title: Prevalence and risk factors of micronutrient deficiencies pre- and post-antiretroviral therapy (ART) among a diverse multicountry cohort of HIV-infected adults.
abstract: OBJECTIVE
  HIV-infected adults have increased risk of several individual micronutrient deficiencies. However, the prevalence and risk factors of concurrent and multiple micronutrient deficiencies and whether micronutrient concentrations change after antiretroviral therapy (ART) initiation have not been well described. The objective of this study was to determine the prevalence and risk factors of individual, concurrent and multiple micronutrient deficiencies among ART-naïve HIV-infected adults from nine countries and assess change in micronutrient status 48 weeks post-ART initiation.
  
  
  METHODS
  A random sub-cohort (n = 270) stratified by country was selected from the multinational PEARLS clinical trial (n = 1571 ART-naïve, HIV-infected adults). We measured serum concentrations of vitamins A, D (25-hydroxyvitamin), E, carotenoids and selenium pre-ART and 48 weeks post-ART initiation, and measured vitamins B6, B12, ferritin and soluble transferrin receptor at baseline only. Prevalence of single micronutrient deficiencies, concurrent (2 coexisting) or conditional (a deficiency in one micronutrient given a deficiency in another) and multiple (≥3) were determined using defined serum concentration cutoffs. We assessed mean changes in micronutrient concentrations from pre-ART to week 48 post-ART initiation using multivariable random effects models.
  
  
  RESULTS
  Of 270 participants, 13.9%, 29.2%, 24.5% and 32.4% had 0, 1, 2 and multiple deficiencies, respectively. Pre-ART prevalence was the highest for single deficiencies of selenium (53.2%), vitamin D (42.4%), and B6 (37.3%) with 12.1% having concurrent deficiencies of all three micronutrients. Deficiency prevalence varied widely by country. 48 weeks post-ART initiation, mean vitamin A concentration increased (p < 0.001) corresponding to a 9% decrease in deficiency. Mean concentrations also increased for other micronutrients assessed 48 weeks post-ART (p < 0.001) but with minimal change in deficiency status.
  
  
  CONCLUSIONS
  Single and multiple micronutrient deficiencies are common among HIV-infected adults pre-ART initiation but vary between countries. Importantly, despite increases in micronutrient concentrations, prevalence of individual deficiencies remains largely unchanged after 48 weeks on ART. Our results suggest that ART alone is not sufficient to improve micronutrient deficiency.
authors.affiliation: Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. Electronic address: rshivak1@jhmi.edu.
authors.forename: Rupak
authors.initials: R
authors.lastname: Shivakoti
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA. Electronic address: pchrist1@jhu.edu.
authors.forename: Parul
authors.initials: P
authors.lastname: Christian
authors.affiliation: Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. Electronic address: weiteng.yang@gmail.com.
authors.forename: Wei-Teng
authors.initials: WT
authors.lastname: Yang
authors.affiliation: Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. Electronic address: nikhil_jhumit@yahoo.com.
authors.forename: Nikhil
authors.initials: N
authors.lastname: Gupte
authors.affiliation: Department of Medicine, University of Witwatersrand, Johannesburg, 2050, South Africa. Electronic address: tmwelase@witshealth.co.za.
authors.forename: Noluthando
authors.initials: N
authors.lastname: Mwelase
authors.affiliation: UNC Lilongwe, Lilongwe, Private Bag A-104, Malawi. Electronic address: ckanyama@unclilongwe.org.
authors.forename: Cecilia
authors.initials: C
authors.lastname: Kanyama
authors.affiliation: Durban International Clinical Research Site, Durban University of Technology, Durban, 4001, South Africa. Electronic address: Pillay@ukzn.ac.za.
authors.forename: Sandy
authors.initials: S
authors.lastname: Pillay
authors.affiliation: University of Zimbabwe Clinical Research Centre, Harare, 999, Zimbabwe. Electronic address: wsamaneka@uzcrc.co.zw.
authors.forename: Wadzanai
authors.initials: W
authors.lastname: Samaneka
authors.affiliation: Hospital Nossa Senhora de Conceição, Porto Alegre, 91350-200, Brazil. Electronic address: breno@ghc.com.br.
authors.forename: Breno
authors.initials: B
authors.lastname: Santos
authors.affiliation: YR Gaitonde Center for AIDS Research and Education, Chennai, 600113, India. Electronic address: poongulali@yrgcare.org.
authors.forename: Selvamuthu
authors.initials: S
authors.lastname: Poongulali
authors.affiliation: National AIDS Research Institute, Pune, 411026, India. Electronic address: directorjalma@gmail.com.
authors.forename: Srikanth
authors.initials: S
authors.lastname: Tripathy
authors.affiliation: Les Centres GHESKIO, Port-Au-Prince, HT-6110, Haiti. Electronic address: criviere@gheskio.org.
authors.forename: Cynthia
authors.initials: C
authors.lastname: Riviere
authors.affiliation: Malawi College of Medicine-Johns Hopkins University Research Project, Blantyre, Malawi. Electronic address: sima.berendes@googlemail.com.
authors.forename: Sima
authors.initials: S
authors.lastname: Berendes
authors.affiliation: Asociacion Civil Impacta Salud y Educacion, Lima, 4, Peru. Electronic address: jrlama@impactaperu.org.
authors.forename: Javier R
authors.initials: JR
authors.lastname: Lama
authors.affiliation: STD/AIDS Clinical Research Laboratory, Instituto de Pesquisa Clinica Evandro Chagas, Fundacao Oswaldo Cruz, Rio de Janeiro, 21045-900, Brazil. Electronic address: sandra.wagner@ipec.fiocruz.br.
authors.forename: Sandra W
authors.initials: SW
authors.lastname: Cardoso
authors.affiliation: Research Institute for Health Sciences, Chiang Mai, 50200, Thailand. Electronic address: patcharaphan@rihes-cmu.org.
authors.forename: Patcharaphan
authors.initials: P
authors.lastname: Sugandhavesa
authors.affiliation: Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, 02111, MA, USA. Electronic address: Alice.Tang@tufts.edu.
authors.forename: Alice M
authors.initials: AM
authors.lastname: Tang
authors.affiliation: Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, 21287, MD, USA. Electronic address: rdsemba@jhmi.edu.
authors.forename: Richard D
authors.initials: RD
authors.lastname: Semba
authors.affiliation: Department of Medicine, Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, 80045, USA. Electronic address: Thomas.Campbell@ucdenver.edu.
authors.forename: Thomas B
authors.initials: TB
authors.lastname: Campbell
authors.affiliation: Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. Electronic address: agupta25@jhmi.edu.
authors.forename: Amita
authors.initials: A
authors.lastname: Gupta
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000008:administration & dosage / Q000009:adverse effects*; D002338:Carotenoids / Q000097:blood; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy; D006801:Humans; D016015:Logistic Models; D008297:Male; D044342:Malnutrition / Q000453:epidemiology* / Q000209:etiology; D018977:Micronutrients / Q000097:blood / Q000172:deficiency*; D015999:Multivariate Analysis; D015995:Prevalence; D012307:Risk Factors; D012643:Selenium / Q000097:blood; D014801:Vitamin A / Q000097:blood; D014807:Vitamin D / Q000097:blood; D014810:Vitamin E / Q000097:blood
chemical_list: D044966:Anti-Retroviral Agents; D018977:Micronutrients; D014801:Vitamin A; D014807:Vitamin D; D014810:Vitamin E; D002338:Carotenoids; D012643:Selenium
keywords: Antiretroviral therapy; Cohort studies; HIV; Micronutrient deficiency; Multiple micronutrients; Vitamins