HIV-1 Infection in Women Is Associated With Severe Nutritional Deficiencies : JAIDS Journal of Acquired Immune Deficiency Syndromes

Secondary Logo

Journal Logo


HIV-1 Infection in Women Is Associated With Severe Nutritional Deficiencies

Baum, Marianna K.*; Shor-Posner, Gail*; Zhang, Guoyan*; Lai, Hong*; Quesada, Jose A.*; Campa, Adriana*; Jose-Burbano, Maria*; Fletcher, Mary Ann; Sauberlich, Howerde; Page, J. Bryan*

Author Information
Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 16(4):p 272-278, December 1, 1997.
  • Free


A synergistic relationship between immune dysfunction and malnutrition has long been recognized(1), suggesting that inadequate nutritional status may be an important cofactor of HIV-1 disease progression. Our studies indicate that many of the nutrient deficiencies that are highly prevalent in asymptomatic HIV-1-infected individuals, including zinc and vitamins A, E, B6, and B12(2), are well documented to impair immunological function(3-5). Furthermore, development of nutrient deficiency has been associated with faster disease progression in vitamin A- or vitamin B12-deficient HIV-1-infected homosexual men(6), and with increased mortality in vitamin A-deficient HIV-1-seropositive drug users(7).

HIV-1-infected men and women who abuse drugs may be particularly vulnerable to nutritional deficiencies due to drug-nutrient interactions as well as relatively poor dietary intake. Addictive drugs of abuse have been shown to produce significant nutritional alterations(8,9), which may contribute to the immunodeficiency observed in HIV-1-infected individuals(4,5). A detailed nutritional profile of the HIV-1-infected drug user, however, has yet to be described. Moreover, although women and their infected children comprise rapidly growing groups of newly diagnosed cases(10-12), little information is available regarding the nutritional status of HIV-1-infected female drug users, whose nutritional requirements and dietary patterns may be different from those of HIV-1-infected male drug users. The present study was designed to evaluate the relationship between immune and nutritional status in HIV-1-infected men and women who abuse drugs.


Study Population

Nutritional and immune measures were available for 125 subjects randomly selected from a cohort of 284 men and women being followed longitudinally for HIV-1 infection and cofactors of disease progression. Subjects were recruited from a street drug-using population, which has been followed for the past 9 years. The HIV antibody status of participants was determined by standard HIV enzyme-linked immunosorbent assay antibody testing, with Western blot confirmation. The 125 HIV-1-seropositive participants were examined every 6 months for 3.5 years at a community-based study clinic, where blood was drawn for evaluation of immune function and nutritional status, and a history and physical examination conducted.

Informed consent was obtained from all individuals, and the investigation was approved by the Human Studies Committee of the University of Miami School of Medicine.

Immunological Parameters

Immune assessment included measurements of lymphocyte subpopulations(CD4, CD8) and immune activation (β2-microglobulin). Flow cytometry and monoclonal antibodies(13) were used to quantitate numbers of circulatory T-helper/inducer (CD4) and T-suppressor/cytotoxic(CD8) cells. β2-Microglobulin was measured by radioimmunoassay(Pharmacia, Uppsala, Sweden), with the use of standards provided by the manufacturers.

Nutritional Laboratory Analysis

Fasting blood samples were obtained from all participants between 8:00 AM and 11:00 AM, to minimize the influence of either the last meal or diurnal variations on specific nutritional, metabolic, and endocrine parameters. After processing, all samples of blood were stored at-70°C, until ready for analysis.

Biochemical determinations of specific nutrient levels known to influence immune function and to be altered in HIV-1-infected individuals were evaluated, as previously described(2).

Briefly, total serum vitamin A and E levels were determined by high-performance liquid chromatography using a simultaneous determination method. Levels of vitamin B6 in all participants were determined by erythrocyte transaminase assay, and total plasma cobalamin levels (vitamin B12) were established by radioisotope dilution assay. Plasma levels of zinc were determined using atomic absorption spectrophotometry with graphite furnace attachment, and selenium levels were evaluated by a standardized fluorometric method, with selenium reference obtained from the National Institute of Standards and Technology(Standard Reference Material 1598), using bovine serum.

