Conclusions and implications for practice

Micronutrient deficiencies increase the risk of adverse pregnancy outcomes in HIV-infected women. Multivitamin supplementation (including B-complex, C, and E) has demonstrated a consistent benefit on pregnancy outcomes among HIV-infected women, including a reduced risk of prematurity, low birth weight, HIV transmission via breastfeeding, and fetal death. Current epidemiological evidence supports the use of multivitamin supplements to reduce the risk of adverse pregnancy outcomes in HIV-infected women. However, the aforementioned studies were conducted on antiretroviral-naive pregnant women; it is not evident if the observed effect of multivitamin supplementation on pregnancy outcomes is generalizable to HIV-infected women taking antiretroviral therapy. There is also insufficient evidence regarding the relative benefit of administering single versus multiple RDA levels of micronutrients in prenatal supplements for HIV-infected women. Ongoing randomized trials in Tanzania may provide evidence regarding the generalizability of these findings, inform multivitamin supplementation dosage and administration, and elucidate the role of micronutrients among HIV-infected individuals receiving antiretroviral therapy.

Vitamin A supplementation has not demonstrated a consistent benefit on the risk of adverse pregnancy outcomes in HIV-infected women. The increased risk of vertical HIV transmission following vitamin A use observed in trials in Tanzania and Zimbabwe is particularly disconcerting. Vitamin A supplementation is therefore not recommended for HIV-infected pregnant women, and should be avoided. There is currently no strong epidemiological evidence to support the use of other micronutrient supplements, such as zinc and selenium, to prevent adverse pregnancy outcomes in HIV-positive women. However, a selenium supplementation trial currently underway in Tanzania may elucidate the role of selenium in perinatal health outcomes among HIV-infected women and their children.

Micronutrient supplementation, however, is unlikely to be a stand-alone mantra for success in preventing adverse pregnancy outcomes in HIV-infected women. The importance of ensuring access to appropriate antiretroviral therapy cannot be overemphasized. The role of nutrition in HIV-infected women taking HAART has not been well-established and warrants further investigation. Further, vulnerable groups such as HIV-infected women, particularly in developing countries, are likely to have multiple micronutrient deficiencies. This is additionally complicated by the fact that micronutrients can have either synergistic or antagonistic interactions with regard to biological effects. For example, iron supplements can interfere with zinc absorption [56, 57], and zinc in high doses may reduce the absorption of iron or copper [58, 59]. Further attention should also be focused on complementary dietary approaches such as food fortification and dietary diversification as potential beneficial and sustainable adjuncts to micronutrient supplementation.

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