initiating from AG accumulation in hair cells, sound transducers of the inner ear immediately after AG administration. After administration, the drug catalyzes cellular oxidative stress due to overproduction of reactive oxygen species. Since oxidative stress inhibits mitochondrial protein synthesis, hair cells undergo apoptotic cell death, resulting in irreversible hearing loss (AO). We identified the following pre-treatment conditions that worsen the causal linkage between MIE and AO: HIV, malnutrition, aging, noise, smoking, and alcohol use. The KEs are: (1) nephrotoxicity, pre-existing hearing loss, and hypoalbuminemia that catalyzes AG accumulation; (2) immunodeficiency and antioxidant deficiency that trigger oxidative stress pathways; and (3) co-administration of mitochondrial toxic drugs that hinder mitochondrial protein synthesis, causing apoptosis. This AOP clearly warrants the development of personalized interventions for patients undergoing MDR-TB treatment. Such interventions (i.e., choosing less ototoxic drugs, scheduling frequent monitoring, modifying nutritional status, avoiding poly-pharmacy) will be required to limit the burden of AG ototoxicity.

Effectiveness of macronutrient supplementation on nutritional status and HIV/AIDS progression: A systematic review and meta-analysis

BACKGROUND & AIMS

Malnutrition is common in Sub-Saharan Africa, weakening the immune function of persons living with HIV infection (PLWH). Being malnourished at the initiation of antiretroviral therapy (ART) leads to higher risk of early mortality and reduced quality of life. Thus, introduction of protein-energy-fortified macronutrient supplements at ART initiation may improve HIV treatment outcomes. This review aimed to evaluate the effectiveness of macronutrient interventions.

METHODS

This systematic review and meta-analysis included 15 studies conducted from 2000 to 2015 among Sub-Saharan African adults.

RESULTS

Six randomized controlled trials and 4 retrospective cohort studies provided data eligible for a meta-analysis. Supplementation significantly increased the overall standardized mean difference (SMD) between baseline and follow-up data in weight (SMD = 0.382, p < .001), BMI (SMD = 0.799, p < .001); fat-free mass (SMD = 0.154, p = .009); and CD4 count (SMD = 0.428, p < .001).

CONCLUSION

Protein-energy-fortified macronutrient supplementation at ART initiation may positively influence nutritional status and immunologic response in PLWH in Sub-Saharan Africa.

Selenium deficiency and pregnancy outcome in pregnant women with HIV in Lagos, Nigeria

OBJECTIVE

To investigate the prevalence of maternal selenium deficiency and its effects on pregnancy outcomes in pregnant women with HIV in Lagos, Nigeria.

METHODS

The present descriptive cross-sectional study enrolled women aged 15-49 years with HIV who were at 14-26 weeks of a singleton pregnancy and were attending Lagos University Teaching Hospital, Lagos, Nigeria, between August 1, 2016, and April 30, 2017. Participants were selected by consecutive sampling and baseline data were collected through interviews. Venous blood samples were obtained to measure selenium concentrations, and associations between low maternal selenium concentrations (defined as <0.89 μmol/L) and pregnancy outcomes were examined using bivariate and multivariate analysis.

RESULTS

The final analysis included 113 patients; selenium deficiency was recorded in 23 (20.4%) patients. Women with selenium deficiency had an approximately eight-fold higher risk of preterm delivery (adjusted odds ratio 7.61, 95% confidence interval 4.37-18.89; P=0.031) and of delivering a term neonate with a low delivery weight (adjusted odds ratio 8.11, 95% confidence interval 3.27-17.22; P=0.012), compared with women with a normal selenium concentration.

CONCLUSION

The prevalence of selenium deficiency among pregnant women with HIV in Lagos was relatively high. The significant associations observed between maternal selenium deficiency and adverse pregnancy outcomes could have implications for the future management of HIV in pregnancy.

Micronutrient supplementation in adults with HIV infection

BACKGROUND

Micronutrient deficiencies are common among adults living with HIV disease, particularly in low-income settings where the diet may be low in essential vitamins and minerals. Some micronutrients play critical roles in maintenance of the immune system, and routine supplementation could therefore be beneficial. This is an update of a Cochrane Review previously published in 2010.

OBJECTIVES

To assess whether micronutrient supplements are effective and safe in reducing mortality and HIV-related morbidity of HIV-positive adults (excluding pregnant women).

SEARCH METHODS

We performed literature searches from January 2010 to 18 November 2016 for new randomized controlled trials (RCTs) of micronutrient supplements since the previous review included all trials identified from searches prior to 2010. We searched the CENTRAL (the Cochrane Library), Embase, and PubMed databases. Also we checked the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and the ClinicalTrials.gov trials registers. We also checked the reference lists of all new included trials.

SELECTION CRITERIA

We included RCTs that compared supplements that contained either single, dual, or multiple micronutrients with placebo, no treatment, or other supplements. We excluded studies that were primarily designed to investigate the role of micronutrients for the treatment of HIV-positive participants with metabolic morbidity related to highly active antiretroviral therapy (HAART). Primary outcomes included all-cause mortality, morbidity, and disease progression.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, and appraised trial quality for risk of bias. Where possible, we presented results as risk ratios (RR) for dichotomous variables, as hazard ratios (HRs) for time-to-event data, and as mean differences (MD) for continuous variables, each with 95% confidence intervals (CIs). Since we were often unable to pool the outcome data, we tabulated it for each comparison. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 33 trials with 10,325 participants, of which 17 trials were new trials. Ten trials compared a daily multiple micronutrient supplement to placebo in doses up to 20 times the dietary reference intake, and one trial compared a daily standard dose with a high daily dose of multivitamins. Nineteen trials compared supplementation with single or dual micronutrients (such as vitamins A and D, zinc, and selenium) to placebo, and three trials compared different dosages or combinations of micronutrients. Multiple micronutrientsWe conducted analyses across antiretroviral therapy (ART)-naive adults (3 trials, 1448 participants), adults on antiretroviral therapy (ART) (1 trial, 400 participants), and ART-naive adults with concurrent active tuberculosis (3 trials, 1429 participants). Routine multiple micronutrient supplementation may have little or no effect on mortality in adults living with HIV (RR 0.91, 95% CI 0.72 to 1.15; 7 trials, 2897 participants, low certainty evidence).Routine supplementation for up to two years may have little or no effect on the average of mean CD4+ cell count (MD 26.40 cells/mm³, 95% CI -22.91 to 75.70; 6 trials, 1581 participants, low certainty evidence), or the average of mean viral load (MD -0.1 log₁₀viral copies, 95% CI -0.26 to 0.06; 4 trials, 840 participants, moderate certainty evidence). One additional trial in ART-naïve adults did report an increase in the time to reach a CD4+ cell count < 250 cells/mm³ after two years of high dose supplementation in Botswana (HR 0.48, 95% CI 0.26 to 0.88; 1 trial, 439 participants). However, the trial authors reported this effect only in the trial arm that received multiple micronutrients plus selenium (not either supplementation alone), which is inconsistent with the findings of other trials that used similar combinations of micronutrients and selenium.In one additional trial that compared high-dose multiple micronutrient supplementation with standard doses in people on ART, peripheral neuropathy was lower with high dose supplements compared to standard dose (incidence rate ratio (IRR) 0.81, 95% CI 0.7 to 0.94; 1 trial, 3418 participants), but the trial was stopped early due to increased adverse events (elevated alanine transaminase (ALT) levels) in the high dose group. Single or dual micronutrientsNone of the trials of single or dual micronutrient supplements were adequately powered to assess for effects on mortality or morbidity outcomes. No clinically significant changes in CD4 cell count (data not pooled, 14 trials, 2370 participants, very low or low certainty evidence) or viral load (data not pooled, seven studies, 1334 participants, very low or low certainty evidence), were reported. Supplementation probably does increase blood concentrations of vitamin D and zinc (data not pooled, vitamin D: 4 trials, 299 participants, zinc: 4 trials, 484 participants, moderate certainty evidence) and may also increase blood concentrations of vitamin A (data not pooled, 3 trials, 495 participants, low certainty evidence), especially in those who are deficient.

