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  AIDS 2010
18th International AIDS Conference (IAC)
July 18-23 2010
Vienna, Austria
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Oral Poster discussion: Shining Light on Vitamin D deficiency
  Reported by Jules Levin
Below is a series of summary slidesets presented from several studies in an oral themed poster session on vitamin D in HIV. All studies report high levels of vitamin D deficiencies ranging from 66% to 80% in HIV+ individuals all in thier mid-40s, several studies find lower levels in African-Americans, some studies allude to associations of low vit D levels with EFV and TDF, one study reported here found protease inhibitor use not associated with lower but with higher vit D levels. We have never studied whether supplementation provides benefit nor if there are safety concerns regarding very high dose supplentation using 20,000 weekly ongoing or 50,000 weekly episodically and anecdotal research I have done suggests concern that supplementation may not result in sustained increased vit D levels; perhaps vitamin D levels get eaten by bu HIV+ individuals.
Evaluation of Vitamin D levels ('59% Vit D Deficient, < 20 ng/mL') in HIV-infected patients at the Center for Comprehensive Care, St. Luke's-Roosevelt Hospital Center. New York. USA
Vani Gandhi, MD
Attending Physician
Center for Comprehensive Care
Director of Integrative Medicine
St. Luke's-Roosevelt Hospital Center
V. Gandhi, JH Kim, G. Psevdos, F. Espinoza, J. Park, V. Sharp

· 1,25-dihydroxyvitamin D is a potent immunomodulator.
· Very few studies have examined VitD levels in HIV infected patients on antiretroviral therapy (ART) and these studies did not find a correlation between VitD status and CD4 cell recovery after initiation of ART.
· Few studies have shown that low VitD levels may be associated with HIV disease progression in the absence of ART.
· HIV infected patients have an increased risk for other infectious diseases, like common cold, influenza, pneumonia, tuberculosis and there is evidence that VitD deficiency is another predisposing factor to acquire such infections.
Van Den Bout-Van Den Beukel C, Fievez L, Michels M et al. Vitamin D deficiency among HIV type 1-infected individuals in the Netherlands effects of antiretroviral therapy. AIDS Res. Hum. Retroviruses 2008. 24:1375-1382. Ginde AA, Mansbach JM, Camargo CA Jr. Vitamin D, respiratory infections, and asthma. Curr Allergy Asthma Rep. 2009 Jan;9(1):81-7.
· VitD deficiency (<20 ng/mL) was noted in 205/342 (59.9%) of HIV-infected patients.
· Prevalent in our patients during the months with decreased sun exposure in the Northeastern United States.
· African Americans more likely to be VitD deficient which was expected.
· Consider checking VitD levels in all HIV-infected patients.
· Consider further studies to evaluate association between VitD deficiency and malignancies, infectious diseases and cardiovascular diseases in HIV-infected patients.
· Holick Michael. Vitamin D deficiency. N Eng J Med 2007:357:266-81.
· Mehta S, Giovannucci E, Mugusi F et al. Vitamin D status of HIV-infected women and its association with HIV disease progression, anemia and mortality. Plos One 2010. 5(1):e8770.
· Tseng M, Giri V, Bruner DW, Giovannucci E. Prevalence and correlates of vitamin D status in African American men. BMC Public Health. 2009 Jun 18;9:191.

High Rates (87%< African-American women at higher risk) of Vitamin D deficiency among HIV-infected and At-risk Women in the United States
Oluwatoyin M Adeyemi, Denis Agniel, Audrey L French, Phyllis Tien, Kathleen Weber, Marshall J Glesby, Maria C Villacres, Anjali Sharma, Daniel Merenstein, Elizabeth T Golub, William Meyer and Mardge Cohen for the WIHS group

· Median age 44 yrs, 61% African American, 22% White, 14% Hispanic.
· For HIV+ women, median CD4 495 (295,662)
· 66% of all women had Vitamin D Deficiency; 22% severe deficiency (<10ng/ml)
· 62% of HIV+ vs 75% of HIV- women were vitamin D deficient (p<0.001).
· Median vitamin D levels were higher in HIV-infected (16, IQR 10-25) than HIV-uninfected women (14, IQR 9-20).
· Only 13% had sufficient Vitamin D levels (>30ng/ml).

