Nutritional knowledge, beliefs and practices in the HIV infected patient

NUTRITION RESEARCH, Vol. 11, pp. 33-40,1991 0271-5317/91 $3.00 + .00 Printed in the USA. Copyright (c) 1991 Pergamon Press plc. All rights reserved.

NUTRITIONAL KNOWLEDGE, BEUEFS AND PRACTICES IN THE HIV INFECTED PATIENT1 Emilio Mantero-Atienza M.D., M.P.H.2'3, Marianna K. Baum Ph.D., R.D.2, Julian J. Javier M.D.2, Gall Shor-Posner Ph.D.2, Carolyn M. Millon Ph.D.2, Jose Szapocznik Ph.D2, Carl Eisdorfer M.D., Ph.D.2, Richard S. Beach M.D., Ph.D," From the University of Miami School of Medicine, Miami, Rorida, USA.

.ABSTRACT Seventy-five HIV-seropositive, asymptomatic other than lymphadenopathy, homosexual males were studied to determine nutritional health beliefs and practices as well as general nutritional knowledge. A total of 80% of the participants reported dietary change at the time of, or subsequent to, HIV diagnosis. The most frequent dietary changes noted were decreased intake of animal products and alcohol in association with increased intake of vegetables, and seafood. The majority of participants (87%) indicated that vitamin and mineral supplements could favorably influence their immune function and thereby delay disease progression, with 59% reporting an increase in vitamins/mineral supplement consumption after HIV diagnosis. Regarding nutritional knowledge, 90% did not know the daily requirements for essential vitamins and minerals. Sources of nutritional information and counseling were most frequently provided by friends (/5%) or newspapers/magazines (48%) and popular books (44%). Asymptomatic HIV-infected patients view nutritional issues as of key importance in maintaining their immune function. They frequently adopt strategies, however, based upon limited information and these strategies may at times, be ill-advised. Practitioners must work to provide the HIV-infected patient with information concerning basic nutritional needs as well as the most recent developments involving nutritional aspects of HIV infection.

Key Words:

HIV Infection, Beliefs, Nutritional Practices, Knowledge INTRODUCTION

The Acquired Immunodeficiency Syndrome (AIDS) has now afflicted over 126,127 individuals in the United States alone, and possibly as many as one million individuals throughout the United States may be infected with the Human Immunodeficiency Virus (HIV-1) (1). As yet, there is no vaccine and only palliative antiviral chemotherapy (e.g., zidovudine (AZT), imuthiol(DIC), dideoxycytidine(DDC)) is available, with DIC and DDC still under investigation (2-4). Consequently, HIVol infected asymptomatic individuals frequentlyseek alternative means of optimizing immune function to prevent disease progression.

1Supported by NIMH Grant # 1-P50-MH42555 2Center for the Biopaychosocial Study of AIDS, University of Miami School of Medicine, 1425 NW 10th Ave. Miami,R. 33136. 3Corresponding Author: Dr. Emilio ManterooAtienza, Department of Epidemiology and Public Health, University of Miami School of Medicine, P.O. Box 016069 CR-669),Miami, Rorida 33101.