AUTHORS' CONCLUSIONS

The analyses of the available trials have not revealed consistent clinically important benefits with routine multiple micronutrient supplementation in people living with HIV. Larger trials might reveal small but important effects.These findings should not be interpreted as a reason to deny micronutrient supplements for people living with HIV where specific deficiencies are found or where the person's diet is insufficient to meet the recommended daily allowance of vitamins and minerals.

Role of divalent metals in infectious disease susceptibility and outcome

BACKGROUND

Divalent metals play important roles in maintaining metabolism and cellular growth of both eukaryotic hosts and invading microbes. Both metal deficiency and overload can result in abnormal cellular function or damage. Given its central role in host-pathogen interactions, subtle alterations of divalent metal homeostasis can occur in the course of infectious diseases which aim, from the host perspective, either to reduce the availability of respective metals to microbes or to use toxic metal accumulation to eliminate pathogens.

AIMS

To provide the reader with background information and clinical data on divalent metal homeostasis in host-pathogen interactions, how this affects the course of infectious disease and whether correction of metal disturbances has shown benefit in infections.

SOURCES

An in-depth analysis of PubMed articles related to the topic of this review published in English between 1970 and 2016 was performed.

CONTENT

From the microbial perspective, divalent metals are essential for growth and pathogenicity and to mount effective protection against antimicrobial host responses, including toxic radical formation. Microbes have evolved multiple strategies to control their access to divalent metals. From the clinical perspective, alterations of divalent metal levels may result in increased or decreased susceptibility to infection and often occur in response to infections. However, keeping in mind the strategies underlying such alterations, for which the term 'nutritional immunity' was coined, the uncritical correction of such divalent metal imbalances may cause harm to patients. This review addresses the role of the divalent metals iron, selenium, zinc, manganese and copper in infectious diseases from a mechanistic and clinical perspective.

IMPLICATIONS

We point out areas of research needed to expand our limited knowledge, hoping to improve the clinical management of patients with infections and to identify promising new targets for treatment by modulation of host or microbe divalent metal metabolism.

Oral zinc for treating diarrhoea in children

BACKGROUND

In developing countries, diarrhoea causes around 500,000 child deaths annually. Zinc supplementation during acute diarrhoea is currently recommended by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF).

OBJECTIVES

To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library 2016, Issue 5), MEDLINE, Embase, LILACS, CINAHL, mRCT, and reference lists up to 30 September 2016. We also contacted researchers.

SELECTION CRITERIA

Randomized controlled trials (RCTs) that compared oral zinc supplementation with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery.

DATA COLLECTION AND ANALYSIS

Both review authors assessed trial eligibility and risk of bias, extracted and analysed data, and drafted the review. The primary outcomes were diarrhoea duration and severity. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses (using either a fixed-effect or random-effects model) and assessed heterogeneity.We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

Thirty-three trials that included 10,841 children met our inclusion criteria. Most included trials were conducted in Asian countries that were at high risk of zinc deficiency. Acute diarrhoeaThere is currently not enough evidence from well-conducted RCTs to be able to say whether zinc supplementation during acute diarrhoea reduces death or number of children hospitalized (very low certainty evidence).In children older than six months of age, zinc supplementation may shorten the average duration of diarrhoea by around half a day (MD -11.46 hours, 95% CI -19.72 to -3.19; 2581 children, 9 trials, low certainty evidence), and probably reduces the number of children whose diarrhoea persists until day seven (RR 0.73, 95% CI 0.61 to 0.88; 3865 children, 6 trials, moderate certainty evidence). In children with signs of malnutrition the effect appears greater, reducing the duration of diarrhoea by around a day (MD -26.39 hours, 95% CI -36.54 to -16.23; 419 children, 5 trials, high certainty evidence).Conversely, in children younger than six months of age, the available evidence suggests zinc supplementation may have no effect on the mean duration of diarrhoea (MD 5.23 hours, 95% CI -4.00 to 14.45; 1334 children, 2 trials, moderate certainty evidence), or the number of children who still have diarrhoea on day seven (RR 1.24, 95% CI 0.99 to 1.54; 1074 children, 1 trial, moderate certainty evidence).None of the included trials reported serious adverse events. However, zinc supplementation increased the risk of vomiting in both age groups (children greater than six months of age: RR 1.57, 95% CI 1.32 to 1.86; 2605 children, 6 trials, moderate certainty evidence; children less than six months of age: RR 1.54, 95% CI 1.05 to 2.24; 1334 children, 2 trials, moderate certainty evidence). Persistent diarrhoeaIn children with persistent diarrhoea, zinc supplementation probably shortens the average duration of diarrhoea by around 16 hours (MD -15.84 hours, 95% CI -25.43 to -6.24; 529 children, 5 trials, moderate certainty evidence).

AUTHORS' CONCLUSIONS

In areas where the prevalence of zinc deficiency or the prevalence of malnutrition is high, zinc may be of benefit in children aged six months or more. The current evidence does not support the use of zinc supplementation in children less six months of age, in well-nourished children, and in settings where children are at low risk of zinc deficiency.

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.

Dual targeting of the thioredoxin and glutathione systems in cancer and HIV

Although the use of antioxidants for the treatment of cancer and HIV/AIDS has been proposed for decades, new insights gained from redox research have suggested a very different scenario. These new data show that the major cellular antioxidant systems, the thioredoxin (Trx) and glutathione (GSH) systems, actually promote cancer growth and HIV infection, while suppressing an effective immune response. Mechanistically, these systems control both the redox- and NO-based pathways (nitroso-redox homeostasis), which subserve innate and cellular immune defenses. Dual inhibition of the Trx and GSH systems synergistically kills neoplastic cells in vitro and in mice and decreases resistance to anticancer therapy. Similarly, the population of HIV reservoir cells that constitutes the major barrier to a cure for AIDS is exquisitely redox sensitive and could be selectively targeted by Trx and GSH inhibitors. Trx and GSH inhibition may lead to a reprogramming of the immune response, tilting the balance between the immune system and cancer or HIV in favor of the former, allowing elimination of diseased cells. Thus, therapies based on silencing of the Trx and GSH pathways represent a promising approach for the cure of both cancer and AIDS and warrant further investigation.

The efficacy of micronutrient-fortified sorghum meal in improving the immune status of HIV-positive adults

BACKGROUND

Micronutrient deficiencies are common and compound the effects of human immunodeficiency virus (HIV) infection in Africa. Nutritional interventions, particularly vitamin A supplementation, may improve immune functioning and delay disease progression.

