extracted text

Property of t he Ce nter

•

ISSUE NO. 35

This newsletter is supported through an independent educational grant from 6/axoWellcome

Integrating Complementary
Therapies With HIV Treatments
landmark study published in 1993 found that one in three adult Americans acknowledged using
some form of nontraditional therapy and that almost three quarters of them had not discussed
this with their healthcare providers. Recent surveys have found a higher percentage of patients
in the HIV community seeking therapies outside the mainstream medical establishment. It
is li e y, therefore, that counselors of people living with HIV will have clients who are either already
pursuing or, at least, considering complementary medical approaches to HIV disease. This issue of
HIV Frontline looks at complementary therapies and the importance of integrating them into standard
antiretroviral therapy (ART) regimens. Our goal is to improve communication regarding treatmentbetween client and counselor, between patient and clinician, and among all members of the treatment team.

Ill What Is Complementary Therapy?
Complementary therapy generally comprises practices
that are not part of the established, traditional healthcare
system in the United States but are used with or in lieu of
traditional Western medicine.
This field encompasses treatment by healers such as
Buddhist, Native-American, ayurvedic, naturopathic,
homeopathic, and folk-remedy practitioners and includes
healing modalities, such as acupuncture, used in traditional Chinese medicine.
Some therapies rely on herbs, vitamins and minerals,
animal products and extracts, amino acids and other
molecular dietary supplements, and diets that include or
exclude certain foods . Other therapies offer "body work"
such as exercise, massage, chiropractic, and acupressure.
Still others, such as hypnosis, yoga, meditation, biofeed-

Inside ...
• Integrating Complementary Therapies ...

*
*
• PML Update
*
HIV News Briefs

back, relaxation therapy, and visualization, focus on the
mind-body connection. There are also quasimedical procedures, including enemas and blood cleansing, and
antioxidant and hyperthermia treatments.
Traditionally, such strategies have been termed "alternative" medicine. Alternative, however, implies that nontraditional medicine is used exclusively. The term
"complementary" is preferred, because it indicates that
the patient is combining approaches and benefiting from
what each one offers.
Until recently, complementary therapy was not taught in
medical schools. Generally, it is not available in hospitals
and may involve substances that are not regulated or
approved by the Food and Drug Administration (FDA).
Some complementary therapies have a place in the treatment of HIV, but the emphasis must be on the word complementary. Most HIV experts believe that no treatment
should replace the current standard of care-maximally
suppressive combination ART with an optimal regimen
for the individual patient and, where necessary, medications to prevent and treat other HIV-related conditions.

• Focus on AIDS-Related Candidiasis

•

Ill From Alternative to Mainstream
Traditional medicine is constantly evolving, and yesterday's
alternative may become tomorrow's standard therapy.
Herbal cures may sound like an alternative, but some of the
(continued on page 2)

www.hivline.com

Winter 199B

HIVfrontline
Editorial

Advisory 80@rd
Richard S. Ferri, PhD,
ANP, ACRN

HIV/AIDS Nurse Practitioner
Crossroads Medical
Harwich, Massachusetts

-

Michele Fontaine, MA, CASAC
Senior Vocational Counselor
Next Step Program
Project Renewal
New York, New York

Susan M. Gallego, MSSW,
LMSW-ACP
Private Practitioner/Consultant
Austin, Texas

Howard A. Grossman, MD
Assistant Clinical Professor of Medicine
Columbia University College of
Physicians & Surgeons
New York, New York

Vincent J. Lynch, DSW
Director, National Research
and Training Center on
Social Work and HIV/AIDS
Boston College
Graduate School of Social Work
Chestnut Hill, Massachusetts

-

Angela Shiloh-Cryer, MSW
Director, Office of
Health Policy and AIDS Funding
New Orleans, Louisiana

-

Barry Zevin, MD
Medical Director
Tom Waddell Health Center
San Francisco, California

Wendy Zizzo, PharmD
Clinical Pharmacist
Carlsbad, California

This newsletter is published by World
Health CME, a division of World Health
Communications Inc., and is supported
through an independent educational grant
from Glaxo Wellcome. The views and opinions expressed herein do not necessarily
reflect those of Glaxo Wellcome, World
Health CME, or the Editorial Advisory
Board. Statements regarding drugs, dosages,
and procedures are not meant to serve as
guidelines in the treatment of patients.
Please see the full prescribing information
before using any agent mentioned in this
publication.
© 1998, World Health CME. All rights
reserved. Printed in the USA. Permission
granted for noncommercial reproduction
of this material.

most valuable drugs in the modern medicine chest, including penicillin, digitalis, and the cancer fighter Taxol®, derive from natural sources. Now, there
is a PDR® (Physicians' Desk Reference) for herbal medicines. Therapies that
rely on the mind-body connection may sound distinctly "new age,"
but approaches such as biofeedback, exercise, and participation in
support groups have proven beneficial and are now embraced by the
medical establishment.
A recent survey published in the Journal of the American Medical Association
found that more than 60% of primary care physicians recommend some type
of complementary therapy to their patients, and nearly 25% of physicians
incorporate such therapies in their practices. At least 40 medical schools offer
elective courses in complementary therapies, and there are increasing numbers
of integrated clinics that provide both traditional and complementary therapies in a single setting.
There is still considerable resistance, however, to the idea of nontraditional
medicine. The New England f oumal of Medicine acknowledged the growing
popularity of complementary therapy in a 1993 survey of its prevalence,
costs, and patterns of use. In 1998, a significant portion of one issue was
devoted to the dangers of nontraditional medicine. It urged that alternatives be
avoided unless and until they are proven safe in rigorous scientific studies.
In 1992, the federal government established the Office of Alternative
Medicine (OAM) to identify and support research in complementary
therapy. OAM sponsors SO projects at 11 research centers, including Bastyr
University in Seattle, the only center devoted to research in HIV. Very little
solid data have emerged since OAM began operations, but it is hoped that its
(continued on page 3)
promise will be fulfilled.
■

Spotting AIDS Fraud

Red flags for anyone seeking treatment
outside the mainstream include
It's a cure
No responsible person claims a cure for
AIDS; the most effective, proven therapies offer only viral suppression and
improved health.
It's good for many things
Not just AIDS, but cancer, baldness,
arthritis, or other conditions. This claim
is a sure sign that the seller is just trying
for the broadest possible market.
It has a secret ingredient
No one, especially someone with the
multiple health problems and vulnerability associated with HIV disease,
should ingest an unknown substance.
It's a conspiracy
Claims that the government, in league

with pharmaceutical companies, is trying to suppress an effective treatment
should probably be dismissed as a
smoke screen masking a questionable
product.
It's been written up, but it's in
a foreign language and/ or hard
to find
Any credible study published in a reputable scientific journal will be readily
available in English in a medical or university library or, increasingly, on the
Internet.
It's available only outside the
United States
Steer clear of treatments that require
travel to clinics in countries where medical practice may be poorly regulated.
Such travel can be expensive and the
treatments dangerous.

HIYEc 0 atline
Government regulation of complementary therapy is
limited, mainly because of the Dietary Supplement
Health and Education Act of 1994. This act sharply
restricts FDA regulation of nondrug products that
promote health but do not claim to prevent or treat a
specific disease. Most vitamins, herbs, botanical extracts,
amino acids, and other dietary supplements, therefore,
have avoided scrutiny by the FDA.

Ill The Spectrum of Complementary
Therapies
Complementary therapies range from approaches that
are known to be beneficial to those that are known to be
harmful or fraudulent. Therapies whose effects are less
evident may be worth trying. Patients should be urged,
however, to try them only after informing their treatment
teams and when combining them with standard therapies.
Most complementary therapies known to be beneficial
involve lifestyle modification, and many have been integrated into traditional medical practices. For people living with HIV, recommended lifestyle changes include
•
•
•
•
•
•
•

Improvement of nutrition and diet
Exercise
Cessation of smoking and other substance use
Stress reduction
Relaxation
Counseling
Participation in support groups

Approaches that may be beneficial and are unlikely to be
detrimental include reasonable amounts of supplementary
vitamins, which may provide nutritional support. (Note:
Excess amounts of water-soluble vitamins, such as Band C,
will be eliminated through urination. Fat-soluble vitamins,
however, such as A, D, E, and K, are stored primarily in
the liver, where most HIV drugs are metabolized.
Excessive amounts of these vitamins may be toxic.)
Other therapies that probably will cause no harm, may
relieve symptoms, and may provide comfort include
•
•
•
•