33

34

E. MANTERO-ATIENZA et al.

HIV-1 infection is essentially a disorder of immune function that leads to opportunistic infections and~ malignancies (5), characterized by a significant degree of malnutrition and wasting in the later stages of AIDS (6). Such malnutrition involves both changes in overall body composition (7) as well as deficiencies of specific nutrients (6-12). As many nutritional factors have been demonstrated to influence multiple parameters of immune function (13), there is considerable interest in the role of nutritional factors in the development and progression of HIV-1 infection among both health professionals and patients. This may be of particular importance, in light of recent evidence from our center demonstrating that HIV-1 infected patients, who are relatively eady in their clinical course, exhibit multiple nutritional and/or metabolic abnormalities (7,11,13,14). In lieu of definitive treatment modalities for HIV-1 infection, asymptomatic infected individuals frequently seek alternative treatments. Many individuals change their dietary patterns and begin using vitamin and mineral supplements. We have recently reported that such supplementation can prove toxic in some individuals (15). The present investigation evaluates nutritional knowledge, beliefs and sources of nutritional information among asymptomatic HIV-infected patients. SUBJECTS AND METHODS Participants in the present investigation were 75 male homosexuals between the ages of 20-50 years. All subjects were HIV-1 seropositive, as documented by Western blot (16), had known of their diagnosis for two months to three years, and remained completely asymptomatic other than persistent generalized lymphadenopathy (CDC Stage III patients) (17). They were free of other known risk factors for HIV infection (e.g., intravenous drug abuse). In addition, they were not affected by any diseases influencing nutritional status or requiring special diets (e.g., diabetes mellitus, inflammatory bowel disease). None of the subjects were taking a medication known to alter nutritional status, nor were they enrolled in any experimental drug trials. All volunteers had achieved at least a 12th grade education. Study participants were recruited from community physicians references, local AIDS-related centers and the University of Miami HIV-screening research clinics. HIV seronegative homosexual male controls (N=50) were selected from the same sources and had similar backgrounds and education levels. Informed consent was obtained from all individuals and the studies were conducted in accordance with the standards of the University of Miami School of Medicine and the National Institutes of Health. Participants were administered a dietary history questionnaire by a trained nutritionist in a standardized fashion. In the present study, subjects were also questioned regarding the use of vitamin and mineral supplements and were asked to bring supplement containers to the interview; for those not bringing containers, subsequent telephone interviews were conducted to determine the brand name and precise contents of the supplements used by the subjects. At the same time, the subjects completed a questionnaire to determine nutritional knowledge and attitudes regarding the relationship between dietary intake, HIV infection, and disease progression. After completion, the questionnaire was reviewed, checked for consistency and completed by the trained nutrifionist. RESULTS The results of the nutritional study revealed that thirty-three percent (33%) of the subjects changed their diet at the time of diagnosis and a further 47% of the subjects reported making dietary modifications soon after diagnosis. Thus, a total of 60 of the 75 participants (80%) reported altering their dietary intake at the time of, or subsequent to, their diagnosis; As shown in Table 1, these dietary modifications were quite variable. Most of the study participants (80%) demonstrated multiple changes, ranging from consuming less whole milk (31%), red meat (37%), butter (21%) and alcohol (33%), to increasing their intake of fruits (32%) vegetables (33%), fish (20%) and whole grain products (21%). Total caloric intake increased after diagnosis in 24% of the study subjects. About half of the study group noted that this increase was an attempt to prevent disease progression, while the other half associated it with increased anxiety. Although some participants reported decreased appetite after diagnosis, only 6% of the subjects reduced their total intake of food, and nearly all of these individuals associated this decrease in food consumption with self-reported depression. To cleady understand the motivation for such dietary alterations, we further questioned the subjects about their health beliefs regarding diet, nutrition and HIV infection. As shown in Table 2, most of the study subjects indicated that body weight was an important factor in disease progression with 45% of the participants reporting that thin individuals were more likely to experience a faster progression of their HIV infection, 59% agreeing that

NUTRITION BELIEFS IN HIV INFECTION

35

weight reduction diets would most likely accelerate the rate of HIV disease progression, and 9% indicating that remaining overweight would delay their HIV disease progression.

Table 1. Changes in Eating Habits after Diagnosis of HIV-Seropositivity same use (%) Whole Milk Butter Margarine Eggs Seafood Red Meat Fruits Vegetables Whole Wheat Bread Whole Grains Alcohol Sugar

62 56 42 62 77 58 63 60 79 92 62 79

decreased use (%)

increased use (%)

31 21 17 25 3 37 5 7 5 3 33 16

7 23 41 13 20 5 32 33 16 5 5 5

Concerning disease onset, only 5% responded that diet and nutritional status could have affected their initial infection with HIV, and only 3% felt that being overweight could protect them from becoming infected with HIV. The majority of the participants (87%) indicated that consuming vitamin/mineral supplements could favorably influence the outcome of their infection. When subjects were asked what type of supplements they were taking, 70% said they were consuming multiple vitamins. While 68% of the study subjects ingested such supplements prior to diagnosis (generally a single multi-vitamin or vitamin/mineral supplement), 59% of them reported increasing intake of vitamin/mineral supplements at or since the time of diagnosis. Additional supplementation most frequently involved specific nutrients in addition to the daily supplement. Table 3 indicates the daily dietary intake of micronutrients, based on food and supplements, for HIV-1 seropositive and HIV-1 seronegative homosexual men. W'~h the exception of selenium (intake obtained only from supplementation), nutrient consumption was well above the RDA in both groups. Table 2. Beliefs of Respondents Regarding Diet, Nutrition and HIV Infection. Belief