AIM

To investigate the effect of fortified sorghum meal provided for 12 months on the immune status of adults with HIV.

METHODS

HIV-infected men and women were enrolled in a double-blind randomized placebo-controlled trial in Kanye, Botswana, to receive either sorghum meal fortified with micronutrients including vitamin A (n = 67) or control (n = 65). Serum retinol, iron, zinc, albumin, CD4 cell count and HIV viral load were assessed at baseline and every 3 months.

RESULTS

Baseline serum retinol levels were 1.6 µmol/l in both groups and no significant difference was observed at the end of the intervention (control group: 1.5 µmol/l; experimental group: 1.6 µmol/l). In addition, there was no significant difference in the mean (Q1, Q3) CD4 cell count; 348 (220, 456) cells/mm(3) for the control group versus 338 (228, 426) cells/mm(3) in the experimental group after intervention.

CONCLUSION

In this study, fortified sorghum meal did not influence serum retinol, CD4 cell count and HIV viral load. Future intervention studies should carefully consider the composition and dosing of food supplements needed to improve immune status and delay disease progression.

Oral zinc for treating diarrhoea in children

BACKGROUND

In developing countries, diarrhoea causes around two million child deaths annually. Zinc supplementation during acute diarrhoea is currently recommended by the World Health Organization and UNICEF.

OBJECTIVES

To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea.

SEARCH METHODS

In February 2012, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2011, Issue 11), MEDLINE, EMBASE, LILACS, CINAHL, mRCT, and reference lists. We also contacted researchers.

SELECTION CRITERIA

Randomized controlled trials comparing oral zinc supplementation with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery.

DATA COLLECTION AND ANALYSIS

Both authors assessed trial eligibility and risk of bias, extracted and analysed data, and drafted the review. Diarrhoea duration and severity were the primary outcomes. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses (using the fixed- or random-effects model) and assessed heterogeneity.The quality of evidence has been assessed using the GRADE methods

MAIN RESULTS

Twenty-four trials, enrolling 9128 children, met our inclusion criteria. The majority of the data is from Asia, from countries at high risk of zinc deficiency, and may not be applicable elsewhere. Acute diarrhoea. There is currently not enough evidence from well conducted randomized controlled trials to be able to say whether zinc supplementation during acute diarrhoea reduces death or hospitalization (very low quality evidence).In children aged greater than six months with acute diarrhoea, zinc supplementation may shorten the duration of diarrhoea by around 10 hours (MD -10.44 hours, 95% CI -21.13 to 0.25; 2175 children, six trials, low quality evidence), and probably reduces the number of children whose diarrhoea persists until day seven (RR 0.73, 95% CI 0.61 to 0.88; 3865 children, six trials, moderate quality evidence). In children with signs of moderate malnutrition the effect appears greater, reducing the duration of diarrhoea by around 27 hours (MD -26.98 hours, 95% CI -14.62 to -39.34; 336 children, three trials, high quality evidence).Conversely, In children aged less than six months, the available evidence suggests zinc supplementation may have no effect on mean diarrhoea duration (MD 5.23 hours, 95% CI -4.00 to 14.45; 1334 children, two trials, low quality evidence), and may even increase the proportion of children whose diarrhoea persists until day seven (RR 1.24, 95% CI 0.99 to 1.54; 1074 children, one trial, moderate quality evidence).No trials reported serious adverse events, but zinc supplementation during acute diarrhoea causes vomiting in both age groups (RR 1.59, 95% 1.27 to 1.99; 5189 children, 10 trials, high quality evidence). Persistent diarrhoea. In children with persistent diarrhoea, zinc supplementation probably shortens the duration of diarrhoea by around 16 hours (MD -15.84 hours, 95% CI -25.43 to -6.24; 529 children, five trials, moderate quality evidence).

AUTHORS' CONCLUSIONS

In areas where the prevalence of zinc deficiency or the prevalence of moderate malnutrition is high, zinc may be of benefit in children aged six months or more.The current evidence does not support the use of zinc supplementation in children below six months of age.

Oral zinc for treating diarrhoea in children

BACKGROUND

In developing countries, diarrhoea causes around two million child deaths annually. Zinc supplementation during acute diarrhoea is currently recommended by the World Health Organization and UNICEF.

OBJECTIVES

To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea.

SEARCH METHODS

In February 2012, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2011, Issue 11), MEDLINE, EMBASE, LILACS, CINAHL, mRCT, and reference lists. We also contacted researchers.

SELECTION CRITERIA

Randomized controlled trials comparing oral zinc supplementation with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery.

DATA COLLECTION AND ANALYSIS

Both authors assessed trial eligibility and risk of bias, extracted and analysed data, and drafted the review. Diarrhoea duration and severity were the primary outcomes. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses (using the fixed- or random-effects model) and assessed heterogeneity.The quality of evidence has been assessed using the GRADE methods

MAIN RESULTS

Twenty-four trials, enrolling 9128 children, met our inclusion criteria. The majority of the data is from Asia, from countries at high risk of zinc deficiency, and may not be applicable elsewhere.Acute diarrhoeaThere is currently not enough evidence from well conducted randomized controlled trials to be able to say whether zinc supplementation during acute diarrhoea reduces death or hospitalization (very low quality evidence).In children aged greater than six months with acute diarrhoea, zinc supplementation may shorten the duration of diarrhoea by around 10 hours (MD -10.44 hours, 95% CI -21.13 to 0.25; 2091 children, five trials, low quality evidence), and probably reduces the number of children whose diarrhoea persists until day seven (RR 0.73, 95% CI 0.61 to 0.88; 3865 children, six trials, moderate quality evidence). In children with signs of moderate malnutrition the effect appears greater, reducing the duration of diarrhoea by around 27 hours (MD -26.98 hours, 95% CI -14.62 to -39.34; 336 children, three trials, high quality evidence).Conversely, In children aged less than six months, the available evidence suggests zinc supplementation may have no effect on mean diarrhoea duration (MD 5.23 hours, 95% CI -4.00 to 14.45; 1334 children, two trials, low quality evidence), and may even increase the proportion of children whose diarrhoea persists until day seven (RR 1.24, 95% CI 0.99 to 1.54; 1074 children, one trial, moderate quality evidence).No trials reported serious adverse events, but zinc supplementation during acute diarrhoea causes vomiting in both age groups (RR 1.59, 95% 1.27 to 1.99; 5189 children, 10 trials, high quality evidence).Persistent diarrhoeaIn children with persistent diarrhoea, zinc supplementation probably shortens the duration of diarrhoea by around 16 hours (MD -15.84 hours, 95% CI -25.43 to -6.24; 529 children, five trials, moderate quality evidence).

AUTHORS' CONCLUSIONS

In areas where the prevalence of zinc deficiency or the prevalence of moderate malnutrition is high, zinc may be of benefit in children aged six months or more.The current evidence does not support the use of zinc supplementation in children below six months of age.

Nutrition and disease progression pre-highly active antiretroviral therapy (HAART) and post-HAART: can good nutrition delay time to HAART and affect response to HAART?