Overall nutritional status was evaluated by prealbumin and retinol binding protein measurements, which are considered to be sensitive indicators of subclinical malnutrition(14). Levels of prealbumin and retinol binding protein were determined by standard radial immunodiffusion, with measurements <15.0 and 3.0 mg/dl considered deficient for prealbumin and retinol binding protein, respectively.

Dietary Intake

Dietary intake was evaluated using a semiquantitative food frequency questionnaire(15), an instrument standardized for nutritional epidemiological studies.

In this cohort, dietary intake was assessed over a 6-month period. Food consumption was evaluated in terms of dietary intake and supplementation from pills, and then was compared with the U.S. Recommended Dietary Allowance (RDA) standards(16).

Statistical Analysis

Comparisons of the distribution of continuous nutritional measurements were made using the Wilcoxon rank-sum test. The statistical significance of observed differences between men and women in dichotomous parameters was examined with the use of the χ2 test. When cell counts were not balanced, the exact permutational method was used to calculate the exact p values. A paired Student's t test was used to compare dietary intake and RDA values. Spearman's correlation procedures were used to examine the relationship between dietary intake and plasma nutrient status.


Group Characteristics

The 125 subjects in this study included 82 men and 43 women, ranging in age from 27 to 61 years (mean age, 40.4 ± 7.5 years). As indicated in Table 1, the majority of the participants were African American (88%), with a smaller proportion of Hispanic (8%) and white (4%) men and women. Socioeconomic status and mean years of education were similar in the men and women. The majority of the population reported yearly income <$10,000 U.S. The major drug of abuse was cocaine, with positive urine toxicology noted in 85% of the men and 80% of the women. The immune status was similar in the men and women.

Group characteristics

Nutritional Status of HIV-1-Infected Men and Women Who Abuse Drugs

Biochemical determinations revealed widespread nutritional abnormalities in the HIV-1-infected drug users. Up to 86% (108 of 125) of the HIV-1-seropositive men and women had at least one nutritional deficiency, with multiple deficiencies observed in 56% of the group.

Table 2 indicates specific differences in plasma nutrient levels between the HIV-1-infected men and women. Overall nutritional status, as determined by prealbumin measurements, was significantly better in the HIV-1-infected men (20.9 ± 6.6 mg/dl), relative to the women(17.3 ± 8.2 mg/dl; p < .01). Moreover, a significantly higher proportion of overly low prealbumin levels (<15 mg/dl) was observed in the women (44%) as compared with 13% in men (p < .01). Measurements of retinol binding protein were similarly significantly lower in the women (3.3 ± 2.0 mg/dl) than in the men (4.1 ± 2.8; p=.02). HIV-1-infected women also exhibited lower levels of the trace element selenium (110 ± 20 µg/L) than the men (120 ± 20 µg/L; p < .01), and had a significantly higher proportion of selenium deficiency (<85 µg/L) relative to the men (16% vs. 3%; p < .01).

In both the male and female groups, micronutrient deficiencies, particularly of zinc and vitamins A and E, were widespread. As shown in Figure 1, 57% of the women and 45% of the men had zinc levels <0.75 mg/dl. Moreover, 49% of the HIV-1-seropositive men and 63% of the infected women exhibited low levels of vitamin A(<0.3 µg/ml), with plasma levels of vitamin E <5 µg/ml noted in 48% of the women and 46% of the men. Deficiency of vitamin B12 (<200 pg/ml) and vitamin B6 (activity coefficient [A/C] > 1.85) was considerably smaller, occurring in 9.3% to 11.6% of the women and 8.5% to 16.3% of the infected men.

Plasma levels of nutrients

Dietary Intake Patterns in HIV-1-Infected Drug Users

Table 3 and 4 indicate dietary consumption patterns for HIV-1-infected men and women. Intake of most micronutrients was at or above the RDA values, although zinc intake was below the RDA for both the women (p <.01) and the men (p < .01).

The proportion of participants reporting use of supplements ranged from a low of 6% to 7% for zinc to a high of 24% to 29% for vitamins B6, B12, E, and A. A comparison of the proportion of deficiency between supplemented and nonsupplemented HIV-1-infected drug users revealed similar levels of deficiency of vitamins B6, B12, A, and zinc. The proportion of vitamin E deficiency, however, was significantly higher in the nonsupplemented(50%), relative to the supplemented group (26%;p < .05).

