SOUTH AFRICA: New report confirms nutrition no substitute for treatment

There is no evidence that better nutrition can substitute for antiretroviral (ARV) treatment, a new report has found. These findings might seem unremarkable anywhere else in the world, but not in South Africa, where the issue of nutrition has been tainted by a damaging debate that has tended to frame it as an alternative to ARVs.

Statements by Health Minister Manto Tshabalala-Msimang, suggesting that eating garlic, beetroot and olive oil, could delay the need to take ARVs, have created widespread confusion in the country with the world's highest HIV caseload.

A multidisciplinary panel of 15 members of the Academy of Science of South Africa (ASSAf), an independent statutory body considered to be the national academy of science for the country, spent nearly two years reviewing an estimated 2,000 studies on the role of nutrition in the HIV and TB pandemics.

Drawing on literature as well as years of field experience, the panel formed a consensus on the role of nutrition and reviewed guidelines from the World Health Organisation (WHO), the South African Department of Health and the Southern African HIV/AIDS Clinicians Society to see how the guidelines matched the science.

The report concluded that no evidence exists to back claims that better nutrition alone can treat HIV or TB - let alone curb these pandemics. Such assertions have led many South Africans to question high-level commitment to ARV promotion and the national rollout.

"Neither poverty nor malnutrition is the cause of HIV/AIDS or tuberculosis," said Prof Este Vorster, director of the Africa Unit for Transdisciplinary Health Research at Northwest University and panel member. "If you've been tested for HIV and you know your status, you need to know that dietary supplements cannot compensate for healthy eating; in the same way, eating healthily cannot compensate for antiretroviral drugs."

Many studies indicated improved outcomes for patients practising better nutrition in addition to drug treatments. For instance, the intake of macronutrients, such as carbohydrates, fats and proteins, was a strong indicator as to how fast people living with HIV and on treatment would progress to AIDS, said Jimmy Volmink, a clinical researcher at the University of Stellenbosch, but such studies on the role of nutrition in HIV and TB were rare.

He noted that among the small number of studies available, most had been conducted in high-income countries, where populations tend to be better nourished and treated. Questions remained as to the applicability of these studies in lower-income settings or even more socio-economically complex settings such as South Africa.

"We might be one country, but we are not one nation yet," he said. "We need to be aware of disparities between the haves and the have-nots; we need to see what works in specific situations."

Nobody wants to be very heavy handed with the traditions of the majority...it's very hard to regulate a tradition that the majority of the population thinks is okay.
Besides identifying a lack of research on nutrition in South Africa, the report noted confusion about the role of nutrition in HIV, which was being exacerbated by a dual system of medicine regulation that subjected "Western" medicine to much more rigorous controls than complementary medicines, such as immune boosters and nutritional supplements.

"If you simply put together something, put it in a bottle and sell it for R300, it's never checked," said Wieland Gevers, ASSAf's executive officer and panel member.

Consequently, HIV-positive people, family members, caregivers and the community were not only confused about the validity of medicines and nutrition, and what roles they played, but also distrustful of medical doctors and prescription treatments, according to the report.

The duality in regulatory practice arises from the contrast between Western scientific tradition, with its enormous emphasis on rigorous testing, and traditional medicine and the politics related to culture in South Africa, he said.

"In traditional medicine, we have a different approach: it is seen as wisdom passed on. It's simply, in a sense, experience in practice," he said. "Traditional medical practitioners say that part of the remedy is the patient's belief in the remedy itself, and it's very hard to test that in a controlled study."

"Also, there are the special conditions of the historical transitions," he said. "Nobody wants to be very heavy handed with the traditions of the majority - about 80 percent of South Africans would go to a traditional healer first; it's very hard to regulate a tradition that the majority of the population thinks is okay," Gevers said.

Although the report did not focus on the debate about the regulation of traditional versus "Western" medicines, it noted the need for better regulation of "traditional" or "alternative" medicines, and to educate the population about their uses. According to Gevers, the health department and the Medical Research Council were moving in that direction.

The report has been released at a tumultuous time for Tshabalala-Msimang and her department. Deputy Health Minister Nozizwe Madlala-Routledge, who was fired less than two weeks ago, has also been at loggerheads with the health minister over her stance on nutrition, ARVs and other health issues.

"I want to stress that this not part of any political issue; the project had a dynamic of its own," Gevers said, pointing out that the timing of ASSAf's report on nutrition was coincidental. "We saw a need for this study; in these highly controversial areas of nutrition everybody's an expert, and you have to be sure of your ground."

The WHO, the South African Health Department and the Southern African HIV/AIDS Clinicians Society, whose guidelines were reviewed, have not yet commented on the study but ASSAf said it was too soon to expect a response. Tshabalala-Msimang received an advanced copy of the report.

"The health department is likely to be preoccupied with other matters right now, but we expect to give a detailed presentation to explore how we can link our research with current interventions," Gevers said.