Effect of Zinc Supplementation vs Placebo on Mortality Risk and HIV Disease Progression Among HIV-Positive Adults With Heavy Alcohol Use
Authors: Matthew S. Freiberg, Debbie M. Cheng, Natalia Gnatienko, Elena Blokhina, Sharon M. Coleman, Margaret F. Doyle, Tatiana Yaroslavtseva, Carly Bridden, Kaku So-Armah, Russell Tracy, Kendall Bryant, Dmitry Lioznov, Evgeny Krupitsky, Jeffrey H. Samet
Journal: JAMA Network Open (2020)

<h3>Importance</h3> Zinc supplementation can reduce alcohol-related microbial translocation and inflammation. <h3>Objective</h3> To assess whether zinc supplementation reduces markers of mortality and risk of cardiovascular disease, reduces levels of inflammation and microbial translocation, and slows HIV disease progression in people with heavy alcohol use who are living with HIV/AIDS. <h3>Design, Setting, and Participants</h3> This study is a double-blinded placebo-controlled randomized clinical trial of zinc supplementation among participants recruited from 2013 to 2015. Participants were recruited from HIV and addiction clinical and nonclinical care sites in St Petersburg, Russia. Participants were adults (aged 18-70 years) with documented HIV infection who were antiretroviral therapy–naive at baseline and had past 30-day heavy alcohol consumption. Data analysis was performed from February 2017 to February 2020. <h3>Intervention</h3> Pharmacy-grade zinc gluconate supplementation (15 mg for men and 12 mg for women, taken daily by mouth for 18 months) was compared with a placebo. <h3>Main Outcomes and Measures</h3> The primary outcome was mortality risk measured as a change in Veterans Aging Cohort Study (VACS) Index score between baseline and 18 months. The VACS Index scores range from 0 to 164, with higher scores indicating higher mortality risk. Secondary outcomes were change in CD4 cell count between baseline and 18 months, the assessment of cardiovascular disease risk (Reynolds Risk Score, which ranges from 0% to 100%, with higher scores indicating higher risk), and changes in inflammatory or microbial translocation biomarkers at 18 months. Adjusted linear regression analyses were performed. <h3>Results</h3> A total of 254 participants (184 men [72%]; mean [SD] age, 34 [6] years) were enrolled in the trial; 126 were randomized to receive zinc, and 128 were randomized to receive placebo. Participants had high CD4 cell counts (mean [SD], 521 [292] cells/mm<sup>3</sup>), and 188 (74%) reported heavy drinking in the past week. In the main analyses, zinc supplementation did not affect changes in the VACS Index score at 18 months (change for zinc, mean [SD], 0.49 [14.6]; median [interquartile range], 0.0 [−7.0 to 6.0]; change for placebo, mean [SD], 5.5 [17.2]; median [interquartile range], 6.0 [−6.0 to 14.0]; adjusted mean difference [AMD], −4.68; 95% CI, −9.62 to 0.25;<i>P</i> = .06) or any secondary outcomes, including change in CD4 cell count (AMD, 41.8 cells/mm<sup>3</sup>; 95% CI, −20.3 to 103.8 cells/mm<sup>3</sup>;<i>P</i> = .19), Reynolds Risk Score (AMD, −0.014; 95% CI, −0.167 to 0.139;<i>P</i> = .85), interleukin-6 level (AMD, −0.13 pg/mL; 95% CI, −0.38 to 0.11 pg/mL;<i>P</i> = .30), dimerized plasmin fragment D level (AMD, −0.21 μg/mL fibrinogen equivalent units; 95% CI, −0.48 to 0.07 μg/mL fibrinogen equivalent units;<i>P</i> = .14), soluble CD14 level (AMD, −38.01 ng/mL; 95% CI, −166.90 to 90.88 ng/mL;<i>P</i> = .56), intestinal fatty acid binding protein level (AMD, 0.08 pg/mL; 95% CI, −0.07 to 0.22 pg/mL;<i>P</i> = .32), and lipopolysaccharide binding protein level (AMD, −0.09 ng/mL; 95% CI, −0.23 to 0.06 ng/mL;<i>P</i> = .24). In the per-protocol analyses, zinc supplementation statistically significantly affected changes in the VACS Index score at 18 months (AMD, −7.49; 95% CI, −13.74 to −1.23;<i>P</i> = .02); however, the adherence rate to zinc supplementation was 51%. <h3>Conclusions and Relevance</h3> Zinc supplementation did not reduce mortality risk, CD4 cell counts, cardiovascular disease risk, and levels of inflammation or microbial translocation in people with heavy alcohol use who are living with HIV/AIDS. Zinc supplementation did not change the VACS Index score but may have been limited by low adherence. <h3>Trial Registration</h3> ClinicalTrials.gov Identifier:NCT01934803