Acupuncture
Massage
Acupressure
Therapeutic touch

Therapies that are ingested may cause side effects and
interfere with prescribed treatments. It is a mistake to
assume that herbs and other natural products are harm-

less. Though many plants (including ·digitalis, opium,
and ephedra) have powerful medicinal properties, some
(such as pennyroyal and jimson weed) are poisonous.
Others-for example, plantain and various "secret"
ingredients in Chinese herbal preparations-may worsen
nausea, diarrhea, and other side effects of prescribed HIV
treatment. Recently, reports of contamination of dietary
supplements with heavy metals and other toxic
substances have caused these unregulated "nutriceuticals" to be viewed negatively.
Not much is known about the interactions between
specific complementary therapies and the drugs used to
treat HIV. This is mainly because of the dearth of scientific
studies on the subject, but reliable anecdotal
information is also sparse. This lack of information can
be attributed to patients' reluctance to admit to the use
of complementary medicines for fear of earning disapproval from their healthcare providers.
Counselors should urge clients to tell their medical teams
about any complementary treatments they are receiving
and unusual foods or dietary supplements they are ingesting. It is a good idea to try only one complementary therapy at a time and note any change in symptoms, for better or worse. Clinicians should be encouraged to elicit and
evaluate this information in a nonjudgmental and
nondismissive manner. The most important thing is to
have complete knowledge, so that the entire treatment
team, including the patient, can watch for negative, or
even positive or synergistic, effects.
Some general categories of complementary therapy are
predictably harmful to people with HIV disease. Raw animal products and other potentially contaminated foods
(including certain fungi) can be fatal, since a weakened
immune system cannot properly fight infection.
Escherichia coli, Salmonella, other disease-causing organisms found in improperly prepared foods, and
Cryptosporidium-associated with poorly filtered tap
water-are considerably more dangerous for people with
compromised immune systems than for those who are
healthy. Raw-milk dairy products can pose a threat to
people with HIV. One-dimensional diets, such as a
macrobiotic diet, do not provide adequate nutrients and
can result in dangerous weight loss and wasting.
Substances that use the same metabolic pathways as protease inhibitors may cause levels of protease inhibitors to
rise or fall suddenly and dramatically, with potential
adverse effects or the emergence of resistant HIV. Any
therapy that requires the patient not to use ART or medications prescribed to prevent or treat opportunistic
(continued on page 4)

HIVfrontline
mentary ~ '(continued from page 3)
infections (Ois) should be reviewed with caution by a
provider of Western medicine.
At the far end of the spectrum are practitioners and treatments that constitute out-and-out fraud. Regrettably,
people living with HIV are susceptible to the hope of
"miracle cures," and there is no shortage of unscrupulous people ready to exploit that hope. Examples of this
include offshore and non-US clinics that offer seemingly
bizarre treatments using ozone and other so-called
antioxidants, blood cleansing, and enemas designed to
"flush" the virus from the system.

Ill Treatment Goals
Surveys studying what draws people to complementary
therapies have found that the higher the level of education and the poorer the health status of the patient, the
more likely that patient is to look beyond what traditional medicine offers. Many people living with HIV are
highly educated about their disease and tend to be
involved and proactive regarding issues of medical care.
In some cases, complementary therapies are culturally
prescribed. Family members, eager to help their loved
ones, may purchase "remedies" or recommend treatments they have heard about in their communities.
There also appears to be a segment of the HIV population that is particularly vulnerable to fraudulent aspects
of nontraditional medicine. Certain members of various
underserved populations, who may lack education,
resources, and access to reliable information about their
disease, may be easy prey for the "miracle cures" and
treatments they hear about.
It makes sense, therefore, to look at reasonable goals for
people living with HIV disease. These goals may be
achieved through the use of traditional medical
approaches, complementary therapies, or a combination
of the two.
For most people living with HIV, the primary objective is
to prolong survival by delaying disease progression,
reducing viral load, and bolstering or rebuilding the
immune system. 'The only therapy that has been proven
in rigorous clinical trials to have achieved this objective
is ART. Controlling Ois is another important task for
which FDA-approved pharmaceuticals are best suited.

For all patients, regardless of their stages of disease and
prognoses, improving quality of life is a significant and
reasonable goal. Complementary therapies, used alone
or with traditional approaches, can make a big difference
in alleviating symptoms, lowering anxiety levels, maintaining good nutrition, and improving general health
and well-being.
Regarding goals that focus on state of mind, complementary therapies can provide answers to issues that
mainstream medicine may not even attempt to address.
These include psychological, emotional, and/or spiritual
support and a sense of empowerment gained from having
choices and taking as much control as possible in
dealing with one's illness.

Ill What Counselors Can

Do

Counselors have an important role in bridging the gap
between mainstream and nonmainstream approaches.
The main task is not to be advocates for one approach
over the other but rather to serve as facilitators of communication and information gathering.
Use discussion of complementary therapies as a
bridge for improved communication

Open discussion by asking clients, "What are you doing
to help yourself be as healthy as possible? What does this
include besides taking the medicine your healthcare
provider has prescribed?" These direct questions will
often elicit information about complementary therapies
the client is using.
Keep discussion open by following up with clients at
subsequent meetings. Ask how things are going, and
make specific reference to complementary approaches
they have mentioned previously.
Establish trust by being understanding

Some patients with HIV are not ready to consider standard medications. It is essential not to abandon these
clients or communicate an attitude that implies, "Come
back when you're ready for ART." Counselors who are
attentive without being judgmental will be able to maintain relationships and gauge client readiness. It is vital to
preserve opportunities for educating clients and monitoring their symptoms and rates of disease progression
until the use of ART is accepted.
(continued on page 5)

HIYfrontline
lnhtgratll19 Complementary Therapies (continued from page 4)
Help clients obtain information

There is a wealth of information about complementary
therapies available in books and other publications, from
AIDS advocacy groups, and on the World Wide Web (see
Resources, below). Not all of this information is reliable,
however. Counselors can steer clients to sources of information and help them evaluate the quality of the sources.
Help clients investigate health insurance coverage
for complementary therapy

Most health insurers do not offer reimbursement, but there
are exceptions. Coverage may be available for therapies
delivered or referred by traditional medical providers or
obtained through integrated medical clinics. A growing
number of insurers and HMOs cover some categories of
complementary therapy. Those most often covered
include biofeedback, acupuncture, and chiropractic. Some
states mandate coverage for treatment by specific types of
licensed practitioners, and thanks to the Ryan White
Comprehensive AIDS Resources Emergency (CARE) Act,
many states have complementary funds set aside for use by
people who are HIV positive.
Help clients evaluate therapies

Become informed about the complementary therapies
most often discussed in the context of HIV disease,
including those that are "hot" and especially those that are
known to be either helpful or dangerous. Encourage clients
to seek out licensed practitioners and ask about published
reports, rather than relying on hearsay and testimonials, on
any complementary therapy they are considering.
■

Help clients make informed choices and recognize
the "red flags" for fraud (see Spotting AIDS Fraud,
page 2)

The FDA has set up a network of AIDS Fraud Task Forces
that operate on a state-by-state basis. Their services
vary-some sponsor public education programs but
primarily collect information about fraudulent therapies;
others will discuss specific therapeutic options and
offer guidance in making informed choices (see
Resources, below).
Help clients talk with their medical teams about
complementary therapy

Unreported use of complementary therapies can adversely
influence the results of traditional treatment. All healthcare professionals should routinely ask patients about their
use of complementary therapies, and counselors should
urge clients to confide the facts to members of their healthcare teams. Regardless of treatment, regular monitoring of
disease progression with CD4 cell count assessment and
viral load testing is essential.
Work with clients to make lists of questions for their
healthcare providers and, if necessary, act as an intermediary to pave the way for constructive discussion of
complementary care. It may be useful for members of
treatment teams to talk with the nontraditional practitioners, both to encourage patient confidence and to
establish a team approach.

Resources

Libraries
Books, magazines, and scientific journals can be found
in public libraries and more specialized university and
medical libraries, many of which are open to the public. The Index Medicus catalogues articles in medical
journals worldwide. This information is available
on line from the National Library of Medicine
(http://www.nlm.nih.gov).
The World Wide Web
Other websites include
Office of Alternative Medicinehttp://altmed.od.nih.gov
Immunet and AIDS Treatment Newshttp://www.aids.org
AIDS Treatment Data Networkhttp://204.179 .124.69 /network
The Body: An AIDS and HIV Information Resource-

http://www.thebody.com
Beacon Clinic-http://www.beaconclinic.org
Health A to Z-http://www.healthatoz.com
AIDS Research Information Centerhttp://www.critpath.org/aric
The Alternative Medicine Home Pagehttp://www.pitt.edu/-cbw/altm.html
AIDS/HIV Internet Resource Centerhttp://members.aol.com/healwell/aids.htm
Internet Grateful Med-http://igm.nlm.nih.gov
Hotlines
AIDS Health Fraud Hotline: (888) 332-1820
(6 PM-9 PM, EST, M-F)
California AIDS Fraud Task Force: (800) 459-4503
(will take out-of-state calls)

H1\fEc 0 atl ine
Candidiasis is the most common HIV-related fungal infection. Prior to the availability of maximally suppressive ART; as many as
90% of HIV-infected individuals could be expected to have at least one episode. Candidiasis is caused by the excessive growth of one
of several yeastlike organisms of the family Candida. Candida can be found on the mucosa/ tissues and in the gastrointestinal (GI)
tracts of most healthy people and is usually harmless. For people with compromised immune systems, Candida can cause infections
that are disagreeable and sometimes painful but usually not life threatening. Its greatest significance is as a sentinel disease-o~en
the first sign that something is amiss with the immune system.
On an emotional level, recurrent candidiasis can be very frustrating for the patient, affecting pleasure derived from food and sexual
activity. Clinicians should be aware of the potential psychological effects, such as stress, associated with this condition.

