On the basis of two Cochrane reviews, we have decided to modify our existing materials and withdraw the recommendation that otherwise healthy adults with HIV take multivitamin supplements. This must not be construed as a recommendation against taking these supplements but as an application of the cautionary principle that medical interventions should only receive a positive recommendation if there is compelling evidence or reason to do so.
The review concluded:
We found no evidence to support antioxidant supplements for primary or secondary prevention. Vitamin A, beta-carotene, and vitamin E may increase mortality. Future randomised trials could evaluate the potential effects of vitamin C and selenium for primary and secondary prevention. Such trials should be closely monitored for potential harmful effects. Antioxidant supplements need to be considered medicinal products and should undergo sufficient evaluation before marketing.
TAC has in a number of statements, a pamphlet and on a web page cautiously recommended that people with HIV consider taking a daily multivitamin supplement. For example our HIV help web page states:
There is some evidence that a daily multivitamin supplement slightly slows progression to AIDS. Consider taking a daily nutritional supplement consisting of vitamins B, C and E. Public health facilities are supposed to provide vitamin supplements to people with HIV for free. However, be aware that most of the claims made about vitamin supplements are exaggerated, often grossly so. It is unclear if vitamin supplements are of any benefit to people who eat enough and healthily. If you do not get free vitamin supplements from the public health system and you can afford to eat healthily, you might prefer to spend your money on something else.
The evidence we have relied on for our cautious recommendation is a competent study on HIV-positive Tanzanian pregnant women conducted by Fawzi et al. titled A Randomized Trial of Multivitamin Supplements and HIV Disease Progression and Mortality.
However, another Cochrane review (published in 2005) of multivitamin supplements by Irlam et al. titled Micronutrient supplementation in children and adults with HIV infection which reviewed 15 clinical trials concluded:
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.
On the basis of these two Cochrane reviews, we have decided to modify our existing materials and withdraw the recommendation that adults with HIV take multivitamin supplements. This must not be construed as a recommendation against taking these supplements but as an application of the cautionary principle that medical interventions should only receive a positive recommendation if there is compelling evidence or reason to do so.
There of course remain specific health conditions where multivitamin supplements are necessary. Vitamin A supplementation in HIV-positive children should be considered. The World Health Organisation also recommends folic acid supplementation in certain circumstances for pregnant women or women of reproductive age.
Furthermore, adequate nutrition including sufficient micronutrients is critical for people with HIV and indeed all people. Food security remains a serious concern in South Africa. Food prices have been rising at a rapid pace, with wages failing to keep up. Two million households in a 2002 survey in South Africa reported members going hungry and the average worker spends over a third of monthly income on food. State-provided food parcels and social grants are consequently critical to preventing and alleviating malnutrition and hunger; TAC will continue to advocate for the efficient and wide-spread implementation of such programmes.
It might also be justifiable for the state to provide vitamin supplementation to under-nourished people. Given that it is hard for the state to differentiate at public health facilities between under-nourished and well-nourished people, the current policy of providing multivitamin supplements to people with HIV might be justifiable and we make no recommendation for or against this.
But our current understanding is that for otherwise healthy HIV-positive adults, at best the benefits of multivitamin supplements are very small. At worst, mortality is slightly increased. Healthy people (including healthy HIV-positive people) who wish to continue taking multivitamin supplements daily should preferably use low doses.
The findings of the two Cochrane Reviews referenced here also raise questions about the ethics of the marketing methods of companies selling multivitamins to the general public. Vitamin advertisements on South African television and in newspapers frequently make misleading statements based on insufficient evidence. The Advertising Standards Authority needs to address this.
TAC will continue to take note of new research on multivitamin supplements and review our position if new compelling evidence is published.