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Guatemala City, Guatemala
Nineteen authors from 6 countries (8 from the United States, 6 from Denmark, 2 from South Africa, and 1 each from Belgium, Canada, and Zimbabwe), 11 of them with medical degrees, contributed the 11 chapters (citing 1009 references) of this very readable and well-edited book. One quotation eloquently captures the quintessential nature of the HIV problem at the dawn of the 21st century: "In industrialized countries, HIV disease has become a chronic disorder that has been modified through the prevention and treatment of invasive opportunistic infections, and by treatment with highly active antiretroviral therapy. The situation is quite different from the developing world, where HIV disease is a relentless, progressive disorder that culminates in the death of the affected individual and the disruption of the family unit." In yet another pithy summary, the book's editor synthesizes the theoretical paradigm: "Micronutrients may affect: (1) progression of HIV infection, (2) sexual HIV transmission, (3) mother-to-child HIV transmission, and (4) morbidity due to common and opportunistic infections in HIV-infected individuals." The book's seemingly implicit mission is to explore accumulated knowledge at the interface of HIV, its associated diseases, and micronutrient intake and status to explore how derivative insights could contribute to solving the problems of prevention and disease management.
Three chapters—the first and the final 2—are integrative overviews. Friis's introductory chapter covers the theory of nutrition-infection interaction, as based on Nevin Scrimshaw's thesis of antagonistic and synergistic interactions. The final chapters cover case management and micronutrient interventions and the HIV pandemic. Chapters 2 and 3 are superbly written but curiously selected. One deals with immune defects wrought by nutrient deficiencies, without any mention of AIDS and without suggesting any homology or analogy with the pathogenesis of immunodeficiency from HIV. The other comprehensively covers oxidative stress and infections and concludes with a discussion of 5 classes of human viruses, including HIV. The book's 6 core chapters each discuss one or more micronutrients in relation to HIV: vitamin A and carotenoids, B vitamins, vitamins C and E, iron, zinc, and selenium. These chapters lack a uniform format (although there is evidence that the editor may have suggested one), and they vary in focus: some concentrate on the nutrient-HIV interaction; others wander into more basic nutritional biochemistry and epidemiology or draw analogies from non-HIV examples. Gauged by the percentage of references in each chapter with the key words HIV, retrovirus, or AIDS in their titles, the focus on the main topic ranges from highs of 56% and 53% for the antioxidant vitamins and B complex chapters, respectively, to lows of 26% and 24% for zinc and iron; the other 2 chapters score 35%. The chapter on iron, however, extensively explores the interaction of this essential element with the array of pathogens that cause the opportunistic infections that characterize the active AIDS syndrome in the immunocompromised host. A similar, systematic search of the literature by the authors of the other micronutrient chapters would have increased the book's clinical relevance.
For a multiauthored volume, Micronutrients and HIV Infection has remarkably and refreshingly little redundancy. Moreover, some authors discuss the adverse consequences of excessive nutrient exposure on the course of HIV and opportunistic infections and the nutrient-nutrient interactions that can arise from nutrient interventions. The book also offers some priceless teaching illustrations, inluding its Figures 1.1 and 11.1 and Tables 2.1 and 3.2.
Although the majority of authors have medical degrees, this volume was clearly written for researchers rather than clinicians. There is little practical clinical advice about disease management and even less guidance for public health programmers and policymakers about transmission prevention. No clinical protocols of prophylactic or therapeutic micronutrient interventions have evolved from the basic research and epidemiologic intervention trials conducted so far. This leaves us with the conviction that other avenues toward making HIV infection a manageable "chronic disorder" for the bulk of its sufferers in low-income societies must be sought—and quickly!