Nutritional supplementation has only modest benefits for patients with HIV

Two studies have cast doubt on the value of nutritional supplements for patients with HIV. The first study, published in the July 1^st edition of Clinical Infectious Diseases showed that the provision of nutritional support has only modest benefits for HIV-positive adults without severe wasting. A separate study conducted amongst HIV-positive children in Uganda, and published in the Journal of the International AIDS Society showed that doubling doses of vitamins and minerals did not affect disease progression, nor did it boost weight or CD4 cell count.

A total of 636 antiretroviral-naïve patients were enrolled in the adult study and on a three-to-one basis were given nutritional supplementation or standard of care. “We observed an improvement in various nutritional parameters in the supplement group, but this was not statistically significantly different from the members of the control group”, comment the investigators.

Nevertheless, the investigators believe that their study has made a number of important contributions, most especially that they showed that it was feasible to deliver nutritional support to a food-insecure population via clinics.

Nutritional supplements and outcomes amongst HIV-positive adults in India

Food insecurity is widespread in the world regions hardest hit by HIV. Malnutrition is common in people with HIV in these areas, and this has been associated with faster disease progression.

Investigators hypothesised that supplementation with added calories and fat would improve the nutritional status of patients with HIV, and possibly their body composition and CD4 cell count.

They therefore conducted a prospective, six-month study in southern India between 2005 and 2007.

At the first baseline visit, patients provided details of their diet to a nutritionist who calculated their daily intake of calories, protein and fat. The patients’ height and weight were assessed and their body mass index calculated. Individuals’ mid-arm circumference was also measured.

Blood samples were obtained to assess the patients’ CD4 cell count and levels of haemoglobin, serum albumin, triglycerides, and cholesterol.

All the patients were given multivitamins and prophylaxis against opportunistic infections.

Nutritional supplementation providing 400 calories per day, 15 g of protein and 6 g of fat was given to three-quarters of patients. The other 25% of patients constituted a control group.

After six months, the effect of supplementation on weight, BMI, body composition, CD4 cell count and blood chemistry was measured.

There was a high rate of discontinuation (30%), and 10% of patients died. The patients who did not complete the study had more advanced HIV disease having significantly lower CD4 cell counts (p < 0.001), and lower serum albumin (p < 0. 001) than individuals who completed the study.

The investigators comment, “patients who were severely ill, who were about to initiate antiretroviral therapy, or who required hospitalisation were not included in the study, and this may have been the group most likely to benefit.”

Of the 361 patients who completed the study, 282 received supplementation. The mean age was 31 years and mean weight was 50 kg. Approximately a third of patients were severely malnourished.

Although patients in the control group had a lower daily calorific intake (1616 vs. 1911, p < 0.001), they nevertheless had a higher baseline CD4 cell count than patients who received supplementation (488 vs. 365 cells/mm³).

The investigator’ first set of analysis showed that supplementation had a number of benefits. Compared to the control group, the individuals who received six months of nutritional supplements had significant gains in weight, BMI, mid-arm circumference, and albumin levels (all p < 0.001).

However, after adjusting for baseline differences in CD4 cell count, age and sex between the two study arms, none of these changes remained statistically significant.

Next, the investigators categorised the patients who received supplementation according to their CD4 cell count: below 200 cells/mm³; 201-499 cells/mm³; and above 500 cells/mm³.

Regardless of CD4 cell count, six months of supplementation increased weight, BMI and mid-arm circumference (p < 0.001).

Improvements were greatest in patients with the lowest CD4 cell counts.

“In summary”, write the investigators, “an energy-dense oral micronutrient supplement did not have additional benefits on nutritional parameters or immune function among antiretroviral therapy-naïve HIV-infected individuals in South India, compared with high-quality standard of care. The effect of supplementation on specific subsets of patients and on preserving immune function needs further research.”

Micronutrients and disease progression in children

A separate study conducted in HIV-positive children in Uganda found that increased doses of key micronutrients did not reduce the risk of disease progression.

A total of 847 children aged between 1 and 5 years were recruited to the study, which is published in the Journal of the International AIDS Society.

The children were randomised to receive double the recommended daily allowance of 14 vitamins and minerals, which were taken daily for twelve months, or the standard daily dose of six vitamins, which were taken for six months.

After twelve months, 6% of the children who received increased amounts of vitamins and minerals had died compared to 7% of those who received the standard dose.

Mortality rates were also similar between the two groups when the investigators restricted their analysis to those taking antiretroviral therapy (7% vs. 7%).

In addition, increased amounts of vitamins and minerals did not have any benefits for either weight or CD4 cell count.