Several studies have investigated a variety of nutritional supplementation interventions in adults with HIV. In this narrative review, we summarize the evidence from 31 clinical trials that explore clinical benefits of macronutrient and micronutrient supplementation in this population while attempting to answer the question of whether good nutrition can delay the time to highly active antiretroviral therapy (HAART) initiation and response. We focused on trials published in English between 1990 and 2010 that reported on CD4 count, viral load, and disease progression or survival. Among 9 macronutrient and 22 micronutrient trials, we found that evidence for improved CD4 count and HIV viral load with nutritional supplementation was limited; only 11.1% and 36.8% of macronutrient and micronutrient supplementation trials, respectively, reported improved CD4 count; and 33.3% and 12.5% of macronutrient and micronutrient trials, respectively, reported decreased viral load. Given their utility as surrogate markers of HIV disease progression, this suggests limited evidence for nutritional interventions having an impact on delaying HAART initiation or on improving HAART response. However, there are challenges in evaluating the effects of nutritional supplementation on clinical disease in that comparisons are difficult due to heterogeneity in study design, patient population, nutrient doses and combinations, baseline levels of deficiency, and study endpoints, including lack of clarity in defining and reporting HAART status. Future studies need to adopt a more rigorous standard design with adequate power and follow-up and require a consensus on composition and dose of nutrient interventions to be tested to more specifically answer the question on the impact of nutritional interventions on HIV disease progression and HAART response.

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. 

Selenium deficiency and HIV infection

Selenium is a non-metallic chemical element of great important to human health. Low selenium levels in humans are associated with several pathological conditions and are a common finding in HIV infected individuals. We conducted a review of the literature to assess if selenium deficiency or selenium supplementation could play a role in modifying the clinical course of HIV disease. Several studies investigated the role of selenium in disease progression, morbidity and mortality in HIV infected individuals. Larger studies were conducted in countries with poor economic resources and limited access to HAART. According to the majority of published studies low selenium levels appear to have an association with mortality, and selenium supplementation appears to play a beneficial role on survival or on slowing disease progression among HIV infected individuals. The role of selenium supplementation on preventing hospital admission among HIV outpatients was also noticed. The literature suggests an association between selenium deficiency and development of HIV associated cardiomyopathy and furthermore, selenium supplementation appears to improve the cardiac function in HIV infected individuals with cardiomyopathy. However, there is conflicting evidence regarding the role selenium in modifying HIV viral load and immune status in HIV infection.

Role of selenium in HIV infection

HIV infection is a global disease that disproportionately burdens populations with nutritional vulnerabilities. Laboratory experiments have shown that selenium has an inhibitory effect on HIV in vitro through antioxidant effects of glutathione peroxidase and other selenoproteins. Numerous studies have reported low selenium status in HIV-infected individuals, and serum selenium concentration declines with disease progression. Some cohort studies have shown an association between selenium deficiency and progression to AIDS or mortality. In several randomized controlled trials, selenium supplementation has reduced hospitalizations and diarrheal morbidity, and improved CD4(+) cell counts, but the evidence remains mixed. Additional trials are recommended to study the effect of selenium supplementation on opportunistic infections, and other HIV disease-related comorbidities in the context of highly active antiretroviral therapy in both developing and developed countries.

Micronutrients, N-acetyl cysteine, probiotics and prebiotics, a review of effectiveness in reducing HIV progression

Low serum concentrations of micronutrients, intestinal abnormalities, and an inflammatory state have been associated with HIV progression. These may be ameliorated by micronutrients, N-acetyl cysteine, probiotics, and prebiotics. This review aims to integrate the evidence from clinical trials of these interventions on the progression of HIV. Vitamin B, C, E, and folic acid have been shown to delay the progression of HIV. Supplementation with selenium, N-acetyl cysteine, probiotics, and prebiotics has considerable potential, but the evidence needs to be further substantiated. Vitamin A, iron, and zinc have been associated with adverse effects and caution is warranted for their use.

Selenium supplementation in HIV-infected patients: is there any potential clinical benefit?

In HIV-infected patients undergoing antiretroviral therapy, the question of whether selenium supplementation has any therapeutic benefit is still open. With recent popular coverage of this issue, many patients have considered using selenium. Clinicians have a duty to ensure that the recommendations they make to their patients are evidence based. The literature search reported here showed that evidence to support standard selenium supplementation in patients with HIV is both limited and insufficient. To definitively answer this clinical question, the overall effect of selenium supplementation would need to be evaluated in a large randomized, controlled trial with solid methodology and strong internal validity. Although the available evidence for selenium supplementation is weak, its low toxicity and side effect profile seem to pose minimal risks, especially at low doses. For patients who want to add selenium to their regimen, discussing the potential risks and benefits as well as close follow-up is warranted.

Oral zinc for treating diarrhoea in children

BACKGROUND

Diarrhoea causes around two million child deaths annually. Zinc supplementation could help reduce the duration and severity of diarrhoea, and is recommended by the World Health Organization and UNICEF.

OBJECTIVES

To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea.

SEARCH STRATEGY

In November 2007, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2007, Issue 4), MEDLINE, EMBASE, LILACS, CINAHL, mRCT, and reference lists. We also contacted researchers.

SELECTION CRITERIA

Randomized controlled trials comparing oral zinc supplementation (>/= 5 mg/day for any duration) with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery.

DATA COLLECTION AND ANALYSIS

Both authors assessed trial eligibility and methodological quality, extracted and analysed data, and drafted the review. Diarrhoea duration and severity were the primary outcomes. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses (using the fixed- or random-effects model) and assessed heterogeneity.

MAIN RESULTS

Eighteen trials enrolling 6165 participants met our inclusion criteria. In acute diarrhoea, zinc resulted in a shorter diarrhoea duration (MD -12.27 h, 95% CI -23.02 to -1.52 h; 2741 children, 9 trials), and less diarrhoea at day three (RR 0.69, 95% CI 0.59 to 0.81; 1073 children, 2 trials), day five (RR 0.55, 95% CI 0.32 to 0.95; 346 children, 2 trials), and day seven (RR 0.71, 95% CI 0.52 to 0.98; 4087 children, 7 trials). The four trials (1458 children) that reported on diarrhoea severity used different units and time points, and the effect of zinc was less clear. Subgroup analyses by age (trials with only children aged less than six months) showed no benefit with zinc. Subgroup analyses by nutritional status, geographical region, background zinc deficiency, zinc type, and study setting did not affect the results' significance. Zinc also reduced the duration of persistent diarrhoea (MD -15.84 h, 95% CI -25.43 to -6.24 h; 529 children, 5 trials). Few trials reported on severity, and results were inconsistent. No trial reported serious adverse events, but vomiting was more common in zinc-treated children with acute diarrhoea (RR 1.71, 95% 1.27 to 2.30; 4727 children, 8 trials).

AUTHORS' CONCLUSIONS

In areas where diarrhoea is an important cause of child mortality, research evidence shows zinc is clearly of benefit in children aged six months or more.

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.

Care and treatment of HIV-infected children in Africa: issues and challenges at the district hospital level

More than 90% of pediatric HIV infection occurs in sub-Saharan Africa and 75% of these children currently die before their fifth birthday. Most HIV-infected children in Africa rely on district hospitals for HIV treatment, but insufficient attention has been paid to improving HIV/AIDS care at this level. Considerable confusion exists about optimal use of combination antiretroviral treatment, prophylaxis for opportunistic infections and other rational healthcare interventions that can greatly improve the quality of life for these children. A simple and inexpensive infant HIV diagnostic assay and alternative laboratory markers of pediatric HIV disease progression would be highly beneficial. Routine anthropometric and neurodevelopmental assessments could help guide initiation and monitoring of antiretroviral therapy. Even in the absence of antiretroviral therapy, interventions such as immunizations, provision of micronutrients and nutrition counseling, prevention and treatment of opportunistic as well as endemic infections (such as helminths and malaria) can substantially reduce pediatric HIV-related morbidity and mortality. The need for pain relief, palliative care, counseling and emotional support is often underestimated. Surmounting the sense of hopelessness by providing district healthcare workers with training in basic pediatric HIV/AIDS care is an urgent priority.

