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Nutritional Supplements Beneficial for HIV+ People Who Do Not Yet Need ART

HIV positive people with CD4 cell counts above 350 cells/mm³ who have not yet started antiretroviral therapy (ART) may reduce their risk of disease progression, immune system decline, and death if they take a multivitamin and selenium supplement, according to a study from Botswana published in the November 27, 2013, issue of JAMA.

Over the course of the HIV/AIDS epidemic, research on the impact of nutrition on disease progression have yielded mixed results. In general, adequate nutrition contributes to overall health and good immune function, but the effects of supplementing specific vitamins or other nutrients are less clear. Some past studies have shown benefits of micronutrient supplementation for people with advanced HIV disease and extensive immune suppression.

Marianna Baum from Florida International University investigated whether long-term micronutrient supplementation is safe and effective in delaying disease progression among adults with early HIV infection who have not yet started ART.

While U.S. guidelines now recommend ART for everyone diagnosed with HIV, regardless of CD4 T-cell count, World Health Organization global guidelines have a treatment initiation threshold of 500 cells/mm³ (raised from 350 cells/mm³ in July 2013).

This analysis included 878 HIV positive adults seen at Princess Marina Hospital in Gaborone, Botswana, between December 2004 and July 2009. All were infected with HIV subtype C, had a CD4 count above 350 cells/mm³ (median 420 cells/mm³), and were not receiving ART.

Participants were randomly assigned to take daily oral multivitamins (B, C, and E) alone, selenium alone, multivitamins plus selenium, or placebo for 24 months. Based on the standard of care at the time of the study, the primary endpoint was reaching a CD4 count below 200 (until May 2008) or 250 cells/mm³, at which point ART was indicated.

Results  

• All 878 randomized participants remained off ART throughout the study.
• Participants who received the combined multivitamins plus selenium supplement had a significantly lower risk of reaching a CD4 cell count <250 cells/mm³ compared with placebo recipients (adjusted hazard ratio [HR] 0.46, or about half the risk).
• The absolute number of people reaching the primary endpoint was 17 vs 32, respectively, with event rates of 4.79 vs 9.22 per 100 person-years.
• The combined supplement was also associated with reduced risk of falling below <350 cells/mm³.
• Participants who received the combined supplement also were less likely to reach a composite secondary endpoint of CD4 cell decline, AIDS-defining conditions, or AIDS-related death (adjusted HR 0.56).
• No effect of supplementation on HIV viral load was observed.
• People who took either multivitamins alone or selenium did not have significantly different outcomes compared with placebo recipients.
• Multivitamin and selenium supplements were generally safe and well-tolerated, with reported adverse events deemed unlikely to be related to the study intervention.
• Participant adherence was good, with 90% taking most of their supplement doses.

"In ART-naive HIV-infected adults, 24-month supplementation with a single supplement containing multivitamins and selenium was safe and significantly reduced the risk of immune decline and morbidity," the researchers concluded. "Micronutrient supplementation may be effective when started in the early stages of HIV disease."

"The evidence from our study presented herein supports the provision of low-cost supplementation with multivitamins combined with selenium for HIV-infected individuals in early stages of the disease who are ART-naive to prolong adequate immune response and prevent AIDS-defining conditions," they added in their discussion.

Although the combined supplements and selenium appeared beneficial in this study, the results cannot be assumed to apply to people with HIV on ART. But supplementation may be a way to help people stay healthy longer off treatment in resource-limited settings were ART is not widely available.

In December a widely reported set of studies of nutritional supplementation for the general HIV negative U.S. population -- including a large meta-analysis conducted for the U.S. Preventive Services Task Force-- found that supplements did not increase survival, reduce the occurrence of cardiovascular events or cancer, or improve cognitive function.

While an editorial in the Annals of Internal Medicine urged the general public to "stop wasting money" on ineffective supplements, specific vitamins and minerals may still be beneficial for people with deficiencies, as more commonly seen in low-income countries.

12/18/13

References

MK Baum, A Campa, S Lai, et al. Effect of Micronutrient Supplementation onDisease Progression in Asymptomatic, Antiretroviral-Naive, HIV-Infected Adults in BotswanaA Randomized Clinical Trial. JAMA310(2):2154-2163. November 27, 2013.

E Guallar, S Stranges, C Mulrow, et al. Enough Is Enough: Stop Wasting Money on Vitamin and Mineral Supplements (Editorial). Annals of Internal Medicine 159(12):850-851-851. December 17, 2013.