Infection and Disease
Candida is one of the many organisms
that normally colonize in the human
body without causing harm. The Candida
population is usually regulated by white
blood cells and other immune defenses
and by components in saliva and other
bodily fluids, especially benign bacteria
that inhabit the GI and genital tracts.
When something occurs that upsets this
balance, however, Candida proliferates.

The most common type of Candida seen in
HIV-infected individuals is Candida albicans.
Less frequently observed species include
Candida tropicalis, Candida parapsilosis,
Candida kruseii, and a closely related
organism, Torulopsis glabrata. These tend
to infect people in whom prior therapy
has resulted in drug resistance.
Recent therapy with broad-spectrum
antibiotics is a common factor in the
development of Candida infection. Such
treatment leads to the elimination not
only of the bacteria causing the illness
being treated but also of the benign bacteria
that ordinarily help keep Candida in
check. Candidiasis is also associated with
diabetes, whose characteristic high blood
sugar provides Candida with a particularly
nourishing
environment.
Usually,
though, candidiasis is a sign of immune
dysfunction. It is frequently observed in
patients with cancer who are on immunesuppressing therapies and patients who
have received transplants and are taking
antirejection drugs. Candidiasis is

especially prevalent among HIV-infected
individuals. HIV-infected women, infants,
and children are particularly vulnerable.
A first episode of candidiasis may occur
long before other symptoms are observed
or HIV is suspected. As HIV disease progresses, the likelihood that one will
develop candidiasis increases as other
risk factors come into play. Antibiotics
prescribed as prophylaxis for other Ols,
for example, may put patients at risk for
candidiasis. Xerostomia (dry mouth),
commonly observed in HIV-infected
patients, promotes the growth of
oropharyngeal candidiasis. The risk of
both occurrence and recurrence is
heightened as CD4 cell counts decline.
'J}lpesi, Signsi, and Symptoms
Candida can be cultured from the saliva,
mucous membranes, and GI tracts of
most people, healthy or ill, and can be
found in the reproductive organs and urinary tracts of many women. It can also be
found in food, soil, and hospital environments and can affect tissues of the
mouth, throat, esophagus, and vagina.
Candida can cause a systemic infectionalthough this is rare-affecting the blood
and vital organs. Signs and symptoms
vary depending on the site of infection.

Oropharyngeal candidiasis is the most
common 01 associated with HIV. It
affects the portion of the pharynx at the
back of the mouth. General symptoms, if
any, include altered taste sensation,

mouth pain or burning, and pain or
difficulty in swallowing. Any or all of
these can interfere with nutrition, a
serious liability for HIV-infected people.
There are four main categories of oropharyngeal candidiasis. Pseudomembranous
candidiasis (also called "thrush") appears as
painless white spots on the tongue, gums,
inner cheeks, and throat. The spots can be
easily scraped away, exposing reddened
and sometimes bleeding areas beneath
them. In contrast, the white spots or patches
of the less common chronic hyperplastic
candidiasis (or leukoplakia), which form
on the tongue and inner cheeks, cannot be
scraped away. Acute atrophic candidiasis
(also called erythematous candidiasis) is
characterized by red patches on the
tongue, inner cheeks, and gums. Chronic
atrophic candidiasis (also called angular
cheilitis) is characterized by painful red or
white cracks at the corners of the mouth.
Esophageal candidiasis occurs when
infection spreads from the mouth and
throat to the esophagus, typical in more
advanced HIV disease. This is one of the
most common GI infections associated
with AIDS and may affect women and
blacks more frequently than whites.
Those at greatest risk have low CD4 cell
counts and high viral loads.
Symptoms include ulcers and erosion of
the esophagus, chest pains, and pain or
difficulty in swallowing, which may be
severe enough to compromise nutritional
(continued on back page)

H1yFront1 ioe
H·l·V

N·E·W·S

B·R·l·E·F·S

■

According to recent data from the National Center for Health Statistics, the AIDS mortality rate in the United States
decreased by 46.4% in 1997, falling to its lowest level since 1987. There were 16,865 AIDS-related deaths in 1997,
compared with 31,130 deaths in 1996. Despite the encouraging news, the United States had the highest HIV/ AIDSrelated mortality rate of 11 industrialized countries.
The number of new HIV infections remained stable at about 40,000. Some researchers are particularly concerned that,
although the decline in AIDS mortality shows great strides in treatment, prevention efforts have not been similarly successful.
■

The Centers for Disease Control and Prevention (CDC) has finished a draft document concerning partner notification in
HIV cases. Some critics say it comes too late, as many states have already begun passing their own laws, many of which
do not parallel the policies outlined by the CDC.
The new CDC guidelines-4 years in the making-recommend developing a comprehensive program that w ould
offer long-term counseling for both sexual and needle-sharing partners, support for clients who choose to notify their
partners, and help in seeking medical evaluation and treatment.
■

As of year-end 1995, the AIDS rate among prisoners in the United States was six times higher than that in the general
population. Although new inmates in federal and most state prisons are not routinely tested for HIV, in part because of
the difficulty of maintaining patient confidentiality, fears about the safety of guards and the high rate of HIV and AIDS
could change this policy.
The US House of Representatives has approved legislation that would require all federal inmates serving at least 6
months to be tested for HIV within 4 months of entering the prison system. Inmate testing would also be mandated if
their bodily fluids come into contact with corrections officers. Results of the tests would be made available to the facility
administrator and the tested inmate.
■

Nationwide, laws that affect HIV-infected people are being passed in response to public fears about the spread of AIDS.
At least 29 states have made it a criminal offense to transmit HIV knowingly. Other laws mandate partner notification
and HIV testing in certain populations, including pregnant women and prison inmates, and permit good Samaritans
and nonmedical personnel to inquire about the HIV statuses of the people they assist.
Many public health officials are worried that the trend toward criminalization will deter HIV-infected people from
seeking help.
SOURCE: CDC National AIDS Clearinghouse. Copyright 1998, Information Inc., Bethesda, MD.

UPDATE
Progressive Multifocal L.eukoencephalopathy
The Summer 1998 issue of HIV Frontline focused on progressive multifocal leukoencephalopathy (PML), an
HIV-related condition for which there is no specific treatment. A letter in the September 17, 1998, issue of the New
England Journal of Medicine cites a case in which 10 patients who had not previously received protease inhibitors
began maximally suppressive ART within 90 days of the onset of PML symptoms. Neurologic conditions improved
markedly in six of the patients, remained unchanged in three, and worsened in one. In half of the patients, JC virus,
which causes PML, was undetectable as much as 1 year after PML was diagnosed. The authors of AIDS Clinical
Trials Group Study 243 responded that they had observed similar results.

HIVfrogtlioe
H W -Flelated Conditions Focus
status. Sometimes, however, esophageal
candidiasis is asymptomatic.
Vaginal candidiasis, familiar to many
women as yeast infection (also known
as monilia), is extremely common in
HIV-infected women. Recurrent bouts
frequently precede oral candidiasis as
an early warning sign of immune dysfunction. After ruling out other causes
(eg, diabetes, pregnancy, or use of
broad-spectrum antibiotics, oral contraceptives, corticosteroids, and other
immunosuppressives), a clinician may
suggest an HIV test for a woman who
has recurrent vaginal candidiasis.
Symptoms include itching; burning
pain; a creamy, cheeselike vaginal discharge; redness with visible white
patches on the labia, vulva, and vaginal tissues, and pain during urination.
Despite the frequency of mucosal
infections with Candida and the
increasing prevalence of candidemia
(bloodstream infection) in hospitalized AIDS patients, visceral infection,
or systemic candidiasis (eg, infection
of the liver, kidneys, or other internal
organs), remains rarely reported.
The heart, kidneys, lungs, eyes, central
nervous system, blood, joints, and
bones are all subject to infection.
Symptoms vary depending on which
organ is affected.
Risk factors for systemic candidiasis
include advanced HIV disease, neutropenia (low white cell count), total parenteral
nutrition (or other therapies requiring
the use of a central venous catheter),
injection drug use, and prophylaxis with
antifungal and/or broad-spectrum antibiotic drugs. Another risk factor is time
spent in a hospital, since illnesses related
to Candida are usually nosocomial
(hospital-acquired) infections.

on:

Cendkliasls

(conttnued from page 6)

Diagnosis

Prevention

Candidiasis is generally diagnosed via
clinical signs. If the condition does not
respond to treatment in a reasonable
amount of time, a culture or biopsy of
lesions may be taken to distinguish
between candidiasis and hairy leukoplakia (associated with Epstein-Barr
virus) or histoplasmosis, both of which
affect HIV-infected people. For esophageal candidiasis, this involves inserting an endoscope down the throat and
scraping the lesions.