Micronutrient interventions and HIV infection: a review of current evidence

OBJECTIVE

To review the current evidence on the role of micronutrient supplementation in HIV transmission and progression.

METHOD

Literature review.

RESULTS

The importance of micronutrients in the prevention and treatment of childhood infections is well known, and evidence is emerging that micronutrient interventions may also affect HIV transmission and progression.

CONCLUSION

Interventions to improve micronutrient intake and status could contribute to a reduction in the magnitude and impact of the global HIV epidemic. However, more research is needed before specific recommendations can be made.

Effects of vitamins, including vitamin A, on HIV/AIDS patients

An estimated 25 million lives have been lost to acquired immune-deficiency syndrome (AIDS) since the immunodeficiency syndrome was first described in 1981. The progress made in the field of treatment in the form of antiretroviral therapy (ART) for HIV disease/AIDS has prolonged as well as improved the quality of life of HIV-infected individuals. However, access to such treatment remains a major concern in most parts of the world, especially in the developing countries. Hence, there is a constant need to find low-cost interventions to complement the role of ART in prevention of HIV infection and slowing clinical disease progression. Nutritional interventions, particularly vitamin supplementation, have the potential to be a low-cost method for being such an intervention by virtue of their modulation of the immune system. Among all the vitamins, the role of vitamin A has been studied most extensively; most observational studies have found that low vitamin A levels are associated with increased risk of transmission of HIV from mother to child. This finding has not been supported by large randomized trials of vitamin A supplementation; on the contrary, these trials have found that vitamin A supplementation increases the risk of mother-to-child transmission (MTCT). There are a number of potential mechanisms that might explain these contradictory findings. One is the issue of reverse causality in observational studies-for instance, advanced HIV disease may suppress release of vitamin A from the liver. This would lead to low levels of vitamin A in the plasma despite the body having enough vitamin A liver stores. Further, advanced HIV disease is likely to increase the risk of MTCT, and hence it would appear that low serum vitamin A levels are associated with increased MTCT. The HIV genome also has a retinoic acid receptor element-hence, vitamin A may increase HIV replication via interacting with this element, thus increasing risk of MTCT. Finally, vitamin A is known to increase lymphoid cell differentiation, which leads to an increase in CCR5 receptors. These receptors are essential for attachment of HIV to the lymphocytes and therefore, an increase in their number is likely to increase HIV replication. Vitamin A supplementation in HIV-infected children, on the other hand, has been associated with protective effects against mortality and morbidity, similar to that seen in HIV-negative children. The risk for lower respiratory tract infection and severe watery diarrhea has been shown to be lower in HIV-infected children supplemented with vitamin A. All-cause mortality and AIDS-related deaths have also been found to be lower in vitamin A-supplemented HIV-infected children. The benefits of multivitamin supplementation, particularly vitamins B, C, and E, have been more consistent across studies. Multivitamin supplementation in HIV-infected pregnant mothers has been shown to reduce the incidence of adverse pregnancy outcomes such as fetal loss and low birth weight. It also has been shown to decrease rates of MTCT among women who have poor nutritional or immunologic status. Further, multivitamin supplementation reduces the rate of HIV disease progression among patients in early stage of disease, thus delaying the need for ART by prolonging the pre-ART stage. In brief, there is no evidence to recommend vitamin A supplementation of HIV-infected pregnant women; however, periodic vitamin A supplementation of HIV-infected infants and children is beneficial in reducing all-cause mortality and morbidity and is recommended. Similarly, multivitamin supplementation of people infected with HIV, particularly pregnant women, is strongly suggested.

Brief Report: Randomized Controlled Trial of Zinc Supplementation for Persistent Diarrhea in Adults With HIV-1 Infection

BACKGROUND

In children, zinc supplementation reduces the incidence and severity of diarrhea.

METHODS

HIV-infected adults with > or =7 days of diarrhea recruited at 3 tertiary hospitals in Lima, Peru, received a zinc sulfate capsule containing 50 mg of elemental zinc twice daily or an identical placebo for 14 days. Outcomes included persistence of diarrhea at day 14 and time until cessation of diarrhea.

RESULTS

The 81 subjects randomized to zinc and 78 randomized to placebo were comparable at baseline, except for higher prevalences of certain enteric pathogens in the zinc group; complete follow-up rates were 62% and 69%, respectively. Zinc concentrations were consistent with zinc deficiency at follow-up in 94% of placebo recipients and 66% of zinc recipients (P = 0.01). Persistence of diarrhea at day 14 according to follow-up interview (60% for zinc-treated patients and 57.4% for placebo-treated patients) or to patient diary (42.2% vs. 31.9%) did not differ significantly. Adjusting for enteric pathogens and CD4 count, the hazard ratio (HR) for zinc supplementation and cessation of diarrhea (according to the diaries) was 0.91 (95% confidence interval [CI]: 0.50 to 1.64).

CONCLUSION

Supplemental zinc had no significant effect on the duration or remission of diarrhea in HIV-infected adults.

Diarrhea in patients with AIDS

Diarrhea in patients with AIDS is a worldwide problem that can have a devastating impact on quality of life for the patient. Chronic diarrhea, usually defined as at least 4 weeks' duration, is more common in patients with low CD4-positive T-lymphocyte counts, signaling advanced immunosuppression. Some organisms, such as Microsporidia, usually cause diarrhea only in the immunosuppressed; others, such as Cryptosporidium, Salmonella, Shigella, and Campylobacter, which are capable of causing diarrhea in the immunocompetent population, produce more severe or prolonged infections in people living with AIDS. Familiarity with the most common pathogens in the clinician's region will help with diagnosis and treatment. Because treatment options vary widely depending upon the infectious agent, thorough microbiologic evaluation is warranted. A stepped diagnostic approach of stool cultures and specialized microscopy and stains for protozoa, followed by sigmoidoscopy or colonoscopy and duodenoscopy with biopsies for histopathological examination is recommended in all patients with persistent, disabling diarrhea who have a CD4 count of less than 200/mm3, and should be considered for those with higher counts on an individual basis. Treatment, tailored to the specific pathogen, may need to be prolonged in the most severely immunocompromised patients to prevent relapse or recrudescence. For patients taking antiretroviral therapy (especially protease inhibitors) in whom no infectious agent can be found, diarrhea may be due to the medications. Nonspecific antidiarrheal agents should be tried until one that suits the patient is found. The most essential component of any therapeutic strategy for a patient with AIDS-associated diarrhea is restoration of the underlying immunologic defect using highly active antiretroviral therapy.

Zinc supplementation to HIV-1-infected pregnant women: effects on maternal anthropometry, viral load, and early mother-to-child transmission

OBJECTIVE

To examine the effect of zinc supplementation to HIV-1-infected pregnant women on viral load, early mother-to-child transmission of HIV (MTCT), and wasting.

