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were searched, and pharmaceutical manufacturers and researchers in the field were contacted to locate any ongoing or unpublished trials.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.

Routine reporting or sentinel surveys for HIV/AIDS surveillance in resource-poor settings: experience in South Africa, 1991-97.

Information from routine and sentinel surveillance was used to monitor the HIV/AIDS epidemic in KwaZulu-Natal, South Africa between 1991 and 1997. Comparisons were made between data obtained from (1) sentinel surveillance for antenatal HIV infection, pulmonary tuberculosis (PTB), and AIDS in a single health district and (2) province-wide sentinel surveillance for antenatal HIV infection, legally required notification of cases of PTB, and voluntary notification of AIDS cases. HIV prevalence among antenatal clinic attenders in the sentinel district rose rapidly and at similar rates to provincial figures: 4.2% vs 4.8% in 1992 to 25.9% vs 26.9% in 1997. PTB incidence increased four-fold in the sentinel district over the study period, whereas provincial PTB figures from passive surveillance fluctuated widely and showed no clear increase (Chi-square for trend 425.5, P<0.00001). AIDS incidence in the sentinel district increased dramatically while provincial data from the voluntary reporting system showed a less consistent and much slower rise (Chi-square for trend 9.07, P=0.003). Incidence of AIDS in 1997 was estimated as 437/10(5) in the sentinel district compared to 32/10(5) in the provincial figures. Routine disease notification and voluntary reporting systems are likely to underestimate the impact of the HIV/AIDS epidemic in resource-poor settings. Sentinel surveillance at representative sites should be developed to validate or replace passive surveillance systems.