Background: Despite findings that selenium supplementation may improve immune functioning, definitive evidence of its impact on human immunodeficiency virus (HIV) disease severity is lacking. Methods: High selenium yeast supplementation (200 µg/d) was evaluated in a double-blind, randomized, placebo-controlled trial. Intention-to-treat analyses assessed the effect on HIV-1 viral load and CD4 count after 9 months of treatment. Unless otherwise indicated, values are presented as mean ± SD. Results: Of the 450 HIV-1-seropositive men and women who underwent screening, 262 initiated treatment and 174 completed the 9-month follow-up assessment. Mean adherence to study treatment was good (73.0%±24.7%) with no related adverse events. The intention-to-treat analyses indicated that the mean change (⌬) in serum selenium concentration increased significantly in the selenium-treated group and not the placebo-treated group (⌬=32.2±24.5 vs 0.5±8.8 µg/L; PϽ.001), and greater levels predicted decreased HIV-1 viral load (PϽ.02), which predicted increased CD4 count (PϽ.04). Findings remained significant after covarying age, sex, ethnicity, income, education, current and past cocaine and other drug use, HIV symptom classification, antiretroviral medication regimen and adherence, time since HIV diagnosis, and hepatitis C virus coinfection. Follow-up analyses evaluating treatment effectiveness indicated that the nonresponding selenium-treated subjects whose serum selenium change was less than or equal to 26.1 µg/L displayed poor treatment adherence (56.8%±29.8%), HIV-1 viral load elevation (⌬=ϩ0.29±1.1 log 10 units), and decreased CD4 count (⌬=−25.8±147.4 cells/µL). In contrast, selenium-treated subjects whose serum selenium increase was greater than 26.1 µg/L evidenced excellent treatment adherence (86.2%±13.0%), no change in HIV-1 viral load (⌬=−0.04±0.7 log 10 units), and an increase in CD4 count (⌬=ϩ27.9±150.2 cells/µL). Conclusions: Daily selenium supplementation can suppress the progression of HIV-1 viral burden and provide indirect improvement of CD4 count. The results support the use of selenium as a simple, inexpensive, and safe adjunct therapy in HIV spectrum disease.

The Veterans Health Affairs is in the process of implementing a new model for the delivery of primary care: The Patient-Centered Medical Home (PCMH). One critical challenge of any PCMH model will be the integration of basic mental health treatment into primary care. Such a mental health integration program must be flexible enough to incorporate new evidence-based treatments as patient demographics and health care needs evolve over time. This paper summarizes the Behavioral Health Laboratory (BHL) care management model, a program already in place in more than 20 Veterans Affairs facilities along with private sector insurance providers, as ideally suited to fill this role in the PCMH. The BHL uses a platform of standardized, software-aided mental health assessments and clinical care managers to deliver evidence-based treatments for depression, anxiety, and substance abuse in primary care settings. The authors review this comprehensive program of screening, assessment, treatment, and referral to specialty care when needed. The BHL program is consistent with the guiding principles of the Patient-Centered Medical Home: applying chronic illness disease management principles to provide more continuous, coordinated, and efficient primary care services to patients with diverse needs. Just as importantly, the authors review how this standardized platform for delivering integrated mental health services provides the flexibility to incorporate novel interventions for a changing population.

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