DESIGN

Double-blind placebo-controlled randomized clinical trial.

SETTING

Antenatal clinic in Dar es Salaam, Tanzania.

SUBJECTS

Four hundred HIV-1-infected pregnant women.

METHODS

Women 12-27 weeks of gestation were randomly assigned to receive a daily oral dose of 25 mg zinc or placebo from the day of the first prenatal visit until 6 weeks postdelivery. Weight and mid-upper arm circumference (MUAC) were measured monthly. HIV status of the babies was assessed at birth and at 6 weeks postpartum. Viral load was assessed in a random sample of 100 women at baseline and at the end of the study.

RESULTS

Zinc had no effects on maternal viral load or early MTCT. Supplementation was related to a significant threefold increase in the risk of wasting (reaching a MUAC value <22 cm) during an average 22 weeks of observation (RR=2.7, 95%CI=1.1, 6.4, P=0.03), and to a 4 mm decline in MUAC during the second trimester (P=0.02).

CONCLUSIONS

Zinc supplementation to HIV-infected pregnant women offers no benefits on viral load or MTCT. The clinical relevance of an apparent decrease in MUAC associated with zinc supplementation is yet to be ascertained. These findings together with the lack of effect on fetal outcomes (reported previously) do not provide support for the addition of zinc supplements to the standard of prenatal care among HIV-infected women.

Micronutrient supplementation in children and adults with HIV infection

BACKGROUND

The scale and impact of the HIV/AIDS pandemic has made the search for simple, affordable, safe, and effective public health interventions all the more urgent. Micronutrient supplements hold the promise of meeting these criteria, but their widespread use needs to be based on sound scientific evidence of effectiveness and safety.

OBJECTIVES

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

SEARCH STRATEGY

The Cochrane Library (CENTRAL), EMBASE, MEDLINE, AIDSearch, CINAHL, and conference proceedings were searched, and pharmaceutical manufacturers and researchers in the field were contacted to locate any ongoing or unpublished trials.

SELECTION CRITERIA

Randomised controlled trials comparing the effects of micronutrient supplements (vitamins, trace elements, and combinations of these) with placebo or no treatment on mortality and morbidity in HIV-infected individuals.

DATA COLLECTION AND ANALYSIS

Two reviewers independently appraised trial quality and extracted data. Study authors were contacted for additional data where necessary. A meta-analysis was not deemed appropriate due to significant heterogeneity between trials.

MAIN RESULTS

Fifteen trials were included. Six trials comparing vitamin A/beta-carotene with placebo in adults failed to show any effects on mortality, morbidity, CD4 and CD8 counts, or on viral load. Four trials of other micronutrients in adults did not affect overall mortality, although there was a reduction in mortality in a low CD4 subgroup. In a large Tanzanian trial in pregnant and lactating women, daily multivitamin supplementation was associated with a number of benefits to both mothers and children: a reduction in maternal mortality from AIDS-related causes; a reduced risk of progression to stage four disease; fewer adverse pregnancy outcomes; less diarrhoeal morbidity; and a reduction in early-child mortality among immunologically- and nutritionally-compromised women. Vitamin A alone reduced all-cause mortality and improved growth in a small sub-group of HIV-infected children in one hospital-based trial, and reduced diarrhoea-associated morbidity in a small HIV-infected sub-group of infants in another trial.

AUTHORS' CONCLUSIONS

There is no conclusive evidence at present to show that micronutrient supplementation effectively reduces morbidity and mortality among HIV-infected adults. It is reasonable to support the current WHO recommendations to promote and support adequate dietary intake of micronutrients at RDA levels wherever possible. There is evidence of benefit of vitamin A supplementation in children. The long-term clinical benefits, adverse effects, and optimal formulation of micronutrient supplements require further investigation.

Studies of vitamins and minerals and HIV transmission and disease progression

HIV-1 infection is having a devastating impact on people in developing countries. Poor nutrition and HIV-related adverse health outcomes contribute to a vicious cycle that may be slowed down by using nutritional interventions, including vitamins and minerals. Among children, periodic supplementation with vitamin A starting at 6 mo of age has been shown to be beneficial in reducing mortality and morbidity among both HIV-infected and uninfected children. Limited data exist on the role of other nutrient supplements among children. Among HIV-infected adults, the safety and the efficacy of vitamin A supplements need further study, although adequate dietary intake of this essential nutrient is recommended. Multivitamin supplements were efficacious in reducing adverse pregnancy outcomes and early childhood infections, and is currently provided to pregnant HIV-infected pregnant women in many programs. The efficacy of such supplements among HIV-negative pregnant women needs further study. Daily multivitamin supplements were found to reduce HIV disease progression among men and women in several observational studies and randomized trials, and to provide an important low-cost intervention that could be provided to adults in early stages of HIV disease to prolong the time before antiretroviral therapy is recommended. Next, research priorities include examining the roles of minerals, including selenium, in HIV infection, as well as determining the safety and the efficacy of micronutrient supplements among individuals who are advanced in their disease and who are receiving antiretroviral therapy.

Nitazoxanide for persistent diarrhoea in Zambian acquired immune deficiency syndrome patients: a randomized-controlled trial

BACKGROUND

Adults with acquired immune deficiency syndrome and persistent diarrhoea in Zambia have intestinal infection, predominantly protozoa.

AIM

To search for treatment which can be offered with minimal investigation, we carried out a double-blind, randomized-controlled trial of nitazoxanide (a drug with a range of activity against parasites and bacteria).

METHODS

Patients with diarrhoea of 1 month duration or longer were randomized to receive nitazoxanide (1000 mg twice daily) or placebo for 2 weeks. End-points were clinical response, parasitological clearance and mortality.

RESULTS

Two hundred and seven adults were randomized; 42 died during the study. The primary assessment of efficacy was made after 17 days. Clinical response was observed in 56 (75%) of 75 patients receiving nitazoxanide and 45 (58%) of 77 patients receiving placebo (P = 0.03). The rate of improvement was markedly higher in patients with CD4 counts under 50 cells/microL receiving nitazoxanide (P = 0.007). The benefit was largely restricted to the period when the drug was being administered. No difference was seen in parasitological clearance between the two groups. Mortality was 19% by 4 weeks of follow-up and did not differ with treatment allocation.

CONCLUSIONS

Nitazoxanide given orally for 14 days was associated with clinical improvement in Zambian acquired immune deficiency syndrome patients with diarrhoea, especially those with very low CD4 counts.

RXR-induced TNF-alpha suppression is reversed by morphine in activated U937 cells

Deficiency in vitamin A has been associated with adverse clinical outcomes in drug users with HIV-1 infection. Retinoids have been demonstrated to suppress proinflammatory cytokine production by immune cells in vitro. These effects are induced by ligand-mediated activation of the retinoid receptors--retinoic acid receptor (RAR) and retinoid X receptor (RXR). In these studies, the effects of all-trans-retinoid acid (ATRA, a RAR agonist), 9-cis-retinoic acid (9cis RA; RAR and RXR agonist), LG101305 (RXR agonist), LG100815 (RAR antagonist) and LG101208 (RXR antagonist) on TNF-alpha production by phytohemagglutanin-activated U937 cells and the modulation of these effects by morphine were examined. TNF-alpha production was suppressed in all cultures exposed to retinoid agonist and antagonist agents. For cells exposed to RXR agonists or RAR antagonist, incubation with morphine resulted in the reversal of TNF-alpha suppression and this effect was inhibited by naloxone. These data suggest that interactions between RXR and morphine are involved in the immune effects of retinoids on TNF-alpha production by activated U937 cells. Such information may be important for understanding interactions between drugs of abuse and immune function in individuals with chronic proinflammatory states such as HIV-1 infection.