Diet and nutrition affected their initial infection Overweight can protect an individual from becoming infected with HIV Being overweight delays HIV disease progression Thin individuals experience more rapid progression of HIV infection Weight reduction diets accelerate the rate of HIV disease progression Exercise produces beneficial effect in HIV infection Vitamlns/Mineral supplements can influence outcome of infection

%of respondents who answered yes 5 3 9 45 59 68 87

E. M A N T E R O - A T I E N Z A et al.

36

Table 3 Dietary Daily Intake of V'damins and Minerals Nutrient

HIV (+) Homosexual Males Mean • SD (N =75)

V'damin A (IU/Day) Vitamin D (IU/Day) Vitamin E (rag/Day) Vitamin C (mg/Day) Thiamin (mg/Day) Riboflavin (rag/Day) Niacin (mg/Day) Pyridoxine (mg/Day) B12 (rag/Day) Iron (rag/Day) Zinc (rag/Day) Copper (mg/Day)* Selenium (mcg/Day)**

26490 • 647 + 224 • 873 + 12.9 9 12.1 • 76.1 • 11.7 • 24.2 • 32.4 + 36.4 + 11.8 + 23.2 +

23238 476 318 620 25.7 22.3 58.7 22.8 28.6 27.7 27.5 5.7 82.5

HIV(-) Homosexual Males M e a n , SD

RDA

(N =50) 19,857 + 12,110 465 i 313 70 + 169.2 508 • 358 5.3 * 9.9 6.3 • 9.9 54.7 • 47.1 6.2 + 9.6 24.8 + 58 22.5 + 14.2 24.2 + 23.5 41.7 • 192.4 30.0 + 9.6

5000 200 10 60 1.4 1.6 1.8 2.2 3 10 15 2-3 70

* ESADDI (Estimated Safe and Adequate Daily Dietary Intake) ** Data based on dietary supplementation only. Specific changes in behavior are indicated in Table 4. As shown in this table, neady 80% of the participants felt nutritional factors could affect their disease progression and consequently, reported dietary modification. In addition, 68% thought proper exercise could also have a beneficial effect while a substantial number of the subjects indicated that a decrease in the consumption of alcoholic beverages or tobacco products (33% and 68%) could have a positive impact.

Table 4 Changes in behavior regarding diet, nutrition and HIV infection.

Behavior Changed diet at the time of diagnosis Changed diet after diagnosis - Increased total intake of foods - Decreased total intake of foods - Consumed supplements prior to diagnosis - Increased Intake of supplements after diagnosis - Decrease in alcohol consumption Decrease in cigarette smoking Decrease intake of salt -

-

-

-

% of respondents who claimed to change behavior 33 47 24 6 68 59 66 31 43

As shown in Table 5, the level of nutritional knowledge and the sources of nutritional information among such asymptomatic HIV-infected patients appeared to be considerably limited. Although most participants knew the quantity of vitamins they were taking, less than 7% of the study population knew the recommended daily intake of vitamin A and D. Moreover, many subjects were not even familiar with important food sources for these vitamins. The majority of the participants (95%) agreed that it was possible to take too many vitamins, although few knew what "too many" meant in quantitative terms with respect to a specific nutrient. Regarding the source of the subject's nutritional knowledge, only 35% of these asymptomatic HIV-infected individuals reported discussing

NUTRITION BELIEFS IN HIV INFECTION

37

nutrition and diet with their pdmary care physician or nutritionist. Most reported obtaining their information from friends (75%), newspapers/magazines (48%) or popular books (44%). (Figure 1) Table 5. Knowledge of respondent concerning nutrition % of participants that responded correctly

Respondents that knew: Recommended daily intake of vitamin A Recommended daily intake of vitamin D - How much supplement of vitamin A is taken - How much supplement of vRamin D is taken Which foods are important sources of vitamin A Which foods are important sources of vitamin D It is possible to take too many vitamins