1] For 10-unit increase
2 Estimated with restricted cubic spline function of CD4 Count, using midpoint of range
· High prevalence of Vitamin D deficiency in the WIHS- (largest study to date on vitamin D in HIV infected adults).
· African American women had the highest rates of Vitamin D deficiency.
· HIV infection was associated with lower rates of vitamin D deficiency.
· In HIV+ women, Efavirenz use was associated with lower Vitamin D levels.
· Important to explore response to vitamin D supplementation and impact on a myriad of health outcomes.

Risk Factors for Vitamin D Deficiency in HIV-1 Infected Adults in the South-Central United States Houston (86% deficient) 200 patients average age 45
"Median serum 25(OH)D was 15.5 (10.9, 24.6). Vitamin D levels were commonly suboptimal (< 30 ng/mL; 86%), deficient (< 20 ng/mL; 64%), or severely deficient (≤ 10 ng/mL; 20.5%)....African-American race was independent predictor of vitamin D deficiency or worse (AOR):3.53; 95% CI: 1.83-6.82; p=0.0002)"
· 1 billion people have vitamin D deficiency worldwide
· Low vitamin D levels (25(OH)D) are associated with poor health outcomes
· Vitamin D deficiency is highly prevalent in HIV-infected populations -- Independent risk factors for vitamin D deficiency include skin pigmentation, winter/spring season, current efavirenz use, and active IDU

We investigated a similar study to determine prevalence and risk factors for vitamin D deficiency in HIV infected patients.
--This is important because our clinic is located at 29°N unlike other studies conducted in latitudes greater than 40°N; skin synthesis of vitamin D is possible annually at the latitude of 32°N or closer to the equator (Holick 1994).
--We also controlled for major confounding factors such as dietary or supplemental vitamin D intake and sunlight exposure unlike some of the other studies.
--Finally, we determined if particular antiretroviral classes such as NNRTIs were associated with vitamin D deficiency.
In a cross-sectional study, we enrolled 200 HIV-infected patients from a private practice in Houston, TX from the Fall of 2008 to end of Winter in 2009.
We excluded patients who were pregnant, had overt cognitive impairment, chronic renal failure (serum creatinine >1.5 mg/dL), hepatic dysfunction (AST or ALT ≥ 5 x upper limit of normal)
At the same time the vitamin D level was drawn from patients (serum 25-hydroxyvitamin D level), we surveyed each patient with a face-to-face vitamin D questionnaire and provider form.
--The vitamin D questionnaire comprised of three sections:
1. daily supplemental vitamin D intake
2. daily dietary vitamin D intake
3. daily sunlight exposure (minutes/day)
--The provider form was used to collect the following relevant information at the same time 25(OH)D was drawn:
-demographics (age, gender and race), body mass index (BMI), current smoking status, previous diagnosis of AIDS, pertinent laboratory markers (CD4, CD4%, CD8, VL, Ca, P, Alb, AP, AST, ALT, CrCl, and 25(OH)D), current antiretroviral use (including patient recall of any missed doses within the past 30 days), and other medication use
Additional relevant demographics include VL<400 (82%), 36% current smokers, 67% used PIs, 20% NNRTIs and 23% had a CD4<200 (AIDS)
Vitamin D deficiency was prevalent in our clinic population:
--64% had vitamin D deficiency (defined as levels less than 20ng/ml)
--20% had severe vitamin D deficiency (defined as less than 10ng/mL)
--14% had optimal/sufficient vitamin D levels (defined as greater than 30ng/mL)