Candidiasis is not generally regarded as a
communicable disease. It is an individual's
vulnerability to the organism that is
responsible for an infective episode.
People with active outbreaks should
avoid oral or vaginal contact with others.

n-eatment
Candidiasis is treated with a variety of
antifungal agents, including nystatin,
clotrimazole, fluconazole, ketoconazole, itraconazole, and amphotericin
B. These are available in various forms:
lozenges and swish-and-swallow liquids for oropharyngeal disease; ointments, pills, and suppositories for
vaginal disease; pills, suspensions, and
intravenous preparations for more
severe or refractory disease.
For a first or mild occurrence, clotrimazole or nystatin will probably be tried.
For more severe episodes, oral therapy
with fluconazole or itraconazole is usually successful. Ongoing prophylaxis
with oral azoles is usually reserved for
patients who have frequent recurrences
after initial therapy because of concern
with the emergence of azole-resistant
Candida species. Amphotericin B is
used intravenously when nothing else
proves effective.
A 10- to 14-day course of treatment usually clears up the condition, though
recurrence is common. Drug resistance
and worsening immune status are factors
in recurrence, but so is the ubiquitous
nature of Candida. There is some suggestion
that poor oral hygiene contributes to
recurrence, as dental cavities may
provide a hiding place for the organism.

Since it is virtually impossible to avoid
exposure to Candida, the best hope
for prevention is improvement of
immune function. There is evidence
that reduced viral loads and increased
CD4 cell counts associated with multidrug antiretroviral regimens may
lower the incidence of candidiasis.
For patients with recurrent disease,
especially when it interferes with food
intake or causes extreme discomfort,
prophylactic fluconazole may be
considered. The risk of resistance,
however, as well as the considerable
expense, must be taken into account.
Good oral hygiene, including regular
dental care, is advised.
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Property of t he Ce nter

•

ISSUE NO. 35

This newsletter is supported through an independent educational grant from 6/axoWellcome

Integrating Complementary
Therapies With HIV Treatments
landmark study published in 1993 found that one in three adult Americans acknowledged using
some form of nontraditional therapy and that almost three quarters of them had not discussed
this with their healthcare providers. Recent surveys have found a higher percentage of patients
in the HIV community seeking therapies outside the mainstream medical establishment. It
is li e y, therefore, that counselors of people living with HIV will have clients who are either already
pursuing or, at least, considering complementary medical approaches to HIV disease. This issue of
HIV Frontline looks at complementary therapies and the importance of integrating them into standard
antiretroviral therapy (ART) regimens. Our goal is to improve communication regarding treatmentbetween client and counselor, between patient and clinician, and among all members of the treatment team.

Ill What Is Complementary Therapy?
Complementary therapy generally comprises practices
that are not part of the established, traditional healthcare
system in the United States but are used with or in lieu of
traditional Western medicine.
This field encompasses treatment by healers such as
Buddhist, Native-American, ayurvedic, naturopathic,
homeopathic, and folk-remedy practitioners and includes
healing modalities, such as acupuncture, used in traditional Chinese medicine.
Some therapies rely on herbs, vitamins and minerals,
animal products and extracts, amino acids and other
molecular dietary supplements, and diets that include or
exclude certain foods . Other therapies offer "body work"
such as exercise, massage, chiropractic, and acupressure.
Still others, such as hypnosis, yoga, meditation, biofeed-

Inside ...
• Integrating Complementary Therapies ...

*
*
• PML Update
*
HIV News Briefs

back, relaxation therapy, and visualization, focus on the
mind-body connection. There are also quasimedical procedures, including enemas and blood cleansing, and
antioxidant and hyperthermia treatments.
Traditionally, such strategies have been termed "alternative" medicine. Alternative, however, implies that nontraditional medicine is used exclusively. The term
"complementary" is preferred, because it indicates that
the patient is combining approaches and benefiting from
what each one offers.
Until recently, complementary therapy was not taught in
medical schools. Generally, it is not available in hospitals
and may involve substances that are not regulated or
approved by the Food and Drug Administration (FDA).
Some complementary therapies have a place in the treatment of HIV, but the emphasis must be on the word complementary. Most HIV experts believe that no treatment
should replace the current standard of care-maximally
suppressive combination ART with an optimal regimen
for the individual patient and, where necessary, medications to prevent and treat other HIV-related conditions.

• Focus on AIDS-Related Candidiasis

•

Ill From Alternative to Mainstream
Traditional medicine is constantly evolving, and yesterday's
alternative may become tomorrow's standard therapy.
Herbal cures may sound like an alternative, but some of the
(continued on page 2)

www.hivline.com

Winter 199B

HIVfrontline
Editorial

Advisory 80@rd
Richard S. Ferri, PhD,
ANP, ACRN

HIV/AIDS Nurse Practitioner
Crossroads Medical
Harwich, Massachusetts

-

Michele Fontaine, MA, CASAC
Senior Vocational Counselor
Next Step Program
Project Renewal
New York, New York

Susan M. Gallego, MSSW,
LMSW-ACP
Private Practitioner/Consultant
Austin, Texas

Howard A. Grossman, MD
Assistant Clinical Professor of Medicine
Columbia University College of
Physicians & Surgeons
New York, New York

Vincent J. Lynch, DSW
Director, National Research
and Training Center on
Social Work and HIV/AIDS
Boston College
Graduate School of Social Work
Chestnut Hill, Massachusetts

-

Angela Shiloh-Cryer, MSW
Director, Office of
Health Policy and AIDS Funding
New Orleans, Louisiana

-

Barry Zevin, MD
Medical Director
Tom Waddell Health Center
San Francisco, California

Wendy Zizzo, PharmD
Clinical Pharmacist
Carlsbad, California

This newsletter is published by World
Health CME, a division of World Health
Communications Inc., and is supported
through an independent educational grant
from Glaxo Wellcome. The views and opinions expressed herein do not necessarily
reflect those of Glaxo Wellcome, World
Health CME, or the Editorial Advisory
Board. Statements regarding drugs, dosages,
and procedures are not meant to serve as
guidelines in the treatment of patients.
Please see the full prescribing information
before using any agent mentioned in this
publication.
© 1998, World Health CME. All rights
reserved. Printed in the USA. Permission
granted for noncommercial reproduction
of this material.

most valuable drugs in the modern medicine chest, including penicillin, digitalis, and the cancer fighter Taxol®, derive from natural sources. Now, there
is a PDR® (Physicians' Desk Reference) for herbal medicines. Therapies that
rely on the mind-body connection may sound distinctly "new age,"
but approaches such as biofeedback, exercise, and participation in
support groups have proven beneficial and are now embraced by the
medical establishment.
A recent survey published in the Journal of the American Medical Association
found that more than 60% of primary care physicians recommend some type
of complementary therapy to their patients, and nearly 25% of physicians
incorporate such therapies in their practices. At least 40 medical schools offer
elective courses in complementary therapies, and there are increasing numbers
of integrated clinics that provide both traditional and complementary therapies in a single setting.
There is still considerable resistance, however, to the idea of nontraditional
medicine. The New England f oumal of Medicine acknowledged the growing
popularity of complementary therapy in a 1993 survey of its prevalence,
costs, and patterns of use. In 1998, a significant portion of one issue was
devoted to the dangers of nontraditional medicine. It urged that alternatives be
avoided unless and until they are proven safe in rigorous scientific studies.
In 1992, the federal government established the Office of Alternative
Medicine (OAM) to identify and support research in complementary
therapy. OAM sponsors SO projects at 11 research centers, including Bastyr
University in Seattle, the only center devoted to research in HIV. Very little
solid data have emerged since OAM began operations, but it is hoped that its
(continued on page 3)
promise will be fulfilled.
■

Spotting AIDS Fraud

Red flags for anyone seeking treatment
outside the mainstream include
It's a cure
No responsible person claims a cure for
AIDS; the most effective, proven therapies offer only viral suppression and
improved health.
It's good for many things
Not just AIDS, but cancer, baldness,
arthritis, or other conditions. This claim
is a sure sign that the seller is just trying
for the broadest possible market.
It has a secret ingredient
No one, especially someone with the
multiple health problems and vulnerability associated with HIV disease,
should ingest an unknown substance.
It's a conspiracy
Claims that the government, in league

with pharmaceutical companies, is trying to suppress an effective treatment
should probably be dismissed as a
smoke screen masking a questionable
product.
It's been written up, but it's in
a foreign language and/ or hard
to find
Any credible study published in a reputable scientific journal will be readily
available in English in a medical or university library or, increasingly, on the
Internet.
It's available only outside the
United States
Steer clear of treatments that require
travel to clinics in countries where medical practice may be poorly regulated.
Such travel can be expensive and the
treatments dangerous.

HIYEc 0 atline
Government regulation of complementary therapy is
limited, mainly because of the Dietary Supplement
Health and Education Act of 1994. This act sharply
restricts FDA regulation of nondrug products that
promote health but do not claim to prevent or treat a
specific disease. Most vitamins, herbs, botanical extracts,
amino acids, and other dietary supplements, therefore,
have avoided scrutiny by the FDA.

