Introduction
CAM for Immune Support
CAM
for HIV- and Medication-Related Symptoms and Their Side Effects
Conclusion
Introduction
Eight or nine years ago, when people would come to my
office in search of a rational opinion regarding the use of complementary
therapies versus the use of conventional medications for treatment of HIV,
there was a great deal to talk about the potential of the anti-oxidant
approaches such as N-acetyl cysteine (N-AC) and high-dose vitamin
C; the failings of AZT as a durable treatment for HIV; the importance of
Bactrim prophylaxis for PCP and Toxoplasmosis, two of the major opportunistic
infections that affect HIV-positive people; and the critical role of nutrition,
exercise, and mind-body practices in maintaining a healthy immune system.
Now when people come for the same discussion, the landscape has shifted
dramatically, but many of the same points need to be addressed. There is
no doubt now—unlike in the late 80s and early 90s—that antiretroviral medications
are the mainstay of HIV treatment and that these drugs have the potential
to prevent disease progression in HIV-positive people in a way no alternative
approach has been able to do. Many people who come to me now with a high
viral load and they are not taking antiretrovirals—but expect a regimen
of vitamins and herbs to fight the virus—get an in-depth discussion of
the evidence for the use of conventional medications. That said, though,
there is still a great deal to say about the role of alternative treatments
in HIV disease.
The two major ways in which I find complementary/alternative
medicine (CAM) strategies helpful with my HIV-positive patients
are in the enhancement of immune function and in the treatment of HIV-related
symptoms and of medication-related side effects.
CAM
for Immune Support
There is a huge amount of interest—not just from people
with HIV, but from people with cancer and other life-threatening illnesses,
as well as from people who simply feel they get sick more often than they
should—in the use of CAM strategies to boost the immune system. There is
some reasonable evidence for the use of some of these strategies, and almost
no evidence for the use of others. Let’s look at a few of the most popular
ones in turn.
Echinacea has been
proven to work well in decreasing the severity and duration of acute upper
respiratory illness (the common cold or URI). Many people use it for prevention
of viral illness, but the studies on this have not proven that it works.
This herb definitely has immune-stimulating properties, increasing levels
of some of the chemical signals that activate T cells and stimulating production
of antibodies. There has been some concern about whether this T-cell stimulating
effect could be dangerous in HIV positive people, as it might cause a rise
in viral load as a result of increasing replication of infected T cells.
In fact, some texts recommend that HIV-positive patients avoid the use
of echinacea. Many clinicians, though, myself included, feel that short-term
use of echinacea for treatment of URI is very unlikely to be dangerous.
If you are having a viral-load measurement done, though, and you have been
recently taking echinacea, you should make sure your practitioner knows
about the possible effect on viral load so that a rise is not interpreted
as a failure of your antiretrovirals. If you have been on echinacea and
there is a rise in your viral load, stop the herb and repeat in two weeks
to determine if this rise is a real medication failure. Because long-term
usage of echinacea has not proven to be beneficial in any studies, and
because there may be some level of risk involved, I do discourage maintenance
use of echinacea for my patients.
Astragalus is a Chinese
herb used in many tonic formulas in Chinese medicine. This herb is also
extremely popular among HIV patients. Like echinacea, it does have proven
immune-stimulating properties. As with all of the herbal remedies I will
mention in this article, there is no definitive evidence that it can alter
the course of HIV disease. Many patients choose to take one of the Chinese
formulae containing Astragalus as part of their immune system “health maintenance.”
Other common constituents in these formulas, which also demonstrate immune-stimulant
effects in the laboratory, are licorice
and maitake, reishi,
and shiitake mushrooms. There is no
evidence of significant harm with any of these formulas, nor has there
been proof of any significant benefit. Licorice can raise blood pressure,
so your blood pressure should be monitored during the course of treatment
with this herb. Some other non-Chinese herbs, also in this same category
of potential but unproven benefit, include cat’s
claw and pau d’Arco, two
South American herbal medicines.
High-dose Vitamin C
is a less popular alternative since the onset of the new generation of
medications, but still quite widely used. Vitamin C at high doses has an
anti-HIV effect in the test tube, as well as anti-oxidant properties. Many
patients choose to use intravenous (IV) vitamin C in hopes of achieving
the super-high levels of vitamin C in the bloodstream required for this
anti-HIV effect. Doses can range from 20 to 60 grams at a treatment. Typically,
people cannot take more than 10 to 20 grams orally per day without developing
diarrhea—so they use the IV approach, which doesn’t cause diarrhea. The
anti-oxidant approach to HIV therapy stems from the finding that much of
the tissue damage done in the body during the progression of HIV disease
is a result of the generation of a type of chemicals in the body called
free radicals, which can be very destructive
to many organ systems. The anti-oxidant substances, which include vitamin
C, vitamin E, beta-carotene,
selenium, alpha-lipoic
acid, grape seed extract,
coenzyme Q10, pycnogenol,
n-acetyl cysteine (N-AC), and many
others, have formed a central part of the “immune support” strategies for
many people with HIV. As with the immune stimulant herbs, although there
is a reasonable theoretical justification for this approach, no one has
yet been proven a definite benefit. Fortunately, most of these substances
are quite safe, so other than the cost, there is probably nothing to be
lost by including them in the overall treatment plan. IV vitamin C should
be given with caution, particularly in people with a family or personal
history of kidney stones or any other significant kidney disease.