Immune and Micronutrient Status

Parameters of immune function were similar in the HIV-1-infected men and women. As shown in Table 1, mean CD4 counts were not significantly different between men (407 ± 291/mm3) and women (470 ± 376/mm3). Additionally, no significant differences in CD8 counts or β2-microglobulin measurements were noted in the HIV-1-seropositive men and women.

FIG. 1:
Micronutrient deficiencies, particularly vitamins A (<0.3µg/ml), E (<5 µg/ml), and zinc (<0.75 µg/ml), were widespread in both HIV-1-infected men (solid bar) and HIV-1-infected women(shaded bar). A significantly higher proportion of selenium deficiency(<85 µg/L) was exhibited in the women relative to the men(**p < .01).
Dietary intake in HIV-1-infected men

Stratification of the data (CD4 count <200/mm3, CD4 count >200/mm3), revealed that the nutritional status among men (n = 55) and women (n = 28) with CD4 counts >200/mm3 was similar. Women with advanced disease (CD4 count ≤200/mm3; n = 11), however, had significantly lower levels of vitamin A (0.22 ± 0.01 µg/ml), vitamin E (5.0 ± 1.6 µg/ml), and selenium (99 ± 19µg/L), as compared with levels in the men with CD4 count ≤200/mm3 (n = 20), which were 0.40 ± 0.20µg/ml for vitamin A (p = .009), 6.5 ± 2.1µg/ml for vitamin E (p = .05), and 117 ± 21 µg/L for selenium(p= .02). Levels of prealbumin (11.3 ± 5.5 mg/dl) and retinol binding protein (2.2 ± 0.93 mg/dl) were also significantly lower in the women with low CD4 counts, as compared with the men whose prealbumin and retinol binding levels were 20.8 ± 7.0 mg/dl, (p = .0008), and 4.6 ± 3.1 mg/dl (p = .0005), respectively.

Dietary intake in HIV-1-infected women

Figure 2 illustrates the proportion of nutrient deficiency in men and women (n = 11) with CD4 counts≤200/mm3. Women with low CD4 counts exhibited significantly more vitamin A deficiency (90%) than men(30%) with CD4 counts <200/mm3 (p < .01). Vitamin E deficiency was also more prevalent in women with CD4 counts <200, occurring in 70% of this group, as compared with only 20% of the men (p < .02). In addition, poorer overall nutritional status, as indicated by overly low levels of prealbumin, was observed in 73% of the women with advanced disease, as opposed to 25% of the men with CD4 counts <200/mm3 (p < .05).

Nutritional Status in Comparison to Other HIV-1-Infected Cohorts

Specific nutrient deficiencies have been previously demonstrated in asymptomatic HIV-1 infection(2). In 100 HIV-1-infected homosexual men, ages 20 to 55 years(2), overtly low blood levels of vitamins A (11%), E (19%), B6 (30%), B12 (11%), and zinc (26%) were documented, whereas mean plasma nutrient levels were within the range considered to be adequate for these micronutrients.

FIG. 2:
Women with advanced disease (n = 11; shaded bar) exhibited significantly more deficiency (<0.3 µg/ml) of vitamins A(**p < .01) and E (<5 µg/ml; *p < .02) compared with men with CD4 counts <200/mm3 (n = 20; solid bar).

Micronutrient concentrations below the normal laboratory range in HIV-1-infected subjects have also been reported in a small proportion of HIV-1-seropositive men and women participating in a study of heterosexual HIV-1 transmission(17). In this investigation, 4% of the participants had low zinc and vitamin E levels and 2% had low selenium and vitamin B6 levels.


In accord with our previous studies indicating abnormal nutrient measurements in HIV-1-infected homosexual men(2,6), the present findings demonstrate that nutritional alterations, known to affect immune function, are widespread among HIV-1-infected men and women who abuse drugs. Although nutritional deficiencies are common in both drug abusers and homosexual men, the prevalence of nutritional alterations varies. Severely decreased levels of antioxidants, vitamins A and E, which were observed in 40% to 50% of the HIV-1-infected men and women who abuse drugs, are not as evident in HIV-1-infected gay men, who exhibit only 10% to 15% deficiency of these nutrients(2), and appear to be rare in men and women participating in a heterosexual HIV-1 transmission study(17). Inadequate zinc status, however, was prominent in both the homosexual men and the drug users, supporting the importance of this nutrient as a sensitive marker of HIV-1 disease progression(18). The impaired antioxidant status of the HIV-1-infected drug user is of particular concern, in light of the importance of antioxidants in immune function, and evidence that antioxidant function may be a significant factor in AIDS(19-21).