Ill The Spectrum of Complementary
Therapies
Complementary therapies range from approaches that
are known to be beneficial to those that are known to be
harmful or fraudulent. Therapies whose effects are less
evident may be worth trying. Patients should be urged,
however, to try them only after informing their treatment
teams and when combining them with standard therapies.
Most complementary therapies known to be beneficial
involve lifestyle modification, and many have been integrated into traditional medical practices. For people living with HIV, recommended lifestyle changes include
•
•
•
•
•
•
•

Improvement of nutrition and diet
Exercise
Cessation of smoking and other substance use
Stress reduction
Relaxation
Counseling
Participation in support groups

Approaches that may be beneficial and are unlikely to be
detrimental include reasonable amounts of supplementary
vitamins, which may provide nutritional support. (Note:
Excess amounts of water-soluble vitamins, such as Band C,
will be eliminated through urination. Fat-soluble vitamins,
however, such as A, D, E, and K, are stored primarily in
the liver, where most HIV drugs are metabolized.
Excessive amounts of these vitamins may be toxic.)
Other therapies that probably will cause no harm, may
relieve symptoms, and may provide comfort include
•
•
•
•

Acupuncture
Massage
Acupressure
Therapeutic touch

Therapies that are ingested may cause side effects and
interfere with prescribed treatments. It is a mistake to
assume that herbs and other natural products are harm-

less. Though many plants (including ·digitalis, opium,
and ephedra) have powerful medicinal properties, some
(such as pennyroyal and jimson weed) are poisonous.
Others-for example, plantain and various "secret"
ingredients in Chinese herbal preparations-may worsen
nausea, diarrhea, and other side effects of prescribed HIV
treatment. Recently, reports of contamination of dietary
supplements with heavy metals and other toxic
substances have caused these unregulated "nutriceuticals" to be viewed negatively.
Not much is known about the interactions between
specific complementary therapies and the drugs used to
treat HIV. This is mainly because of the dearth of scientific
studies on the subject, but reliable anecdotal
information is also sparse. This lack of information can
be attributed to patients' reluctance to admit to the use
of complementary medicines for fear of earning disapproval from their healthcare providers.
Counselors should urge clients to tell their medical teams
about any complementary treatments they are receiving
and unusual foods or dietary supplements they are ingesting. It is a good idea to try only one complementary therapy at a time and note any change in symptoms, for better or worse. Clinicians should be encouraged to elicit and
evaluate this information in a nonjudgmental and
nondismissive manner. The most important thing is to
have complete knowledge, so that the entire treatment
team, including the patient, can watch for negative, or
even positive or synergistic, effects.
Some general categories of complementary therapy are
predictably harmful to people with HIV disease. Raw animal products and other potentially contaminated foods
(including certain fungi) can be fatal, since a weakened
immune system cannot properly fight infection.
Escherichia coli, Salmonella, other disease-causing organisms found in improperly prepared foods, and
Cryptosporidium-associated with poorly filtered tap
water-are considerably more dangerous for people with
compromised immune systems than for those who are
healthy. Raw-milk dairy products can pose a threat to
people with HIV. One-dimensional diets, such as a
macrobiotic diet, do not provide adequate nutrients and
can result in dangerous weight loss and wasting.
Substances that use the same metabolic pathways as protease inhibitors may cause levels of protease inhibitors to
rise or fall suddenly and dramatically, with potential
adverse effects or the emergence of resistant HIV. Any
therapy that requires the patient not to use ART or medications prescribed to prevent or treat opportunistic
(continued on page 4)

HIVfrontline
mentary ~ '(continued from page 3)
infections (Ois) should be reviewed with caution by a
provider of Western medicine.
At the far end of the spectrum are practitioners and treatments that constitute out-and-out fraud. Regrettably,
people living with HIV are susceptible to the hope of
"miracle cures," and there is no shortage of unscrupulous people ready to exploit that hope. Examples of this
include offshore and non-US clinics that offer seemingly
bizarre treatments using ozone and other so-called
antioxidants, blood cleansing, and enemas designed to
"flush" the virus from the system.

Ill Treatment Goals
Surveys studying what draws people to complementary
therapies have found that the higher the level of education and the poorer the health status of the patient, the
more likely that patient is to look beyond what traditional medicine offers. Many people living with HIV are
highly educated about their disease and tend to be
involved and proactive regarding issues of medical care.
In some cases, complementary therapies are culturally
prescribed. Family members, eager to help their loved
ones, may purchase "remedies" or recommend treatments they have heard about in their communities.
There also appears to be a segment of the HIV population that is particularly vulnerable to fraudulent aspects
of nontraditional medicine. Certain members of various
underserved populations, who may lack education,
resources, and access to reliable information about their
disease, may be easy prey for the "miracle cures" and
treatments they hear about.
It makes sense, therefore, to look at reasonable goals for
people living with HIV disease. These goals may be
achieved through the use of traditional medical
approaches, complementary therapies, or a combination
of the two.
For most people living with HIV, the primary objective is
to prolong survival by delaying disease progression,
reducing viral load, and bolstering or rebuilding the
immune system. 'The only therapy that has been proven
in rigorous clinical trials to have achieved this objective
is ART. Controlling Ois is another important task for
which FDA-approved pharmaceuticals are best suited.

For all patients, regardless of their stages of disease and
prognoses, improving quality of life is a significant and
reasonable goal. Complementary therapies, used alone
or with traditional approaches, can make a big difference
in alleviating symptoms, lowering anxiety levels, maintaining good nutrition, and improving general health
and well-being.
Regarding goals that focus on state of mind, complementary therapies can provide answers to issues that
mainstream medicine may not even attempt to address.
These include psychological, emotional, and/or spiritual
support and a sense of empowerment gained from having
choices and taking as much control as possible in
dealing with one's illness.

Ill What Counselors Can

Do

Counselors have an important role in bridging the gap
between mainstream and nonmainstream approaches.
The main task is not to be advocates for one approach
over the other but rather to serve as facilitators of communication and information gathering.
Use discussion of complementary therapies as a
bridge for improved communication

Open discussion by asking clients, "What are you doing
to help yourself be as healthy as possible? What does this
include besides taking the medicine your healthcare
provider has prescribed?" These direct questions will
often elicit information about complementary therapies
the client is using.
Keep discussion open by following up with clients at
subsequent meetings. Ask how things are going, and
make specific reference to complementary approaches
they have mentioned previously.
Establish trust by being understanding

Some patients with HIV are not ready to consider standard medications. It is essential not to abandon these
clients or communicate an attitude that implies, "Come
back when you're ready for ART." Counselors who are
attentive without being judgmental will be able to maintain relationships and gauge client readiness. It is vital to
preserve opportunities for educating clients and monitoring their symptoms and rates of disease progression
until the use of ART is accepted.
(continued on page 5)

HIYfrontline
lnhtgratll19 Complementary Therapies (continued from page 4)
Help clients obtain information

There is a wealth of information about complementary
therapies available in books and other publications, from
AIDS advocacy groups, and on the World Wide Web (see
Resources, below). Not all of this information is reliable,
however. Counselors can steer clients to sources of information and help them evaluate the quality of the sources.
Help clients investigate health insurance coverage
for complementary therapy

Most health insurers do not offer reimbursement, but there
are exceptions. Coverage may be available for therapies
delivered or referred by traditional medical providers or
obtained through integrated medical clinics. A growing
number of insurers and HMOs cover some categories of
complementary therapy. Those most often covered
include biofeedback, acupuncture, and chiropractic. Some
states mandate coverage for treatment by specific types of
licensed practitioners, and thanks to the Ryan White
Comprehensive AIDS Resources Emergency (CARE) Act,
many states have complementary funds set aside for use by
people who are HIV positive.
Help clients evaluate therapies

Become informed about the complementary therapies
most often discussed in the context of HIV disease,
including those that are "hot" and especially those that are
known to be either helpful or dangerous. Encourage clients
to seek out licensed practitioners and ask about published
reports, rather than relying on hearsay and testimonials, on
any complementary therapy they are considering.
■

Help clients make informed choices and recognize
the "red flags" for fraud (see Spotting AIDS Fraud,
page 2)

The FDA has set up a network of AIDS Fraud Task Forces
that operate on a state-by-state basis. Their services
vary-some sponsor public education programs but
primarily collect information about fraudulent therapies;
others will discuss specific therapeutic options and
offer guidance in making informed choices (see
Resources, below).
Help clients talk with their medical teams about
complementary therapy

Unreported use of complementary therapies can adversely
influence the results of traditional treatment. All healthcare professionals should routinely ask patients about their
use of complementary therapies, and counselors should
urge clients to confide the facts to members of their healthcare teams. Regardless of treatment, regular monitoring of
disease progression with CD4 cell count assessment and
viral load testing is essential.
Work with clients to make lists of questions for their
healthcare providers and, if necessary, act as an intermediary to pave the way for constructive discussion of
complementary care. It may be useful for members of
treatment teams to talk with the nontraditional practitioners, both to encourage patient confidence and to
establish a team approach.

