Many people living with HIV will consider taking a multivitamin or supplement at some time. The UKfAR survey found that over half of respondents took some form of supplement, with a multivitamin being most common.  It’s not surprising as a quick search on the internet for vitamins and HIV results in a plethora of sites, with many asserting that multivitamins are essential to stay healthy. People can take a whole range of vitamins, supplements and remedies, some of which are specifically marketed at positive people and a few cost as much as £100 for one month’s supply.

Rather surprisingly the research on whether taking vitamins is of any benefit to positive people is rather limited. The difficulty in working out what is good and what is not occurs for a number of reasons including:

• Studies showing positive people are deficient in vitamins are dated and may not be applicable to those on stable ART and with healthy CD4 counts.
• The studies on vitamins have either been small scale or conducted on those in resource poor settings / without access to ART
• There have been few scientifically rigorous studies on vitamins conducted on healthy positive people.
• Research into vitamins and supplements is not something that big pharmaceutical companies are interested in.

There is no doubt that nutrition and good health are linked; it is also true that some positive people may be malnourished and deficient in certain vitamins, and therefore might benefit from a supplement. However it is not clear if healthy positive people are generally more deficient in vitamins than the general population. Most of the research is still from the pre ART era when many positive people were very ill and had low CD4 counts.

It is true that some positive people do suffer from body shape changes and weight loss, due to metabolic changes and higher energy expenditure, indeed studies have indicated that positive people tend to burn more calories (Batterman, 2005); additionally HIV and other infections may damage the gut lining, leading to reduce uptake of vitamins and minerals. However people eating well and who eat sensibly may receive enough vitamins from their food.

Studies in developing countries have shown that daily doses of a micronutrient supplement produced a significant increase in CD4 and CD8 cell counts when compared with those given placebo. However one of these studies was conducted in Tanzania on HIV-infected pregnant women who were not receiving ART (Fawci, 2004) . The other, in Thailand demonstrated that a micronutrient supplement decreased overall HIV-associated mortality in positive people by 50% compared with a placebo. The supplement was most effective for people with low (<200) CD4 counts, but again the partipiants were not on ART (Jiamton, 2003).

Other studies have suggested that a vitamin and micronutrient supplement may help increase CD4 counts. A study in the Journal of AIDS indicated that the use of K-PAX, which sells for around £100 for a month’s supply, resulted in an increase in CD4 counts by an average of 65 cells versus a 6-cell decline in the placebo group at 12 weeks (Kaiser, 2006). The author of the study, Dr Kaiser, claims that the micronutrient supplement administered to HIV-infected patients taking stable ART significantly enhances CD4 reconstitution. However Dr Kaiser did not mention that he had a financial interest in KPAX when he submitted the article and although participants were on stable ART neither group seemed to have an undetectable viral load. There was a drop in viral load in the treatment group from 4291 to 897 copies compared with an increase from 2648 to 5935 in the placebo. The trial only included 40 people and more information is needed to understand why the placebo group had a drop in CD4 count and an increase in viral even thought they were on stable therapy.

A more recent study by the St Luke’s-Roosevelt Hospital in New York concluded that 6 months of K-PAX supplementation resulted in no significant change to CD4 counts or viral load, based on a cohort of 60 HIV positive people who were on standard antiretroviral therapy. However they did note a statistically significant increase in body weight after 6 months on K-PAX of around 1.4Kg (Tsveniashvili, 2011).

To confuse matters further a poster was presented at the XVIII International AIDS Conference in 2010 suggesting that an antioxidant pill did improve immune reconstitution and began to reverse mitochondrial damage over an 8-week period. This was a randomized study of 25 HIV positive people on stable antiretroviral treatment, 13 taking an antioxidant supplement (a single pill containing B-complex, vitamins C and E, selenium, zinc, N-acetyl-cysteine, and alpha-lipoic acid) and 12 people taking a placebo. (Baum M, 2010). Although the study hasn’t been published and the number of participants was small, it is interesting.

The preliminary results of our own study, which has yet to be analysed are also interesting; those that stated they took vitamins and supplements had higher CD4 counts and reported less illness than those who did not.

Many people take the precautionary principle – it may not work but it does no harm. However studies in the general population have not only found no benefit to taking a vitamin supplement, but that they may cause harm. The Cochrane review of antioxidant vitamin pill supplementation in over 200,000 people found no evidence to support antioxidant supplements to prevent mortality in either healthy people or patients with various diseases. In fact they concluded that taking vitamin A, beta-carotene, and vitamin E may actually increase mortality.

Other studies have found that people who take vitamins smoked more, did less exercise and were less likely to choose healthy food because they thought taking a ‘healthy’ vitamin compensated for unhealthy actions. (Win-Bun Chiou, 2001). Another study showed that woman who routinely used complementary or alternative therapies were 1.69 times more likely to report missing antiretroviral drugs. Our own study found that people who reported using vitamins were less likely to take their medication on time, although were less likely to miss to dose (Owen-Smith, 2007).

There are other issues to consider as well, some supplements can interact with HIV medication and people may be spending money on vitamins with little or no benefit.

Healthy positive people probably get enough vitamins from their food and the evidence is very clear that getting vitamins from a balanced diet is far and away the best option.

However although ART has been successful at reducing viral load, many positive people still don’t have normal CD4 counts. Furthermore the majority of HIV positive people in our survey reported a range of issues that impacted their quality of life. If there are vitamins and supplements that could strengthen the immune system or improve people’s quality of life it makes sense to conduct proper scientifically rigorous trials to establish what is beneficial or not – something UKfAR is looking to do. This information could improve the quality of life of thousands of positive people.