Re: Re: Response to Gregory Benvenuti 11 December 2004
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Peter J Flegg,
Physician
Blackpool, UK, FY3 8NR

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Re: Re: Re: Response to Gregory Benvenuti

Benvenuti raises an important point that of malnutrition in South Africa (and by extension, in much of the developing world where HIV is prevalent). He certainly seems to have seen the evidence for this first hand, and may well be seeing clinical cases of pellagra. When I worked in Zimbabwe, I commonly saw cases of pellagra, primarily because a diet consisting mainly of maize-meal was low in both nicotinic acid and in tryptophan, its amino acid precursor.

Malnutrition and vitamin deficiency may co-exist or be clinically confused with AIDS, they predispose to other infections and worsens HIV/AIDS survival. Just because HIV causes illness, it does not mean every disease in an HIV prevalent population is due to HIV, and doctors must guard against this error of assumption. It would also be easy to expect HIV therapy will miraculously solve all the problems of someone with HIV, but it would have little impact if that person is malnourished and has other untreated infections.

We need to ensure that funding to assist development in Africa is maintained and is not diverted to provide HIV medications simply because is seems politically expedient to do so and generates favourable headlines. Resources to tackle HIV are sorely needed, but these must be provided over and above traditional development aid.

Benvenuti mentions the use of Bactrim (cotrimoxazole). As an infection specialist I am usually against the widespread empirical prescription of an antibiotics, preferring to target individuals who are shown to be at risk of opportunistic infections and who may most benefit from the use of such a drug. However, Benvenuti may not be aware that a recent study in HIV-infected Zambian children using cotrimoxazole showed that it cut mortality by a third (1). The message is that if one has HIV, irrespective of stage, then it is worthwhile taking these drugs to prevent infection.

(1) Gibb, D et al. Lancet 2004; 306:1865-1871

Competing interests: None declared