This study also indicates that HIV-1-infected female drug users exhibit poorer overall nutritional status than male users, despite similar immune function, as measured by CD4 counts and β2- microglobulin, and comparable dietary intake. Furthermore, in women with advanced HIV-1 disease, nutritional alterations are especially prominent, with significantly lower plasma levels of vitamins A and E, selenium, retinol binding protein, and prealbumin noted in the women relative to the men. The causes for the low plasma levels and severe nutritional deficiencies exhibited in HIV-1-seropositive women with advanced disease remain unclear, and are most likely multifactorial in origin.

There is substantial evidence to indicate that nutritional status may be an important determinant of survival in AIDS. Severe malnutrition is frequently encountered in the later stages of infection, and marked wasting is one of the most prominent characteristics of advanced disease. Although nutritional factors are not likely to be the most important etiological determinants, they may influence initial susceptibility to HIV-1 infection and have a significant impact on the rate and form of disease expression. Inadequate visceral protein status, as measured by low serum albumin levels, has been demonstrated to have a significant prognostic influence on survival(22,23) and be associated with mortality in HIV-1-infected individuals(24,25). A number of studies suggest that antioxidant status is critical for the proper function of healthy immune cells, and that failure of antioxidant function may be an important factor in AIDS(19-21). A decline in plasma selenium levels, which is part of the antioxidant defense system, has been reported in HIV/AIDS patients(26-30), and is associated with a dramatic increased risk of mortality(31). Consistent with the present findings, studies by Semba et al. have reported widespread vitamin A deficiency in HIV-1-infected intravenous drug users, in association with decreased survival(7). In addition, the development of vitamin A or vitamin B12 deficiency in HIV-1-seropositive homosexual men has been associated with a decline in CD4 count(6). Normalization of vitamin A, vitamin B12, and zinc, on the other hand, has been linked to higher CD4 counts and slower disease progression(6), suggesting that normalization may increase symptom-free survival.

Women have been reported to have poorer survival after AIDS diagnosis than men in some(32-37) but not all(38-44) studies. Additionally, there is evidence to indicate that opportunistic infections (e.g., bacterial pneumonia) occur significantly more in HIV-1-infected women than in men(37,45). These findings may reflect differences in access to health care and experimental therapy, as well as differences in ethnicity and socioeconomic status(46-48), circumstances that could also affect nutritional status and contribute to HIV-1-related mortality. The present investigation reveals that HIV-1 disease in female drug users is associated with a marked, deficient nutritional status, which may be an important determinant of disease progression and survival. Further investigation will be required to determine the mechanisms by which the micronutrient profile is altered in HIV-1-infected male and female drug users, and whether correction can be of therapeutic value in reducing risk of opportunistic infection and slowing disease progression.

Acknowledgments: We thank Noaris Rodriguez for the editorial preparation of this article. This study was supported by National Institute of Mental Health grant number MH50239-05(M.K.B.) and National Institutes of Health and Fogarty International Center grant number 2D43TW00017-08 (M.K.B.).