7 5 80

-

-

50

-

41

-

31

-

95

DISCUSSION Patients infected with HIV are faced with the dilemma of an infection with a very high rate of morbidity and mortality for which, at present, only experimental and palliative treatments are available in symptomatic stages of the disease (2-4). Significant malnutrition and wasting frequently characterize the full blown AIDS patient (6). For those individuals in the relatively "eady" clinical stages of HIV infection there is little information available on possible strategies to avoid and/or delay HIV disease progression. Considerable interest has now been generated in those cofactors which may be involved in allowing certain individuals to remain asymptomatic for years, while others quickly progress to overt disease and death (18). A cofactor mentioned frequently by investigators in HIV research is the possible role of diet and nutrition in the development and progression of HIV infection (19-20). The present findings indicate that many HIV-infected individuals change their diet and begin to consume or increase intake of vitamin and mineral supplements, possibly as a result of the limited treatment options available to them. These dietary changes largely involve decreased intake of butter, eggs, whole milk and red meat, along with increased intake of fish, fruits and vegetables, and whole grain products. Of interest, these changes closely reflect the most widely publicized dietary guidelines currently available in this country, i.e., those to reduce the risk of developing coronary heart disease (21). It is quite likely that in the absence of additional nutritional information, such individuals adopt those dietary changes which have been associated with improved health, whatever the original intent of the dietary changes. Of further interest, a number of the subjects (43 %) also reported they had markedly lowered their intake of salt as well, apparently having derived this nutritional information from diets designed to reduce risk of developing and/or controlling hypertension. Thus, many of the subjects were undertaking significant dietary changes in order to alter the development of clinically evident HIV infection. They were, however, utilizing the recommended dietary guidelines pertaining to chronic diseases of considerably different origin.

E. MANTERO-ATIENZA et al.

38

Figure 1

SOURCES OF NUTRITIONAL INFORMATION HIV-SEROPOSITIVE PATIENTS

AMONG

801

!

i60 ii Q. 40

o

~e

20

Friends

Newspapers

Popular Books

Health Publications "AIDS" Professionals Underground

The dietary changes (e.g., those associated with a decreased cardiovascular risk profile) adopted by many participants may be particularly iU-suitedfor patients infected with HIV. Such diets frequently emphasize foods with decreased caloric density and decreased levels of saturated fatty acids and, thus, are inconsistent with the subjects efforts to increase their total food/caloric intake. Moreover, because, many patients axpadence minimal, but progressive, weight loss, it is possible that these individuals should be, in fact, consuming diets with high caloric density (6). The cardiovascular diets also attempt to reduce serum cholesterol by providing very low levels of dietary cholesterol. Although no statistically significant differences were found in serum cholesterol levels of AIDS patients, HIV seropositive subjects, and controls, the HIV infected individuals showed a definite trend to lower levels of cholesterol throughout disease progression (22). There is evidence to indicate that adequate cholesterol may be important for normal lymphocyte function (23), and low serum cholesterol may be particularly disadvantageous, therefore, in the HIV-infected patient who tends to have altered levels of dietary cholesterol (24). Variations in serum cholesterol levels have also been associated with a number of cancers (25) and thus may be important in the development of opportunistic malignancies, e.g., Kaposi's sarcoma, B cell lymphomas, in the HIV-infected patient. It should be noted that the reduction of meat and animal product intake, without ensuring adequate altemative dietary sources of these nutrients, may be particularly inadvisable in light of the significant incidence of deficiencies of vitamin B12, pyridoxine, foiate, copper and selenium that have been associated with early HIV infection (7-10,11,13,14). On the other hand a high caloric diet, especially foods too high in fats should not be recommended, since this type of diet could further impair gastrointestinal dysfunction, e.g. diarrhea, which is frequently observed in the HIV infected patient (26). A high protein diet may be more advantageous under such circumstances since HIV infected patients experience preferential loss of lean body mass. The assessment of nutritional knowledge in these subjects revealed relatively limited knowledge of nutritional concepts and dietary requirements. Lessthan 7% of the subjects knew the requirements for vitamins A and D and less than 40% knew the important food sources of these vitamins. The majority of participants who were taking vitamin/mineral supplements, however, did know how much of the various vitamins they were taking. Of particular concern is the finding that many individuals were taking large quantities of potentially toxic nutrients, such as vitamins A and D (15) although the possibility of consuming toxic quantities was recognized by these same subjects. The highest recorded intake of vitamin A among these subjects was 140,000 IU/day with an additional 30% of the participants consuming over 10 times the RDA for vitamin A. The signs and symptoms of vitamin A toxicity are relatively non-specific and many are characteristic of HIV infection as well, making it difficult to evaluate toxicity. Thus, while most participants realized that such excessive intake of specific nutrients could prove toxic, many nonetheless adopted such strategies with the belief that this strategy could halt or delay their HIV disease progression. The intake of selenium, based on supplementation alone, was above the RDA in 22% of the patients. Our recent studies in asymptomatic HIV seropositive homosexual men with high plasma selenium levels have revealed no signs and symptoms of toxicity. However, IgG and IgM were below normal limits, compared to individuals of the same group but with normal selenium levels (p< 0.05). Moreover, the natural killer cells activity of high selenium level subjects was significantly higher than the group with low selenium level, underscoring the

