February 5, 2008
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There's nothing like hearing the results of studies directly from those who actually conducted the research. It is these women and men who are transforming HIV treatment and care. In this interview, you'll meet one of these impressive HIV researchers and read an explanation of the study he is presenting at CROI 2008. Accompanying me on this interview is Gerald Pierone, M.D., an HIV clinician/researcher and the founder and executive director of the AIDS Research and Treatment Center of the Treasure Coast in Fort Pierce, Fla.
Richard Rutstein, M.D.
My name is Rick Rutstein and I'm from the Children's Hospital of Philadelphia. I direct the Special Immunology Family Care Center there, which provides care to HIV-infected children with perinatally acquired HIV infection.
My presentation was on vitamin D deficiency in children with perinatally acquired HIV infection.1 We found that among [perinatally HIV-infected] children in Philadelphia, there was a higher rate of vitamin D insufficiency and deficiency when compared to healthy controls from the same city. We also noted that ethnic background -- specifically, being African American or of black race -- size and age corresponded to having a higher risk of low vitamin D levels.
We found that PTH [parathyroid hormone] levels were not well correlated with the vitamin D levels. We found that there was no specific medication regimen that was correlated with vitamin D levels. We did note that among the teenagers with HIV infection, those who had lower CD4+ counts -- i.e., less than 500 -- had a higher incidence of vitamin D deficiency.
[Our] recommendations would be that, in the absence of risks of increasing vitamin D intake, we believe everybody should be on an increased intake of vitamin D, and probably calcium, to preserve bone health and for the believed immunologic improvements seen with adequate vitamin D levels.
Bonnie Goldman: Could you define "insufficient" vitamin D levels?
Richard Rutstein: For this study, vitamin D levels were defined as normal if they were above 30 ng/mL, insufficient if they were 11 to 29 ng/mL and deficient [if they were] less than 11 ng/mL. Several studies have looked at levels that defined above 15 [as normal] and below 15 as deficient, but the national nutrition groups tend to use the three-step definitions.
Bonnie Goldman: I noticed that the control group was half as likely to be of black race. Do you think the results are biased because of that?
Richard Rutstein: In our multivariate analysis, we controlled for African-American or black race. We found that, more than [the impact of] HIV status [on vitamin D deficiency] was, in fact, the [impact of] ethnic background. Wintertime and HIV status both played a role, but the largest risk factor was simply ethnic background.
Bonnie Goldman: Do you think diet had anything to do with it?
Richard Rutstein: I'm sure it did. In a previous study that looked at these healthy controls, the diet was generally insufficient for vitamin D.2 In previously published results by researchers for the REACH [Reaching for Excellence in Adolescent Care and Health] network of teenagers, [it was] found that the average HIV at-risk or infected adolescent had very low calcium and vitamin D intake.3
Gerald Pierone: Hi, I'm Gerry Pierone from the AIDS Research and Treatment Center of the Treasure Coast. When the average clinician thinks about vitamin D deficiency, two things come to mind: seasonal variation and, perhaps, women being at more risk than men. Did you find this in your study?
Richard Rutstein: That's a good point. Seasonal variation was one of the risk factors, with the winter season -- specifically the coldest months, from December to February -- having the highest rate of vitamin D deficiency. When you're in the Northern Hemisphere and Philadelphia, we still saw some vitamin D insufficiency and deficiency even in the warmest months. Also, females tended to have a 2.5 times increased risk of being vitamin D deficient as well.
Gerald Pierone: So what I'm hearing is: very high risk of vitamin D deficiency in your population. Are you routinely placing your HIV-infected youngsters on vitamin D replacement? If so, how much?
Richard Rutstein: We'd always carried the suggestion that all children and teenagers should be on one general multivitamin a day. We did not push hard with that. With this data now, I'm encouraging all of our patients to actually be on multivitamins -- and actually take two a day, which would give them 800 units of vitamin D daily. I feel that there is no evidence of risk at that level. There have been studies that have shown much higher levels are safe in adults. At the very least, you'll get your vitamin D level up to normalized in these children.
Bonnie Goldman: Do you have average CD4+ counts for these patients?
Richard Rutstein: We did it by immunologic class. At the time of study, 65% were CDC [U.S. Centers for Disease Control and Prevention] Class One, which meant their CD4+ counts were above 500. There were 27% that were in Class Two, which is CD4+ count between 200 and 500. Only 7% were in Class Three [CD4+ count below 200]. The average CD4+ count overall was 706. Most of the children were, virologically, in good control, with 54% being virologically suppressed.
Bonnie Goldman: What was the average age?
Richard Rutstein: The average age was 13 and a half in our HIV-infected group and just over 12 on the control subjects.
Bonnie Goldman: It's striking that 55% of the control group had vitamin D insufficiency. Was that expected?
Richard Rutstein: It was expected. The control data was done in a very large study by the same researchers that we worked with in the GI [gastrointestinal] division at Children's Hospital.2 We had known that data from beforehand, which encouraged us to look within our group. Again, among the REACH study that was done among infected adolescents as well as HIV-negative but at-risk adolescents, it found a very high rate of vitamin D insufficiency as well.3
Bonnie Goldman: Had this been found previously?
Richard Rutstein: This was the first study that we know of that looked at a sizable group of children who had perinatally acquired HIV infection.
Bonnie Goldman: Do you think this would be found similarly in HIV-infected adults?
Richard Rutstein: I have no doubt that it would be.
Bonnie Goldman: Thank you very much.
This transcript has been lightly edited for clarity.
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