By: Ben Kligler, MD
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.
HIV- or medication-related diarrhea
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.

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.