NUTRITION BELIEFS IN HIV INFECTION

39

effect of such dietary practice in the Immune function (27). Those professionals working with HIV-Infected individuals must be alert for the signs of vitamin/mineral intoxication and remind their patients of the possible danger associated with such excessive levels of intake. Since most of the nutritional information these individuals are receiving is not from a well-oriented source (friends, magazines), health professionals dealing with the HIV infected population must make it possible for their patients to receive the most adequate orientation about their nutrient intake. Our research group, in addition, has simultaneously studied HIV-infected individuals, who remain asymptomatic other than persistent generalized lymphadenopathy (CDC Stage III patients), with regard to a wide range of dietary and nutritional variables. A profile of serum biochemical parameters revealed deficiencies in a significant proportion of these subjects. Nutritional inadequacies occurring most frequently were those of pyridoxine, vitamin B12, folete and selenium (7,9,11,13,16). These nutritional alterations appear to play a role in the progressive immune dysregulation that characterizes patients with HIV infection (24), and occurred in spite of dietary intakes that met or even exceeded the recommended dietary allowances (15). The present findings should provide a greater understanding of the dietary/nutritional knowledge beliefs and practices of clinically asymptomatic HIV-infected patients. Only now are we beginning to develop a basis of knowledge regarding the nutritional status of patients with HIV infection, particularly in its early stages. It.seems evident that there is a critically important need for such information. Although our findings could be appiied to other HIV positive populations, we should remain cautious when extrapolating the results of this investigation to high risk groups such as IV drug abusers based on the multifactorial etiology of nutritional abnormalities in such populations. Normalization of nutritional/metabolic abnormalities that occur earlier in the course of HIV infection may provide an important locus of intervention in HIV disease progression. In addition, a normal nutritional status may also be of importance for greater effectiveness of other Intervention modalitiea, such as antiviral chemotherapy. While the basic knowledge regarding nutritional aspects of HIV infection is being developed, care-givers should be aware that the HIV-infected patient views diet and nutrition as an important means of protecting his/her health. Moreover, such patients may adopt dietary alterations and initiate consumption of large quantities of vitamins and minerals in an attempt to preserve their immune function and to halt the progression of ~:lisease. However, these adaptations are frequently performed against a background of limited nutritional knowledge. Health care professionals should, therefore, encourage open dialogue with their patients regarding these issues, and must be prepared to provide the most complete and current information available to the HIV-infected patient.

1.

REFERENCES Centers for Disease Control. Update: Acquil'ed immunodeficiency syndrome United States. MMWR 1990; 39:81.

2.

Fischl MA, Richman DD, Grieco MH, Gottlieb MS, Volberding PA, Laskin OL, Leedom JM, Groopman JE, Mildvan D, Schooley RT, Jackson GG, Durack DT, King D, and the AZI" Collaborative Working Group. The efficacy of azidothymidine (AZT) in the treatment of patients with AIDS and AIDS-related complex. A double-blind, placebo-controlled trial. N Engl J Med 1987; 317:185-91.

3.

Crumpacker C, Heagy W, Bubley G, Monroe JE, Finberg R, Hussey S, Schnipper L, Lucey D, Lee TH, McLane MF, Essex M, Mulder C. Ribavirin treatment of acquired immunodeficiency syndrome (AIDS) and the acquired-immunodeficiency-syndrome-related complex (ARC). Ann Int Med 1987; 107:664-74.

4.

Lang JM, Torraine JL, Trepo C, Choutet P, Kirstetter M, Falkenrodt A, Herviou L, Livrozet JM, Retornaz G, Touraine F, Renoux G, Renoux M, Musset M, Caraux J, and the AIDS-Imuthiol french Study Group. Randomized double-blind, placebo - controlled trial of dithiocarb sodium ("imuthiol") in human immunodeficiencyvirus infection. Lancet 1988; 2:702-6.

5.