Plasma vitamin A and zinc levels in HIV-infected adults in Cape Town, South Africa

A cross-sectional study of 132 adults attending an HIV clinic in Cape Town, South Africa, was conducted to determine predictors of low plasma vitamin A and Zn levels. No patients were on antiretroviral therapy. The possible confounding effect of the acute-phase response was controlled by including C-reactive protein levels in multivariate analysis and by excluding active opportunistic infections. Retinol levels were low (<1.05 micromol/l) in 39 % of patients with early disease (WHO clinical stages I and II) compared with 48 and 79 % of patients with WHO stage III and IV respectively (P<0.01). Plasma Zn levels were low (<10.7 micromol/l) in 20 % of patients with early disease v. 36 and 45 % with stage III and IV disease respectively (P<0.05). C-reactive protein levels were normal in 63 % of subjects. Weak, positive associations were found between CD4+ lymphocyte count and plasma levels of retinol (r 0.27; 95 % CI 0.1, 0.43) and Zn (r 0.31; 95 % CI 0.25, 0.46). Multivariate analysis showed the following independent predictors of low retinol levels: WHO stage IV (odds ratio 3.4; 95 % CI 2.1, 5.7) and body weight (odds ratio per 5 kg decrease 1.15; 95 % CI, 1.08, 1.25), while only body weight was significantly associated with low Zn levels (OR per 5 kg decrease 1.19; 95 % CI 1.09, 1.30). CD4+ lymphocyte count <200/microl was not significantly associated with either low retinol or Zn levels. In resource-poor settings, simple clinical features (advanced disease and/or weight loss) are associated with lowered blood concentrations of vitamin A and/or Zn. The clinical significance of low plasma retinol and/or Zn levels is unclear and more research is required to establish the role of multiple micronutrient intervention strategies in HIV disease.

Morbidity and nutritional impairment in relation to CD4 count in a Zambian population with high HIV prevalence

The HIV epidemic has greatly increased morbidity in many African cities and severe undernutrition is a prominent feature of the clinical presentation. However, there is little information about the relationship of morbidity or nutritional status to immune damage at a population level. We report a cross-sectional study of morbidity and nutritional status in relation to CD4 count in an impoverished urban community in Lusaka, Zambia, at enrollment into a longitudinal study. Over a 2 month period in 1999, 261 (52%) of 506 adults resident in one area were interviewed and examined. Of 186 adults who consented to testing, 33 (51%) of 65 who were HIV seropositive reported symptoms of disease compared to 39 (32%) of 121 who were HIV seronegative (OR 2.2, 95%CI 1.1-4.2; P=0.02). Peripheral blood CD4 counts in HIV seronegative individuals were broadly similar to norms in developed countries, but 8 (7%) had CD4 counts below 500 cells/microl. Morbidity in HIV seropositive adults was dominated by tuberculosis (n=11), other respiratory infections (5) or persistent diarrhoea (4), and affected individuals had a wide range of CD4 counts. Nutritional impairment was evident in HIV seropositive adults with clinical evidence of opportunistic infection (OI), not those with asymptomatic HIV infection. Unexpectedly, we also noted that systolic blood pressure was reduced progressively in HIV infection and in those with OI. In conclusion, HIV-related morbidity was dominated by a small number of treatable infectious diseases occurring over a wide range of CD4 count. Nutritional impairment was associated with OI.

Improved methods and assumptions for estimation of the HIV/AIDS epidemic and its impact: Recommendations of the UNAIDS Reference Group on Estimates, Modelling and Projections

UNAIDS and WHO produce biannual country-specific estimates of HIV/AIDS and its impact. These estimates are based on methods and assumptions that reflect the best understanding of HIV epidemiology and demography at the time. Where significant advances are made in epidemiological and demographic research, the methods and assumptions must evolve to match these advances. UNAIDS established an Epidemiology Reference Group in 1999 to advise them and other organisations on HIV epidemiology and methods for making estimates and projections of HIV/AIDS. During the meeting of the reference group in 2001, four priority areas were identified where methods and assumptions should be reviewed and perhaps modified: a) models of the HIV epidemic, b) survival of adults with HIV-1 in low and middle income countries, c) survival of children with HIV-1 in low and middle income countries, and d) methods to estimate numbers of AIDS orphans. Research and literature reviews were carried out by Reference Group members and invited specialists, prior to meetings held during 2001-2. Recommendations reflecting the consensus of the meeting participants on the four priority areas were determined at each meeting. These recommendations were followed in UNAIDS and WHO development of country-specific estimates of HIV/AIDS and its impact for end of 2001.

HIV: effectiveness of complementary and alternative medicine

Outcome studies examining the efficacy of CAM among people living with HIV-AIDS are often conducted among small sample sizes with very little follow-up data or time points. Generalizability of many of the study findings is further limited by participant attrition. It is difficult to conduct clinical studies on chronically ill patients without participants dropping out, typically because the study demands coupled with their illness become too burdensome. Several studies have been conducted that include control groups, double-blind designs, and randomization. These scientifically sound studies have demonstrated promising results that strongly indicate a need for further research with larger samples in a prospective research design so that safety and efficacy can be determined over time. Many of the studies with small sample sizes reported trends, but did not find statistical significance. Increasing sample sizes in future studies is necessary to evaluate the scientific merit of these trends. Moreover, researchers need to evaluate the clinical and statistical significance in CAM use. The psychologic benefits of taking CAM should not be underestimated. For the purposes of this article, the authors did not include psychologic outcomes; however, there is evidence suggesting that decreasing depression can decrease HIV-related somatic complaints [69]. Studies need also to examine the effectiveness of CAM on psychologic outcomes and physical outcomes. This article and the authors' own research (Gore-Felton C et al, unpublished data) have revealed a high prevalence of alternative supplement use in conjunction with HIV medication, indicating an urgent need to understand the health benefits and the health risks of alternative supplements among patients with HIV and AIDS. Patients and physicians need more empirically based research to examine the toxicities, interactions, and health benefits of CAM. Many patients do not report the use of CAM to their physicians and very few physicians record treatments in the clinical record [70]. This will likely change as CAM becomes more widely recognized as a legitimate medical intervention; however, controlled outcome studies among large, diverse samples of people living with HIV-AIDS are needed. Health care providers need to assess the use of herbal and alternative therapy practices by their patients. Some patients may not be aware that they are taking a supplement or plant-based herb. Furthermore, some patients may believe that they are using something innocuous and even healthy simply because it came from a health food store. Understanding the contraindications of alternative therapies is necessary to prevent deleterious outcomes and to facilitate the safe and efficacious use of CAM in the management of HIV disease and related symptoms. As the epidemic in the United States continues to rise among women and minority populations, clinical research trials must include ethnically diverse patient populations that are gender balanced. Current available studies indicate that many CAM interventions may improve the quality of life of people living with HIV-AIDS; however, further studies using longitudinal, controlled designs are needed to accurately assess the safety of such interventions.