Resources

Libraries
Books, magazines, and scientific journals can be found
in public libraries and more specialized university and
medical libraries, many of which are open to the public. The Index Medicus catalogues articles in medical
journals worldwide. This information is available
on line from the National Library of Medicine
(http://www.nlm.nih.gov).
The World Wide Web
Other websites include
Office of Alternative Medicinehttp://altmed.od.nih.gov
Immunet and AIDS Treatment Newshttp://www.aids.org
AIDS Treatment Data Networkhttp://204.179 .124.69 /network
The Body: An AIDS and HIV Information Resource-

http://www.thebody.com
Beacon Clinic-http://www.beaconclinic.org
Health A to Z-http://www.healthatoz.com
AIDS Research Information Centerhttp://www.critpath.org/aric
The Alternative Medicine Home Pagehttp://www.pitt.edu/-cbw/altm.html
AIDS/HIV Internet Resource Centerhttp://members.aol.com/healwell/aids.htm
Internet Grateful Med-http://igm.nlm.nih.gov
Hotlines
AIDS Health Fraud Hotline: (888) 332-1820
(6 PM-9 PM, EST, M-F)
California AIDS Fraud Task Force: (800) 459-4503
(will take out-of-state calls)

H1\fEc 0 atl ine
Candidiasis is the most common HIV-related fungal infection. Prior to the availability of maximally suppressive ART; as many as
90% of HIV-infected individuals could be expected to have at least one episode. Candidiasis is caused by the excessive growth of one
of several yeastlike organisms of the family Candida. Candida can be found on the mucosa/ tissues and in the gastrointestinal (GI)
tracts of most healthy people and is usually harmless. For people with compromised immune systems, Candida can cause infections
that are disagreeable and sometimes painful but usually not life threatening. Its greatest significance is as a sentinel disease-o~en
the first sign that something is amiss with the immune system.
On an emotional level, recurrent candidiasis can be very frustrating for the patient, affecting pleasure derived from food and sexual
activity. Clinicians should be aware of the potential psychological effects, such as stress, associated with this condition.

Infection and Disease
Candida is one of the many organisms
that normally colonize in the human
body without causing harm. The Candida
population is usually regulated by white
blood cells and other immune defenses
and by components in saliva and other
bodily fluids, especially benign bacteria
that inhabit the GI and genital tracts.
When something occurs that upsets this
balance, however, Candida proliferates.

The most common type of Candida seen in
HIV-infected individuals is Candida albicans.
Less frequently observed species include
Candida tropicalis, Candida parapsilosis,
Candida kruseii, and a closely related
organism, Torulopsis glabrata. These tend
to infect people in whom prior therapy
has resulted in drug resistance.
Recent therapy with broad-spectrum
antibiotics is a common factor in the
development of Candida infection. Such
treatment leads to the elimination not
only of the bacteria causing the illness
being treated but also of the benign bacteria
that ordinarily help keep Candida in
check. Candidiasis is also associated with
diabetes, whose characteristic high blood
sugar provides Candida with a particularly
nourishing
environment.
Usually,
though, candidiasis is a sign of immune
dysfunction. It is frequently observed in
patients with cancer who are on immunesuppressing therapies and patients who
have received transplants and are taking
antirejection drugs. Candidiasis is

especially prevalent among HIV-infected
individuals. HIV-infected women, infants,
and children are particularly vulnerable.
A first episode of candidiasis may occur
long before other symptoms are observed
or HIV is suspected. As HIV disease progresses, the likelihood that one will
develop candidiasis increases as other
risk factors come into play. Antibiotics
prescribed as prophylaxis for other Ols,
for example, may put patients at risk for
candidiasis. Xerostomia (dry mouth),
commonly observed in HIV-infected
patients, promotes the growth of
oropharyngeal candidiasis. The risk of
both occurrence and recurrence is
heightened as CD4 cell counts decline.
'J}lpesi, Signsi, and Symptoms
Candida can be cultured from the saliva,
mucous membranes, and GI tracts of
most people, healthy or ill, and can be
found in the reproductive organs and urinary tracts of many women. It can also be
found in food, soil, and hospital environments and can affect tissues of the
mouth, throat, esophagus, and vagina.
Candida can cause a systemic infectionalthough this is rare-affecting the blood
and vital organs. Signs and symptoms
vary depending on the site of infection.

Oropharyngeal candidiasis is the most
common 01 associated with HIV. It
affects the portion of the pharynx at the
back of the mouth. General symptoms, if
any, include altered taste sensation,

mouth pain or burning, and pain or
difficulty in swallowing. Any or all of
these can interfere with nutrition, a
serious liability for HIV-infected people.
There are four main categories of oropharyngeal candidiasis. Pseudomembranous
candidiasis (also called "thrush") appears as
painless white spots on the tongue, gums,
inner cheeks, and throat. The spots can be
easily scraped away, exposing reddened
and sometimes bleeding areas beneath
them. In contrast, the white spots or patches
of the less common chronic hyperplastic
candidiasis (or leukoplakia), which form
on the tongue and inner cheeks, cannot be
scraped away. Acute atrophic candidiasis
(also called erythematous candidiasis) is
characterized by red patches on the
tongue, inner cheeks, and gums. Chronic
atrophic candidiasis (also called angular
cheilitis) is characterized by painful red or
white cracks at the corners of the mouth.
Esophageal candidiasis occurs when
infection spreads from the mouth and
throat to the esophagus, typical in more
advanced HIV disease. This is one of the
most common GI infections associated
with AIDS and may affect women and
blacks more frequently than whites.
Those at greatest risk have low CD4 cell
counts and high viral loads.
Symptoms include ulcers and erosion of
the esophagus, chest pains, and pain or
difficulty in swallowing, which may be
severe enough to compromise nutritional
(continued on back page)

H1yFront1 ioe
H·l·V

N·E·W·S

B·R·l·E·F·S

■

According to recent data from the National Center for Health Statistics, the AIDS mortality rate in the United States
decreased by 46.4% in 1997, falling to its lowest level since 1987. There were 16,865 AIDS-related deaths in 1997,
compared with 31,130 deaths in 1996. Despite the encouraging news, the United States had the highest HIV/ AIDSrelated mortality rate of 11 industrialized countries.
The number of new HIV infections remained stable at about 40,000. Some researchers are particularly concerned that,
although the decline in AIDS mortality shows great strides in treatment, prevention efforts have not been similarly successful.
■

The Centers for Disease Control and Prevention (CDC) has finished a draft document concerning partner notification in
HIV cases. Some critics say it comes too late, as many states have already begun passing their own laws, many of which
do not parallel the policies outlined by the CDC.
The new CDC guidelines-4 years in the making-recommend developing a comprehensive program that w ould
offer long-term counseling for both sexual and needle-sharing partners, support for clients who choose to notify their
partners, and help in seeking medical evaluation and treatment.
■

As of year-end 1995, the AIDS rate among prisoners in the United States was six times higher than that in the general
population. Although new inmates in federal and most state prisons are not routinely tested for HIV, in part because of
the difficulty of maintaining patient confidentiality, fears about the safety of guards and the high rate of HIV and AIDS
could change this policy.
The US House of Representatives has approved legislation that would require all federal inmates serving at least 6
months to be tested for HIV within 4 months of entering the prison system. Inmate testing would also be mandated if
their bodily fluids come into contact with corrections officers. Results of the tests would be made available to the facility
administrator and the tested inmate.
■

Nationwide, laws that affect HIV-infected people are being passed in response to public fears about the spread of AIDS.
At least 29 states have made it a criminal offense to transmit HIV knowingly. Other laws mandate partner notification
and HIV testing in certain populations, including pregnant women and prison inmates, and permit good Samaritans
and nonmedical personnel to inquire about the HIV statuses of the people they assist.
Many public health officials are worried that the trend toward criminalization will deter HIV-infected people from
seeking help.
SOURCE: CDC National AIDS Clearinghouse. Copyright 1998, Information Inc., Bethesda, MD.

UPDATE
Progressive Multifocal L.eukoencephalopathy
The Summer 1998 issue of HIV Frontline focused on progressive multifocal leukoencephalopathy (PML), an
HIV-related condition for which there is no specific treatment. A letter in the September 17, 1998, issue of the New
England Journal of Medicine cites a case in which 10 patients who had not previously received protease inhibitors
began maximally suppressive ART within 90 days of the onset of PML symptoms. Neurologic conditions improved
markedly in six of the patients, remained unchanged in three, and worsened in one. In half of the patients, JC virus,
which causes PML, was undetectable as much as 1 year after PML was diagnosed. The authors of AIDS Clinical
Trials Group Study 243 responded that they had observed similar results.

HIVfrogtlioe
H W -Flelated Conditions Focus
status. Sometimes, however, esophageal
candidiasis is asymptomatic.
Vaginal candidiasis, familiar to many
women as yeast infection (also known
as monilia), is extremely common in
HIV-infected women. Recurrent bouts
frequently precede oral candidiasis as
an early warning sign of immune dysfunction. After ruling out other causes
(eg, diabetes, pregnancy, or use of
broad-spectrum antibiotics, oral contraceptives, corticosteroids, and other
immunosuppressives), a clinician may
suggest an HIV test for a woman who
has recurrent vaginal candidiasis.
Symptoms include itching; burning
pain; a creamy, cheeselike vaginal discharge; redness with visible white
patches on the labia, vulva, and vaginal tissues, and pain during urination.
Despite the frequency of mucosal
infections with Candida and the
increasing prevalence of candidemia
(bloodstream infection) in hospitalized AIDS patients, visceral infection,
or systemic candidiasis (eg, infection
of the liver, kidneys, or other internal
organs), remains rarely reported.
The heart, kidneys, lungs, eyes, central
nervous system, blood, joints, and
bones are all subject to infection.
Symptoms vary depending on which
organ is affected.
Risk factors for systemic candidiasis
include advanced HIV disease, neutropenia (low white cell count), total parenteral
nutrition (or other therapies requiring
the use of a central venous catheter),
injection drug use, and prophylaxis with
antifungal and/or broad-spectrum antibiotic drugs. Another risk factor is time
spent in a hospital, since illnesses related
to Candida are usually nosocomial
(hospital-acquired) infections.

on:

Cendkliasls

(conttnued from page 6)

Diagnosis

Prevention

Candidiasis is generally diagnosed via
clinical signs. If the condition does not
respond to treatment in a reasonable
amount of time, a culture or biopsy of
lesions may be taken to distinguish
between candidiasis and hairy leukoplakia (associated with Epstein-Barr
virus) or histoplasmosis, both of which
affect HIV-infected people. For esophageal candidiasis, this involves inserting an endoscope down the throat and
scraping the lesions.