Ho DD, Pomerantz RJ, Kaplan JC. Pathogenesis of infection with human immunodeficiency virus. N Eng J Med 1987; 317:278-86.

6.

Kotler DP, Wang J, Pierson RN. Body composition studies in patients with the acquired immunodeficiency syndrome. Am J Clin Nutr 1985; 42:1255-65.

7.

Mantero-Atienza E, Beach RS, Eisdorfer C, Fordyce-Baum MK. Indices of nutritional status in eady HIV infection. Archives AIDS Research 1989; 111:275-85.

40

E. MANTERO-ATIENZA et al.

8.

Dworkin BM, Rosenthal WS, Wormser GP, Weiss L Selenium deficiency in the acquired immunodeficlency syndrome. JPEN 1986; 10:405-7.

9.

Smith I, Howells DW, Kendall B, Levinsky R, Hyland K. Folate deficiency and demyelination in AIDS. Lancet 1987; 2:215.

10.

Colman N, Grossman F. Nutritional factors in epidemic Kaposi's sarcoma. Semin Oncol 1987; 14:54-62.

11.

Fordyce-Baum MK, Mantero-Atienza E, Fletcher MA, Morgan R, Eisdorfer C, van Riel F, Beach RS. Pyddoxine deficien=cyand immune function in early HIV-1 infection. J Acquir Immune Defic Syndr 1990; In press.

12.

Chandra RK. Nutritional regulation of immunity and risk of infection in old age. Immunology 1989; 65(2):141-7.

13.

BeachRS, Mantero-Atienza E, Eisdorfer C, Fordyce-Baum MK. Altered folate metabolism in early HIV infection, JAMA 1988; 259:517.

14.

BeachRS, Mantero-Atienza E, Eisdorfer C, Fordyce-Baum MK. Altered folate metabolism in eady HIV infection. In response to Tilkan, et al JAMA 1988; 259:3128-9.

15.

Fordyce-Baum MK, Mantero-Atienza E, Morgan R, van Riel F, Beach RS. Toxic levels of dietary supplementation in HIV-l-infected patients. Arch AIDS Res 1990; IV:137-48.

16.

SamgadharanMG, Popovic M, Brach L, Schupbach J, Gallo RC. Antibodies reactive with human Tlymphotropic retrovirus (HTLV-III). Science 1984; 224:506-8.

17.

Centers for Disease Control. Revision of the CDC surveillance case definition for acquired immune deficiency syndrome. MMWR 1987; 361 (Suppl 15):2S-14S.

18.

Rothenberg R, Woeljel M, Stoneburner R, Milberg J, Parker R, Truman B. Survival with the acquired immunodeficiency syndrome. Expedence with 5833 cases in New York City. N Eng J Med 1987; 517:1297302.

19.

Gray RH. Similarities between AIDS and PCM. Am J Public Health 1983; 99:565-8.

20.

BeachRS, Laura PF. Nutrition and the acquired immunodeficiency syndrome. Ann Int Med 1983; 99:565-6.

21.

Dietary Goals for the US. Prepared by Select Committee on Nutrition and Human Needs. United States Senate. Washington. US Gov Print Off Cat NO Y4 N95:D 63/3, 1977.

22.

Grunfeld C, Kotler DP, Hamadeh MD, Tierney BS, Wang J, Pierson RN. Hypertriglyceddemia in the acquired immunodeficiency syndrome. Am J Med 1989; 86:27-31.

23.

Dabrowski M, Peel W, Thomas A. Plasma membrane cholesterol regulates human lymphocyte cytotoxic function. Eur J Immunol 1980; 10:821-7.

24.

Anonymous. Lower cholesterol values in HIV infected patients. Fortschr'Kteder Merdizin 1989; 107:10-3.

25

WilliamsR, Sodie M, Feinleib M, McNamara M, Kannel WB, Dawber TR. Cancer incidence by levels of cholesterol. JAMA 1981; 245:247-52.

26.

FarthingMJG, Keusch GT. Enteric infection. Mechanisms, manifestations and management. In: Farthing MJG and Keusch GT, eds. Raven Press New York, 1989; p5.

27.

Mantero-AtienzaE, Gavancho MC, Javier JJ, Shor-Posner G, Beach RS, Baum MK. Selenium status in asymptomatic HIV-1 seropositive men. JPEN 1990, In press.

Accepted for publication November 7, 1990.