[afro-nets] Prolonging Survival Among Children Without Access to ART (3)

[Wendy Holmes <holmes@burnet.edu.au>]

Prolonging Survival Among Children Without Access to ART (3)
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Dear Bradford,

Thanks for sending your positive e-mail to AFRO-NETS, and I do
agree with much that you say. Your message highlights the need
for evidence in guiding advice for people with HIV, and there
have been many more clinical trials evaluating anti-retroviral
drugs than nutritional interventions. Now that the efficacy of
ARV drugs is known, it is of course much more complicated to de-
sign ethical trials that enable assessment of the additional
value of other interventions. This is why Fawzi et al's recent
report of their randomised trial of multivitamin supplements in
Tanzania was especially significant (see abstract below - men-
tioned on AFRO-NETS before but worth flagging again). Interven-
tions that can effectively prolong survival and delay the need
for ARVs are badly needed.

Your emphasis on taking responsibility is important - we know
that a sense of control, and reduced stress, can both benefit
the function of the immune system. But it's not true that com-
plementary therapies can't have toxic effects. In fact, vitamin
and other supplements can have unintended and unpredicted ef-
fects, which may vary with the dose taken - another reason why
they need to be studied. Also, it's sometimes a problem that
people with HIV that could benefit from ARVs become ill because
they prefer their complementary therapies and fear the side-
effects of the drugs.

Of course we also need to bear in mind that many people, and
children, with HIV aren't able to have a varied diet, or even
adequate calories, let alone anti-retroviral drugs.

Best wishes,

Wendy Holmes MB BS MSc
Deputy Director Technical Programs
Centre for International Health
Macfarlane Burnet Institute for Medical Research and Public
Health
GPO Box 2284, Melbourne, Australia 3001
mailto:holmes@burnet.edu.au


--
Fawzi W, Msamanga GI, Spiegelman D et al. A Randomized Trial of
Multivitamin Supplements and HIV Disease Progression and Mortal-
ity. N Engl J Med 2004;351:23-32.

Abstract

Background
Results from observational studies suggest that micronutrient
status is a determinant of the progression of human immunodefi-
ciency virus (HIV) disease.

Methods
We enrolled 1078 pregnant women infected with HIV in a double-
blind, placebo-controlled trial in Dar es Salaam, Tanzania, to
examine the effects of daily supplements of vitamin A (preformed
vitamin A and beta carotene), multivitamins (vitamins B, C, and
E), or both on progression of HIV disease, using survival mod-
els. The median follow-up with respect to survival was 71 months
(interquartile range, 46 to 80).

Results
Of 271 women who received multivitamins, 67 had progression to
World Health Organization (WHO) stage 4 disease or died ­ the
primary outcome ­ as compared with 83 of 267 women who received
placebo (24.7 percent vs. 31.1 percent; relative risk, 0.71; 95
percent confidence interval, 0.51 to 0.98; P=0.04). This regimen
was also associated with reductions in the relative risk of
death related to the acquired immunodeficiency syndrome (0.73;
95 percent confidence interval, 0.51 to 1.04; P=0.09), progres-
sion to WHO stage 4 (0.50; 95 percent confidence interval, 0.28
to 0.90; P=0.02), or progression to stage 3 or higher (0.72; 95
percent confidence interval, 0.58 to 0.90; P=0.003). Multivita-
mins also resulted in significantly higher CD4+ and CD8+ cell
counts and significantly lower viral loads. The effects of re-
ceiving vitamin A alone were smaller and for the most part not
significantly different from those produced by placebo. Adding
vitamin A to the multivitamin regimen reduced the benefit with
regard to some of the end points examined.

Conclusions
Multivitamin supplements delay the progression of HIV disease
and provide an effective, low-cost means of delaying the initia-
tion of antiretroviral therapy in HIV-infected women.