1. Scrimshaw NS, Taylor CE, Gordon JE. Interactions of nutrition and infection. Am J Med Sci 1959;237:367-81.
2. Beach RS, Mantero-Atienza E, Shor-Posner G, et al. Specific nutrient abnormalities in asymptomatic HIV-1 infection. AIDS 1992;6:701-8.
3. Baum MK, Mantero-Atienza E, Shor-Posner G, et al. Association of vitamin B6 status with parameters of immune function in early HIV-1 infection. J Acquir Immune Defic Syndr 1991;4:1122-32.
4. Beisel WR. Single nutrients and immunity. Am J Clin Nutr 1982;35(Suppl):417-68.
5. Gershwin ME, Beach RS, Hurley LS. Nutrition and immunity. Orlando: Academic Press, 1985.
6. Baum MK, Shor-Posner G, Lu Y, et al. Micronutrients and HIV-1 disease progression. AIDS 1995;9:1051-6.
7. Semba RD, Graham NMH, Caiaffa WT, Margolick JB, Clement L, Clahov D. Increased mortality associated with vitamin A deficiency during human immunodeficiency virus type 1 infection.Arch Intern Med 1993;153:2149-53.
8. Watson RR, Mohs ME. Effects of morphine, cocaine, and heroin on nutrition. Prog Clin Biol Res 1990;325:413-8.
9. Huggins ND, Khaled MA, Cornwell PE, Alvarez JO. Nutritional status and immune function in cocaine and heroin abusers and in methadone treated subjects. Res Commun Subst Abuse 1991;12:209-15.
10. Centers for Disease Control. AIDS in women-United States.MMWR Morb Mortal Wkly Rep 1990;39:845-6.
11. Brookmeyer R. Reconstruction and future trends of the AIDS epidemic in the United States. Science 1991;253:37-42.
12. Miller HG, Turner CF, Moses LE, eds. AIDS: The second decade. Washington, DC: National Academy Press, 1990:48-60.
13. Parker J, Adelsberg B, Azen SP, et al. Leukocyte immunophenotyping by flow cytometry in a multisite study: standardization, quality control and normal values in the transfusion safety study.Clin Immunol Immunopathol 1990;55:187-220.
14. Shetty PS, Jung RT, Wastrasiewicz KE, et al. Rapid-turnover transport proteins: an index of subclinical protein-energy malnutrition.Lancet 1979;2:230-2.
15. Willett WC, Sampson L, Stampler M, et al. Reproducibility and validity of a semi-quantitative food frequency questionnaire. Am J Epidemiol 1985;122:51-65.
16. National Research Council. Recommended dietary allowances, 10th ed. Washington, DC: National Academy Press, 1989.
17. Skurnick JH, Bogden JD, Baker H, Kemp FW, Sheffet A, Quattrone G, Louria DB. Micronutrient profiles in HIV-1 infected heterosexual adults. J Acquir Immun Defic Synd 1996;12:75-83.
18. Graham NMH, Sorensen D, Odaka N, et al. Relationship of serum copper and zinc levels to HIV-1 seropositivity and progression to AIDS. J Acquir Immune Defic Syndr 1991;4:976-80.
19. Revillard JP, Vincent CMA, Favier AE, et al. Lipid peroxidation in human immunodeficiency virus infection. J Acquir Immune Defic Syndr 1992;5:637-8.
20. Papadopulos-Eleopulos E. Reappraisal of AIDS - is the oxidation induced by the risk factors the primary cause? Med Hypoth 1988;25:151-62.
21. Malvy DJ-M, Richard M-J, Arnaud J, Favier A, Amedee-Manesme O. Relationship of plasma malondialdehyde, vitamin E and anti-oxidant micronutrients to human immunodeficiency virus-1 seropositivity.Clin Chim Acta 1994;224:89-94.
22. Bauer T, Ewig S, Hasper E, Rockstroh JK, Lederitz B. Predicting in-hospital outcome in HIV-associated Pneumocystis carinii pneumonia.Infection 1995;23:272-7.
23. Ott M, Fischer H, Polat H et al. Bioelectrical impedance analysis as a predictor of survival in patients with human immunodeficiency virus infection. J Acquir Immune Defic Syndr 1995;9:20-5.
24. Ewig S, Bauer T, Schneider C, et al. Clinical characteristics and outcome of Pneumocystis carinii pneumonia in HIV-infected and otherwise immunosuppressed patients. Eur Respir J 1995;8:1548-53.
25. Cheblowski RJ, Grosvenor MB, Bernhard NH, Morales LS, Bulcavage LM. Nutritional status, gastrointestinal dysfunction and survival in patients with AIDS. Am J Gastroenterol 1989;84:1288-93.
26. Dworkin BM, Rosenthal WS, Wormser GP, Weiss L, Nunez M, Coline C, Herp A. Abnormalities of blood selenium and glutathione peroxidase in patients with acquired immunodeficiency syndrome and AIDs-related complex. Biol Trace Elem Res 1988;20:86-96.