Mind-body strategies
has the strongest evidence of all the CAM approaches to support its use
as a safe long-term strategy for boosting immune function. Test-tube, animal,
and human studies have all definitively proven the impact of poorly-controlled
stress on immune function. There is no conclusive large trial yet proving
its benefit in HIV, but a program of 10 to 15 minutes twice daily of either
meditation, visualization, yoga, or other “centering” physical exercise
(or other relaxation strategy) should absolutely be a part of everyone’s
overall immune support program. Likewise, nutrition
and aerobic exercise are critical to
healthy immune function, and need individually tailored approaches for
everyone.
CAM
for HIV- and Medication-Related Symptoms and Their Side Effects
HIV- or medication-related diarrhea
The advent of protease inhibitors
(PIs), the most potent class of anti-HIV medication to be developed to
date, revolutionized the medical treatment of HIV. However, many patients,
particularly those on Viracept (one of the most popular PIs), deal with
an intermittent but chronic diarrhea as a side effect of their treatment.
The amino acid glutamine, although
it will not stop the diarrhea in the way Imodium or other medications might,
is excellent for promoting bowel health, improving nutrient absorption,
and generally minimizing diarrhea symptoms. The dose is flexible—most people
take a total of two grams or so per day, usually with meals—and there are
no side effects or medication interactions to be concerned about. Probiotics—the
class of “friendly” bacteria that includes Acidophilus, lactobacillus,
and many other species that normally inhabit the intestinal tract and help
maintain smooth bowel function—can also be taken in supplement form and
can be very helpful.
Peripheral neuropathy
Both the virus and a number of the antiviral medications
can cause a painful nerve syndrome called peripheral neuropathy. Acupuncture
can be very useful in treating this condition. Studies of this have been
somewhat equivocal, but in my practice, a number of patients have had wonderful
results with acupuncture. Generally, you will need at least four to six
sessions with the acupuncturist to determine if it is going to be helpful
for you, and you may then need a one- to two-times-per-month maintenance
schedule to keep the condition under control for the long term.
Liver function abnormalities
Almost all of the medications taken to fight HIV have
the potential to cause some elevation in the liver function tests, which
even if there are no physical symptoms, can be a cause for concern. This
is especially true in people who have co-infection with hepatitis C in
addition to HIV. Milk thistle is a
wonderful herbal medicine I use in almost all of my HIV-positive patients.
It has been shown in a number of studies to help with the regeneration
of liver cells damaged by exposure to a chemical agent. Although it has
not been studied specifically in HIV disease, I have seen a number of my
patients’ elevated liver function tests return to normal once they started
on milk thistle. This herb should be taken in a standardized extract form,
containing between 400 to 500 milligrams of the active constituent silymarin
in the daily dose. There are no adverse effects and no known drug interactions
with this herbal treatment.
Depression
Living with a chronic illness can be difficult. Many
patients are not willing to take on an additional medication for treatment
of depression and are looking for a “natural” alternative. Unfortunately,
St. John’s wort, an herb that can be
quite helpful for some cases of depression, should not be used
in people on protease inhibitors, as it can lower the serum levels of these
medications quite significantly. One other option to consider is the nutritional
supplement called s-adenosyl methionine,
or SAM-e, which in a dose of 400 to
800 milligrams twice daily, can be very helpful in treating a mild depression.
To date, there is no known interaction between SAM-e and antiretroviral
medications.
Hyperlipidemia (high cholesterol)
The protease inhibitors have a tendency to substantially
raise cholesterol in some people. There are two herbal remedies that have
proven benefit in treating high cholesterol and can be used safely with
antiretroviral medications. The first is garlic,
which if taken in a dose of one clove daily, can lower cholesterol up to
ten percent with virtually no side effects (except a bit of odor!). If
you prefer tablets, garlic in this form will work just as well. The second
is red rice yeast, which is marketed
under the name Cholestin. Although not effective for everyone, this product
can produce a dramatic drop in cholesterol in some people and is perfectly
safe.
Conclusion
Everyone who is on antiretroviral medications and also
using herbs and supplements must be sure to keep their healthcare provider
informed about their regimen. As more research is done, we may learn more
about interactions between herbal medicines and HIV medications that will
have a potentially significant impact on treatment. If your provider is
not aware of your use of herbs and supplements, he or she cannot help you
stay up to date with the emerging information on interactions, both beneficial
and otherwise.
RELATED PROGRAMS