Albendazole chemotherapy for AIDS-related diarrhoea in Zambia--clinical, parasitological and mucosal responses

BACKGROUND

Albendazole reduces diarrhoea in African AIDS patients, but it is unclear if the clinical response to treatment reflects pathogen eradication and/or mucosal recovery.

METHODS

Adults with HIV-related persistent diarrhoea were treated with albendazole 800 mg twice daily for 14 days. Clearance of parasites was evaluated at 3 and 6 weeks by stool microscopy. At baseline and at 6 weeks duodenal biopsies were taken for electron microscopy (EM) and morphometry.

RESULTS

Ten (7%) of 153 patients had cryptosporidiosis, 54 (37%) had isosporiasis and 23 (16%) had microsporidiosis. By 3 weeks, these protozoa were cleared in 27 (46%) of 59 patients initially positive. By 6 weeks, 34 (39%) of 87 patients experienced complete clinical response, 18 (21%) partial response and 35 (40%) no response. Crypt depth increased by 15% over 6 weeks (P < 0.001), but villous height increased only in patients with complete response (median + 50 microm, interquartile range (IQR) 2-90, compared to patients with partial (+ 4 microm, IQR -15,41) or no response (-13 microm, IQR -2,12; P=0.008)). Fifteen patients died: body mass index < 17.5 kg/m(2) and crypt depth < 180 microm independently predicted death.

CONCLUSIONS

Albendazole therapy reduced the burden of protozoal infection and promoted mucosal recovery in patients with a complete clinical response.

Micronutrients and child health: studies in international nutrition and HIV infection

Increasing data link micronutrient deficiencies to excess childhood morbidity and mortality, and similar relationships have been noted in the study of nutrition and HIV infection. We review epidemiologic studies that have examined the relationship between micronutrient deficiencies and health outcomes in childhood and HIV infection, as well as clinical trials of micronutrient supplementation. Vitamin A supplementation among communities at risk of deficiency effectively reduces mortality and morbidity in children younger than age 5, and vitamin A may be especially effective in HIV-infected children. Vertical transmission of HIV has not to date been affected by maternal micronutrient supplementation. In children with poor dietary zinc intake and/or bioavailability, zinc supplementation reduces the incidence and severity of diarrheal diseases, as well as the occurrence of pneumonia. Vitamin A therapy has not been associated with improved growth, whereas some trials have shown that zinc supplementation is associated with greater increments in height. Further trials of micronutrient supplementation are warranted.

Post-infective diarrhoea

When diarrhoea caused by gastroenteritis persists for more than two weeks it is referred to as persistent diarrhoea in developing countries. Whilst the Control of Diarrhoeal Diseases programme has decreased mortality from acute diarrhoea, mortality from persistent diarrhoea has not been so responsive. A number of factors have been identified which are determinants for the progression of an acute episode to one which persists in developing communities. In one study from west Africa, current infection with Cryptosporidium parvum was the most significant factor. In studies from Brazil and India, continuing infection with enteropathogenic Escherichia coli was identified in 50% of infants with persistent diarrhoea. Persistent small intestinal mucosal damage is of key importance in such children. Management of established cases is complex and difficult. However, there is clear evidence that zinc is involved in the recovery of small intestinal mucosa after injury. Zinc supplementation may indeed significantly reduce the duration of persistent diarrhoea. However, the whole question of public health supplementation with zinc, vitamin A, or other supplements, is contentious at present.

Vitamin A and HIV infection: disease progression, mortality, and transmission

Among HIV-infected individuals, many nutritional factors that influence disease progress, mortality, and transmission are not well understood. Of particular interest is the role of vitamin A. The benefits of vitamin A have been recognized since ancient times by Egyptian physicians who successfully treated night blindness with vitamin A. Contemporary scientists have since recognized the importance of vitamin A and have provided evidence that it may help in repairing damaged mucosal surfaces; what remains unclear, however, is its role during HIV infection. In this review, we examine the evidence provided in both observational studies and randomized controlled trials that assessed the effect of vitamin A during HIV infection.

Phenotypic and functional considerations in the evaluation of immunity in nutritionally compromised hosts

It is well established that proper nutrition is critical to the development of an effective immune system and to enhance the natural immunosurveillance and its effector mechanisms. This enhancement could be mediated either by increasing the frequency and absolute numbers of effector cells or by up-regulation of the cellular mechanisms by which these effector cells carry out their functions. Even in the Western world, large sectors of society often remain undernourished and show suboptimal immune responses, but the relationship between nutrition and immunity is best seen in developing and underdeveloped countries. Although there are many large-scale field studies that investigate the issue of nutrition and immunity, there are relatively few data that go beyond descriptive measurements and directly address how well the immune system functions. This review summarizes interactions between nutrition and immunity and focuses on practical aspects for evaluation of the immune function in the field.

Nutritional Contributions to the CNS Pathophysiology of HIV-1 Infection and Implications for Treatment

Nutritional deficiencies are commonplace in patients with human immunodeficiency virus type 1 (HIV-1) infection, and recent research has indicated that nutritional factors may play an important role in the pathogenesis of HIV-1 disease. Although nutritional deficiencies are unlikely to be the primary causative factor in disease progression, they may contribute to cognitive dysfunction, neurologic abnormalities, mood disturbance, and immune dysregulation associated with HIV-1 infection. Furthermore, deficiencies of specific micronutrients have been associated with increased risk of HIV-1-associated mortality. This article will briefly summarize the role of macronutrient deficiency, the interactions of specific micronutrient deficiencies with neuropsychiatric functioning, and the role of these factors in HIV-1 disease progression. Since recent research has shown that normalization of many nutritional deficits and supplementation beyond normal levels are associated with improvements in neuropsychiatric functioning, potential treatment implications will also be discussed.

Malnutrition, morbidity and mortality in children and their mothers

While being underweight or stunted is recognized as an important risk factor for increased prevalence and severity of infection and high mortality rates, there is increasing evidence for an independent role for micronutrient deficiency. Improving vitamin A status reduces mortality among older infants and young children and reduces pregnancy-related mortality; it also reduces the prevalence of severe illness and clinic attendance among children. Improving Zn status reduces morbidity from diarrhoeal and respiratory infection. Treatment of established infection with vitamin A is effective in measles-associated complications, but is not as useful in the majority of diarrhoeal or respiratory syndromes. Zn supplements, however, have significant benefit on the clinical outcome of diarrhoeal and respiratory infections. Concerns that Fe supplements might increase morbidity if given in malarious populations appear to be decreasing, in the light of new studies on Fe supplements showing improved haemoglobin without an increase in morbidity. Breast-feeding, well known to protect against diarrhoea, is also important in protecting against respiratory infection, especially in the young infant. Transmission of human immunodeficiency virus (HIV) in breast milk is recognized, but new data showing reduced transmission in infants who receive exclusive breast-feeding rather than mixed feeding reinforces the importance of promoting this practice in areas where environmental contamination precludes the safe use of other infant feeding regimens. The presence of subclinical mastitis, now recognized to occur in approximately 20 % of mothers in several developing countries, has been shown to increase the concentration of HIV in breast milk. Preliminary findings suggest that the prevalence of subclinical mastitis is reduced by dietary supplements containing antioxidants. Governments and international agencies now have a strong scientific basis to be much more active and innovative in the introduction of focused nutrition interventions especially micronutrients, for the control of infection.