This is a slide that depicts the relationship between ARV use, race, and vitamin D levels
Please note that the solid line represents sufficient vitamin D levels (those greater than 30ng/mL) and the dashed line represents deficient vitamin D levels (those less than 20ng/mL);
these parameters further emphasize the high prevalence of vitamin D deficiency in this study population and the very few who have sufficient vitamin D levels.
Multivariate analysis from our study showed that the only independent risk factors that were significantly associated with vitamin D deficiency were African American race, increased BMI, and low daily supplemental vitamin D intake.
--Worth-noting, current smoker use was significantly associated with vitamin D deficiency (OR was 1.971 (95% CI: 1.048-3.704, p=0.0351) in univariate analysis and trending towards significance in the multivariate analysis.
With regards to race, this figure shows that African Americans have lower vitamin D levels than both Caucasians and Hispanics (with Hispanics having lower vitamin D levels than Caucasians). This trend held true for the most part especially, for those on ARVs, except the Hispanics on NNRTIs had lower vitamin D levels than African Americans and Caucasians (however, only three Hispanic patients were on NNRTIs)
--It is also not understood why Caucasians have lower vitamin D levels than AA and Hispanic for those not using ARVs
With regards to ARV use, those patients on NNRTIs had slightly lower vitamin D levels than those on PIs regardless of race.
--As a part of this study, the association between antiretroviral class use and severe vitamin D deficiency was also assessed. For those on NNRTIs (n=10) OR was 1.996 (95% CI: 0.833-4.783, p=0.1211) and those on PIs (n=18) OR was 0.590 (95% CI: 0.266-1.306, p= 0.1928).
--For those not on ARVs, patients tended to have slightly higher vitamin D levels than those on ARVs for all races except for Caucasians. The reason for this trend is not understood.
--Median CD4(%) for those on ARVs was 450 (23.5%) and 231 (16%) for those not on ARVs. Studies have shown that vitamin D status does not effect CD4 cell count recovery in treatment-naïve patients starting ARVs and that there is no significant correlation between 25(OH)D and CD4 cell counts.

High Prevalence of Vitamin D Deficiency Among HIV-Infected Patients in LA (66%, 28% <20 ng/mL)
Dr. Catherine Chien, Claudia Carlotti, Dr. Laveeza Bhatti, Pam Jongthavorn, Dr. Miguel Valdes-Suerias, Dr. Paul DenOuden, Dr. Shilpa Sayana, Dr. Homayoon Khanlou
AIDS Healthcare Foundation
Department of Medicine
Los Angeles, CA USA
465 patients were identified based on our search criteria. Mean age was 45 years old (range 19-73); 388 males (83%), 72 females (15%), 5 transgender (2%); 161 Caucasian (35%), 151 Hispanic (32%), 139 African-American (30%), 12 Asian-Pacific-Islander (3%), 2 Native-American (< 1%). Mean CD4 count was 520 cells/mm3 (range 8-2352); mean HIV-RNA-level was 9347 copies/mL (3.97 log 10) [range < 48-879,550; 1.68-5.94 log10]. Of these patients, inadequate vitamin-D levels were identified in 306 patients (66%) of whom 174 (38%) met criteria for vitamin-D insufficiency and 132 (28%) met criteria for vitamin-D-deficiency. 159 patients (34%) were found to have normal vitamin-D levels.
Conclusions: Two-thirds of HIV-infected patients screened were found to be insufficient or deficient in vitamin-D stores. Given the known association between vitamin D and other infectious processes, it seems reasonable to add vitamin-D measurement and supplementation to the routine management of HIV-infected patients. The impact of vitamin-D deficiency warrants further research.

No Association of Vitamin D Levels with Individual Antiretroviral Agents, Duration of HIV Infection, Alkaline Phosphatase Levels nor Bone Mineral Density Findings
T Rashid, E Devitt, S Mandalia, I Meryon, L Waters, M Bower, R Jones, M Nelson Department of HIV Medicine Chelsea and Westminster Hospital London, UK