Many people with HIV decide to take extra vitamins and minerals to try to protect or strengthen their immune systems. Evidence that they help is controversial, but studies have shown that people with HIV may have lower levels of some vitamins in their bloodstream than uninfected people, including vitamins A, E, B₆, B₁₂ and zinc.

It does not automatically follow from this that taking extra vitamins or minerals will help.

If vitamins or minerals are reduced in the body due to an unmet increased need for them, by the body, to deal with HIV, then supplementation may be helpful.

If they are depleted because the virus is making use of them, as may be the case with zinc, then increasing the levels may increase virus activity and make disease worse. This may be why zinc supplementation has been associated with more rapid progression of HIV disease in asymptomatic people with HIV, although it has been reported as having positive effects in more advanced disease.

If they are depleted because HIV-related changes in the gut or elsewhere are preventing them from being absorbed or turned into active forms within the body, then just taking more by mouth may make no difference.

It may be a good idea to take one multivitamin and mineral supplement each day which contains one to two times the recommended daily intake for the general population. HIV clinics or general practitioners may be able to prescribe this multivitamin supplement.

In resource-poor settings, where most people with HIV are undiagnosed, this approach may not be effective in improving the situation of people with increased nutritional needs as a result of HIV infection. Alternative options, notably fortification of key staple foods with vitamins and minerals, are being adopted in some countries - including Nigeria and South Africa - as a way of addressing problems in the general population, especially among children and could be especially helpful to people with HIV.

Multivitamin and micronutrient use in HIV

The benefits of vitamin and mineral therapy in HIV disease remain controversial. In patients who are not taking anti-HIV drugs, there is some evidence that supplementation can slow the progress of disease, possibly by redressing the alteration of vitamin and mineral levels caused by chronic infection.

A large study conducted in South Africa found that a daily vitamin B complex and multivitamin delayed the onset of AIDS and death. While the result suggests that nutritional status may affect the course of HIV disease, it is not known whether vitamin supplements delay HIV disease progression among people with superior nutritional status compared with participants in the study (Kanter 1999).

Another study which took place in Thailand found that supplementation with a wide spectrum micronutrient tablet was associated with a reduced risk of death in people with advanced HIV disease. People with CD4 counts between 101 and 200 cells/mm³ who received the supplement in the placebo-controlled study were 67% less likely to die during the 48 weeks study. People with CD4 cell counts below 100 cells/mm³ who received the supplement were 75% less likely to die. No impact was seen, however, at CD4 counts above 200 cells/mm³, and supplementation did not affect the risk of hospital admissions. Supplementation also had no significant effect on CD4 cell count or plasma viral load (Jiamton 2003).

Taken together, these and other studies have produced mixed results, although the evidence that supplementation may be of benefit in pregnancy is more convincing. See Supplementation in pregnancy and breastfeeding in Anti-HIV therapy: Options during pregnancy for more information.

However, one potential drawback of micronutrient supplementation is the increased shedding of HIV from the vagina. This may increase the risk of sexual and mother-to-child transmission of the virus. One double-blind placebo-controlled trial of 400 women in Kenya showed that vaginal shedding was increased 2.5-fold, particularly in the women who did not have selenium deficiency before starting treatment. This study also saw an increase in CD4 and CD8 cell counts in the treated women, but no significant effect on viral loads (McClelland 2004). However, similar effects have not been observed in all trials, including a placebo-controlled study of 140 Thai patients, in which no significant effects of supplementation on male or female genital HIV shedding were seen (Jiamto 2004).

In patients taking anti-HIV therapy, a broad-spectrum micronutrient formula developed by a Californian HIV practitioner has been shown to significantly increase CD4 cell counts by 25% over 12 weeks when used as an adjunct therapy to highly active antiretroviral therapy (HAART). The micronutrient was tested in a randomised and placebo-controlled study involving 40 HIV-infected people with peripheral neuropathy.