Candidiasis is not generally regarded as a
communicable disease. It is an individual's
vulnerability to the organism that is
responsible for an infective episode.
People with active outbreaks should
avoid oral or vaginal contact with others.

n-eatment
Candidiasis is treated with a variety of
antifungal agents, including nystatin,
clotrimazole, fluconazole, ketoconazole, itraconazole, and amphotericin
B. These are available in various forms:
lozenges and swish-and-swallow liquids for oropharyngeal disease; ointments, pills, and suppositories for
vaginal disease; pills, suspensions, and
intravenous preparations for more
severe or refractory disease.
For a first or mild occurrence, clotrimazole or nystatin will probably be tried.
For more severe episodes, oral therapy
with fluconazole or itraconazole is usually successful. Ongoing prophylaxis
with oral azoles is usually reserved for
patients who have frequent recurrences
after initial therapy because of concern
with the emergence of azole-resistant
Candida species. Amphotericin B is
used intravenously when nothing else
proves effective.
A 10- to 14-day course of treatment usually clears up the condition, though
recurrence is common. Drug resistance
and worsening immune status are factors
in recurrence, but so is the ubiquitous
nature of Candida. There is some suggestion
that poor oral hygiene contributes to
recurrence, as dental cavities may
provide a hiding place for the organism.

Since it is virtually impossible to avoid
exposure to Candida, the best hope
for prevention is improvement of
immune function. There is evidence
that reduced viral loads and increased
CD4 cell counts associated with multidrug antiretroviral regimens may
lower the incidence of candidiasis.
For patients with recurrent disease,
especially when it interferes with food
intake or causes extreme discomfort,
prophylactic fluconazole may be
considered. The risk of resistance,
however, as well as the considerable
expense, must be taken into account.
Good oral hygiene, including regular
dental care, is advised.
To add your name to the malling list for this
publication, please send your request to
HIV Frontline, World Health CME
41 Madison Avenue, 42nd Floor
New York, New York 10010-2202
HIV Frontline is also available
on the World Wide Web, through
the HIV Information NetworksM at
http://www.hivline.com

Now there is also an
HIV Frontline Fax Newsletter,
bringing you timely reports from
major national and international
medical conferences. To receive
this publication by fax, send us
your fax number. (You can also
receive the fax newsletter in the
mail if you prefer.)



Property of t he Ce nter

•

ISSUE NO. 35

This newsletter is supported through an independent educational grant from 6/axoWellcome

Integrating Complementary
Therapies With HIV Treatments
landmark study published in 1993 found that one in three adult Americans acknowledged using
some form of nontraditional therapy and that almost three quarters of them had not discussed
this with their healthcare providers. Recent surveys have found a higher percentage of patients
in the HIV community seeking therapies outside the mainstream medical establishment. It
is li e y, therefore, that counselors of people living with HIV will have clients who are either already
pursuing or, at least, considering complementary medical approaches to HIV disease. This issue of
HIV Frontline looks at complementary therapies and the importance of integrating them into standard
antiretroviral therapy (ART) regimens. Our goal is to improve communication regarding treatmentbetween client and counselor, between patient and clinician, and among all members of the treatment team.

Ill What Is Complementary Therapy?
Complementary therapy generally comprises practices
that are not part of the established, traditional healthcare
system in the United States but are used with or in lieu of
traditional Western medicine.
This field encompasses treatment by healers such as
Buddhist, Native-American, ayurvedic, naturopathic,
homeopathic, and folk-remedy practitioners and includes
healing modalities, such as acupuncture, used in traditional Chinese medicine.
Some therapies rely on herbs, vitamins and minerals,
animal products and extracts, amino acids and other
molecular dietary supplements, and diets that include or
exclude certain foods . Other therapies offer "body work"
such as exercise, massage, chiropractic, and acupressure.
Still others, such as hypnosis, yoga, meditation, biofeed-

Inside ...
• Integrating Complementary Therapies ...

*
*
• PML Update
*
HIV News Briefs

back, relaxation therapy, and visualization, focus on the
mind-body connection. There are also quasimedical procedures, including enemas and blood cleansing, and
antioxidant and hyperthermia treatments.
Traditionally, such strategies have been termed "alternative" medicine. Alternative, however, implies that nontraditional medicine is used exclusively. The term
"complementary" is preferred, because it indicates that
the patient is combining approaches and benefiting from
what each one offers.
Until recently, complementary therapy was not taught in
medical schools. Generally, it is not available in hospitals
and may involve substances that are not regulated or
approved by the Food and Drug Administration (FDA).
Some complementary therapies have a place in the treatment of HIV, but the emphasis must be on the word complementary. Most HIV experts believe that no treatment
should replace the current standard of care-maximally
suppressive combination ART with an optimal regimen
for the individual patient and, where necessary, medications to prevent and treat other HIV-related conditions.

• Focus on AIDS-Related Candidiasis

•

Ill From Alternative to Mainstream
Traditional medicine is constantly evolving, and yesterday's
alternative may become tomorrow's standard therapy.
Herbal cures may sound like an alternative, but some of the
(continued on page 2)

www.hivline.com

Winter 199B

HIVfrontline
Editorial

Advisory 80@rd
Richard S. Ferri, PhD,
ANP, ACRN

HIV/AIDS Nurse Practitioner
Crossroads Medical
Harwich, Massachusetts

-

Michele Fontaine, MA, CASAC
Senior Vocational Counselor
Next Step Program
Project Renewal
New York, New York

Susan M. Gallego, MSSW,
LMSW-ACP
Private Practitioner/Consultant
Austin, Texas

Howard A. Grossman, MD
Assistant Clinical Professor of Medicine
Columbia University College of
Physicians & Surgeons
New York, New York

Vincent J. Lynch, DSW
Director, National Research
and Training Center on
Social Work and HIV/AIDS
Boston College
Graduate School of Social Work
Chestnut Hill, Massachusetts

-

Angela Shiloh-Cryer, MSW
Director, Office of
Health Policy and AIDS Funding
New Orleans, Louisiana

-

Barry Zevin, MD
Medical Director
Tom Waddell Health Center
San Francisco, California

Wendy Zizzo, PharmD
Clinical Pharmacist
Carlsbad, California

This newsletter is published by World
Health CME, a division of World Health
Communications Inc., and is supported
through an independent educational grant
from Glaxo Wellcome. The views and opinions expressed herein do not necessarily
reflect those of Glaxo Wellcome, World
Health CME, or the Editorial Advisory
Board. Statements regarding drugs, dosages,
and procedures are not meant to serve as
guidelines in the treatment of patients.
Please see the full prescribing information
before using any agent mentioned in this
publication.
© 1998, World Health CME. All rights
reserved. Printed in the USA. Permission
granted for noncommercial reproduction
of this material.

most valuable drugs in the modern medicine chest, including penicillin, digitalis, and the cancer fighter Taxol®, derive from natural sources. Now, there
is a PDR® (Physicians' Desk Reference) for herbal medicines. Therapies that
rely on the mind-body connection may sound distinctly "new age,"
but approaches such as biofeedback, exercise, and participation in
support groups have proven beneficial and are now embraced by the
medical establishment.
A recent survey published in the Journal of the American Medical Association
found that more than 60% of primary care physicians recommend some type
of complementary therapy to their patients, and nearly 25% of physicians
incorporate such therapies in their practices. At least 40 medical schools offer
elective courses in complementary therapies, and there are increasing numbers
of integrated clinics that provide both traditional and complementary therapies in a single setting.
There is still considerable resistance, however, to the idea of nontraditional
medicine. The New England f oumal of Medicine acknowledged the growing
popularity of complementary therapy in a 1993 survey of its prevalence,
costs, and patterns of use. In 1998, a significant portion of one issue was
devoted to the dangers of nontraditional medicine. It urged that alternatives be
avoided unless and until they are proven safe in rigorous scientific studies.
In 1992, the federal government established the Office of Alternative
Medicine (OAM) to identify and support research in complementary
therapy. OAM sponsors SO projects at 11 research centers, including Bastyr
University in Seattle, the only center devoted to research in HIV. Very little
solid data have emerged since OAM began operations, but it is hoped that its
(continued on page 3)
promise will be fulfilled.
■

Spotting AIDS Fraud

Red flags for anyone seeking treatment
outside the mainstream include
It's a cure
No responsible person claims a cure for
AIDS; the most effective, proven therapies offer only viral suppression and
improved health.
It's good for many things
Not just AIDS, but cancer, baldness,
arthritis, or other conditions. This claim
is a sure sign that the seller is just trying
for the broadest possible market.
It has a secret ingredient
No one, especially someone with the
multiple health problems and vulnerability associated with HIV disease,
should ingest an unknown substance.
It's a conspiracy
Claims that the government, in league

with pharmaceutical companies, is trying to suppress an effective treatment
should probably be dismissed as a
smoke screen masking a questionable
product.
It's been written up, but it's in
a foreign language and/ or hard
to find
Any credible study published in a reputable scientific journal will be readily
available in English in a medical or university library or, increasingly, on the
Internet.
It's available only outside the
United States
Steer clear of treatments that require
travel to clinics in countries where medical practice may be poorly regulated.
Such travel can be expensive and the
treatments dangerous.