27. Cirelli A, Ciardi M, De Simone C, Sorice F, Giordano R, Ciarelli L, Constantini S. Serum selenium concentration and disease progress in patients with HIV infection. Clin Biochem 1991;24:211-4.
28. Mantero-Atienza E, Sotomayor MG, Shor-Posner G, Fletcher MA, Sauberlich HR, Beach RS, Baum MK. Selenium status and immune function in asymptomatic HIV-1 seropositive men. Nutr Res 1991;11:1237-50.
29. Staal FJT, Ela SW, Roederer M, Anderson MT, Herzenberg LA. Glutathione deficiency and human immunodeficiency virus infection.Lancet 1992;339:909-12.
30. Allavena C, Dousset B, May T, Dubors F, Canton P, Nelleville F. Relationship to trace element, immunological markers, and HIV-1 infection progression. Biol Trace Elem Res 1995;47:133-8.
31. Baum MK, Shor-Posner G, Lai S, et al. High risk of mortality in HIV infection is associated with selenium deficiency. J Acquir Immune Defic Syndr Hum Retrovirol 1997;15:370-4.
32. Blum S, Singh TP, Gibbons J, et al. Trends in survival among persons with acquired immunodeficiency syndrome in New York City. The experience of the first decade of the epidemic. Am J Epidemiol 1994;139:351-61.
33. Piette J, Mor V, Fleishman J. Patterns of survival with AIDS in the United States. Health Serv Res 1991;26:75-95.
34. Rothenberg R, Woelfel M, Stoneburner R, Milberg J, Parker R, Truman B. Survival with the acquired immunodeficiency syndrome-experience with 5833 cases in New York city. N Engl J Med 1987;317:1297-302.
35. Buira E, Gatell JM, Miro JM, et al. Influence of treatment with zidovudine (ZDV) on the long-term survival of AIDS patients. J Acquir Immune Defic Syndr 1992;5:737-42.
36. Whyte BM, Swanson CE, Cooper DA. Survival of patients with the acquired immunodeficiency syndrome in Australia. Med J Aust 1989;150:358-62.
37. Melnick SL, Sherer R, Louis TA, et al. Survival and disease progression according to gender of patients with HIV infection. JAMA 1994;272:1915-1921.
38. Lundgren JD, Pedersen C, Clumeck N, et al. Survival differences in patients with AIDS, 1979-1989. BMJ 1994;308:1068-73.
39. Chang HH, Morse DL, Noonan C, et al. Survival and mortality patterns of an acquired immunodeficiency syndrome (AIDS) cohort in New York state. Am J Epidemiol 1993;138:341-9.
40. Egger M, Twisselmann W, Ledergerber B, et al. Differences in progression of HIV infection between men and women [letter].BMJ 1995;310:941.
41. Iatrakis GM, Shah PN, Smith JR, Kitchen VS, Barton S. Survival of men and women with AIDS: a comparative study [letter].Genitourin Med 1994;70:290.
42. Phillips AN, Antunes F, Stergious G, et al. A sex comparison of rates of new AIDS-defining diseases and death in 2554 AIDS cases. AIDS 1994;8:831-5.
43. Cozzi-Lepri A, Pezzotti P, Dorrucci M, Phillips AN, Rezza G. HIV disease progression in 854 women and men infected through injecting drug use and heterosexual sex and followed for up to nine years from seroconversion. BMJ 1994;309:1537-42.
44. Chaisson RE, Keruly JC, Moore RD. Race, sex, drug use, and progression of human immunodeficiency virus disease. N Engl J Med 1995;333:751-6.
45. Greenberg AE, Thomas PA, Landesman SH, et al. The spectrum of HIV-1 related disease among outpatients in New York City. AIDS 1992;6:849-59.
46. Fleming PL, Ciesielski CA, Byers RH, Castro KG, Berkelman RL. Gender differences in reported AIDS-indicative diagnoses. J Infect Dis 1993;168:61-7.
47. Stein M, Pieete J, Mor V, et al. Differences in access to zidovudine(AZT) among asymptomatic HIV-infected persons. J Gen Intern Med 1991;6:35-40.
48. Mocroft A, Johnson MA, Phillips AN. Factors affecting survival in patients with the acquired immunodeficiency syndrome. AIDS 1996;10:1057-65.
49. Interagency Board for Nutrition Monitoring and Related Research. Nutritional status and nutrition-related health measurements. InThird Report on Nutrition Monitoring in the United States, vol. 1. 1994;160-93.
    50. Pelch SM, Senti FR. Analysis of zinc data from the Second National Health and Nutrition Examination Survey (NHANES II). J Nutr 1985;115:1393-7.

    HIV-1-positive women; HIV-1-positive men; Drug users; Nutritional status

    © Lippincott-Raven Publishers.