The specially designed micronutrient combined 15 minerals, 15 vitamins and the anti-oxidants alpha lipoic acid, N-acetyl cysteine (NAC) and acetyl L-carnitine (Kaiser 2004). The formula was manufactured without the fillers, binders or lubricants found in commercially-available supplements. These can inhibit absorption, bioavailability or tolerance in metabolically compromised people.

A recent editorial in AIDS has called for more research into the benefits and drawbacks of micronutrient supplementation, both in patients taking HAART and those who are not taking any anti-HIV therapy. For example, research is needed into the possible roles of supplementation in patients with low-level viraemia or with poor CD4 cell count responses to treatment. Questions still surround the benefits of supplementation in resource-poor settings, especially outside Africa. There is also uncertainty surrounding the benefits of vitamins and minerals in reducing oxidative stress and bone loss, and their effects in patients co-infected with tuberculosis or hepatitis B or C (Tang 2005).

The benefits of multinutrient supplementation demonstrated by some trials in HIV-positive patients have recently been used by a vitamin salesman, Matthias Rath, in support of his claims that antiretroviral treatment is toxic and that high-dose vitamins should be used to treat HIV and AIDS. Rath has accused the United States, the United Kingdom, the World Bank and the United Nations of misleading patients by only advocating the use of antiretrovirals, in order to support the pharmaceutical industry. However, he selectively quotes and distorts information from scientific papers to imply that multivitamins alone can be used to treat AIDS, often running full-page advertisements that read like news articles, in a high-profile media campaign including a website, newspapers in South Africa and the United States and pamphlets and posters distributed in city centres and townships in South Africa.

High doses of vitamins and minerals

Some researchers have advocated taking high doses of some vitamins and minerals in order to boost the immune system. Although research remains inconclusive, it is worth noting that some can be toxic in high doses. These are:

• Vitamin A: large amounts can cause liver and bone damage, vomiting and headache. Doses above 9mg for men or 7.5mg for women may be harmful. Pregnant women should not take supplements containing vitamin A before consulting their doctors as high intakes may harm the unborn child.

• Vitamin C: doses above 1000mg per day may lead to kidney stones; special care is needed if you are also taking indinavir (Crixivan).

• Vitamin E: doses above 800mg per day are associated with adverse effects; special care is needed if you are taking anti-coagulants or you have haemophilia.

• Zinc: doses above 75mg per day have been linked to copper deficiency, neutropenia and anaemia. Doses above 15mg per day in one study were associated with an increased risk of developing HIV-related symptoms.

• Selenium: more than 750µg per day are associated with immune suppression.

• Vitamin B₆: more than 2g per day associated with nerve damage, but even doses as low as 50mg per day have been associated with peripheral sensory neuropathy

For further information on individual vitamins and minerals, and theories on which deficiencies should be corrected, see the individual entries in Drugs used by people with HIV: Micronutrients.

References

Jiamto S et al. A randomized placebo-controlled trial of the impact of multiple micronutrient supplementation on HIV-1 genital shedding among Thai subjects. J Acquir Immune Defic Syndr 37: 1216-1218, 2004.

Jiamton S et al. A randomized trial of the impact of multiple micronutrient supplementation on mortality among HIV-infected individuals living in Bangkok. AIDS 17: 2461-2469, 2003.

Kaiser J et al. Broad-spectrum micronutrient supplementation in HIV-infected patients with dideoxynucleoside-related peripheral neuropathy: a prospective, double-blind, placebo-controlled trial Eleventh Conference on Retroviruses and Opportunistic Infections, San Francisco, abstract 494, 2004.

Kanter AS et al. Supplemental vitamin B and progression to AIDS and death in black South African patients infected with HIV. Letter. J Acquir Immune Defic Syndr 21: 252-253, 1999.

McClelland RS et al. Micronutrient supplementation increases genital tract shedding in HIV-1 women: results of a randomised trial. J Acquir Immune Defic Syndr 37: 1657-1663, 2004.

Tang AM et al. Micronutrients: current issues for HIV care providers. AIDS 19: 847-861, 2005.