HIYEc 0 atline
Government regulation of complementary therapy is
limited, mainly because of the Dietary Supplement
Health and Education Act of 1994. This act sharply
restricts FDA regulation of nondrug products that
promote health but do not claim to prevent or treat a
specific disease. Most vitamins, herbs, botanical extracts,
amino acids, and other dietary supplements, therefore,
have avoided scrutiny by the FDA.

Ill The Spectrum of Complementary
Therapies
Complementary therapies range from approaches that
are known to be beneficial to those that are known to be
harmful or fraudulent. Therapies whose effects are less
evident may be worth trying. Patients should be urged,
however, to try them only after informing their treatment
teams and when combining them with standard therapies.
Most complementary therapies known to be beneficial
involve lifestyle modification, and many have been integrated into traditional medical practices. For people living with HIV, recommended lifestyle changes include
•
•
•
•
•
•
•

Improvement of nutrition and diet
Exercise
Cessation of smoking and other substance use
Stress reduction
Relaxation
Counseling
Participation in support groups

Approaches that may be beneficial and are unlikely to be
detrimental include reasonable amounts of supplementary
vitamins, which may provide nutritional support. (Note:
Excess amounts of water-soluble vitamins, such as Band C,
will be eliminated through urination. Fat-soluble vitamins,
however, such as A, D, E, and K, are stored primarily in
the liver, where most HIV drugs are metabolized.
Excessive amounts of these vitamins may be toxic.)
Other therapies that probably will cause no harm, may
relieve symptoms, and may provide comfort include
•
•
•
•

Acupuncture
Massage
Acupressure
Therapeutic touch

Therapies that are ingested may cause side effects and
interfere with prescribed treatments. It is a mistake to
assume that herbs and other natural products are harm-

less. Though many plants (including ·digitalis, opium,
and ephedra) have powerful medicinal properties, some
(such as pennyroyal and jimson weed) are poisonous.
Others-for example, plantain and various "secret"
ingredients in Chinese herbal preparations-may worsen
nausea, diarrhea, and other side effects of prescribed HIV
treatment. Recently, reports of contamination of dietary
supplements with heavy metals and other toxic
substances have caused these unregulated "nutriceuticals" to be viewed negatively.
Not much is known about the interactions between
specific complementary therapies and the drugs used to
treat HIV. This is mainly because of the dearth of scientific
studies on the subject, but reliable anecdotal
information is also sparse. This lack of information can
be attributed to patients' reluctance to admit to the use
of complementary medicines for fear of earning disapproval from their healthcare providers.
Counselors should urge clients to tell their medical teams
about any complementary treatments they are receiving
and unusual foods or dietary supplements they are ingesting. It is a good idea to try only one complementary therapy at a time and note any change in symptoms, for better or worse. Clinicians should be encouraged to elicit and
evaluate this information in a nonjudgmental and
nondismissive manner. The most important thing is to
have complete knowledge, so that the entire treatment
team, including the patient, can watch for negative, or
even positive or synergistic, effects.
Some general categories of complementary therapy are
predictably harmful to people with HIV disease. Raw animal products and other potentially contaminated foods
(including certain fungi) can be fatal, since a weakened
immune system cannot properly fight infection.
Escherichia coli, Salmonella, other disease-causing organisms found in improperly prepared foods, and
Cryptosporidium-associated with poorly filtered tap
water-are considerably more dangerous for people with
compromised immune systems than for those who are
healthy. Raw-milk dairy products can pose a threat to
people with HIV. One-dimensional diets, such as a
macrobiotic diet, do not provide adequate nutrients and
can result in dangerous weight loss and wasting.
Substances that use the same metabolic pathways as protease inhibitors may cause levels of protease inhibitors to
rise or fall suddenly and dramatically, with potential
adverse effects or the emergence of resistant HIV. Any
therapy that requires the patient not to use ART or medications prescribed to prevent or treat opportunistic
(continued on page 4)

HIVfrontline
mentary ~ '(continued from page 3)
infections (Ois) should be reviewed with caution by a
provider of Western medicine.
At the far end of the spectrum are practitioners and treatments that constitute out-and-out fraud. Regrettably,
people living with HIV are susceptible to the hope of
"miracle cures," and there is no shortage of unscrupulous people ready to exploit that hope. Examples of this
include offshore and non-US clinics that offer seemingly
bizarre treatments using ozone and other so-called
antioxidants, blood cleansing, and enemas designed to
"flush" the virus from the system.

Ill Treatment Goals
Surveys studying what draws people to complementary
therapies have found that the higher the level of education and the poorer the health status of the patient, the
more likely that patient is to look beyond what traditional medicine offers. Many people living with HIV are
highly educated about their disease and tend to be
involved and proactive regarding issues of medical care.
In some cases, complementary therapies are culturally
prescribed. Family members, eager to help their loved
ones, may purchase "remedies" or recommend treatments they have heard about in their communities.
There also appears to be a segment of the HIV population that is particularly vulnerable to fraudulent aspects
of nontraditional medicine. Certain members of various
underserved populations, who may lack education,
resources, and access to reliable information about their
disease, may be easy prey for the "miracle cures" and
treatments they hear about.
It makes sense, therefore, to look at reasonable goals for
people living with HIV disease. These goals may be
achieved through the use of traditional medical
approaches, complementary therapies, or a combination
of the two.
For most people living with HIV, the primary objective is
to prolong survival by delaying disease progression,
reducing viral load, and bolstering or rebuilding the
immune system. 'The only therapy that has been proven
in rigorous clinical trials to have achieved this objective
is ART. Controlling Ois is another important task for
which FDA-approved pharmaceuticals are best suited.

For all patients, regardless of their stages of disease and
prognoses, improving quality of life is a significant and
reasonable goal. Complementary therapies, used alone
or with traditional approaches, can make a big difference
in alleviating symptoms, lowering anxiety levels, maintaining good nutrition, and improving general health
and well-being.
Regarding goals that focus on state of mind, complementary therapies can provide answers to issues that
mainstream medicine may not even attempt to address.
These include psychological, emotional, and/or spiritual
support and a sense of empowerment gained from having
choices and taking as much control as possible in
dealing with one's illness.

Ill What Counselors Can

Do

Counselors have an important role in bridging the gap
between mainstream and nonmainstream approaches.
The main task is not to be advocates for one approach
over the other but rather to serve as facilitators of communication and information gathering.
Use discussion of complementary therapies as a
bridge for improved communication

Open discussion by asking clients, "What are you doing
to help yourself be as healthy as possible? What does this
include besides taking the medicine your healthcare
provider has prescribed?" These direct questions will
often elicit information about complementary therapies
the client is using.
Keep discussion open by following up with clients at
subsequent meetings. Ask how things are going, and
make specific reference to complementary approaches
they have mentioned previously.
Establish trust by being understanding

Some patients with HIV are not ready to consider standard medications. It is essential not to abandon these
clients or communicate an attitude that implies, "Come
back when you're ready for ART." Counselors who are
attentive without being judgmental will be able to maintain relationships and gauge client readiness. It is vital to
preserve opportunities for educating clients and monitoring their symptoms and rates of disease progression
until the use of ART is accepted.
(continued on page 5)

HIYfrontline
lnhtgratll19 Complementary Therapies (continued from page 4)
Help clients obtain information

There is a wealth of information about complementary
therapies available in books and other publications, from
AIDS advocacy groups, and on the World Wide Web (see
Resources, below). Not all of this information is reliable,
however. Counselors can steer clients to sources of information and help them evaluate the quality of the sources.
Help clients investigate health insurance coverage
for complementary therapy

Most health insurers do not offer reimbursement, but there
are exceptions. Coverage may be available for therapies
delivered or referred by traditional medical providers or
obtained through integrated medical clinics. A growing
number of insurers and HMOs cover some categories of
complementary therapy. Those most often covered
include biofeedback, acupuncture, and chiropractic. Some
states mandate coverage for treatment by specific types of
licensed practitioners, and thanks to the Ryan White
Comprehensive AIDS Resources Emergency (CARE) Act,
many states have complementary funds set aside for use by
people who are HIV positive.
Help clients evaluate therapies

Become informed about the complementary therapies
most often discussed in the context of HIV disease,
including those that are "hot" and especially those that are
known to be either helpful or dangerous. Encourage clients
to seek out licensed practitioners and ask about published
reports, rather than relying on hearsay and testimonials, on
any complementary therapy they are considering.
■

Help clients make informed choices and recognize
the "red flags" for fraud (see Spotting AIDS Fraud,
page 2)

The FDA has set up a network of AIDS Fraud Task Forces
that operate on a state-by-state basis. Their services
vary-some sponsor public education programs but
primarily collect information about fraudulent therapies;
others will discuss specific therapeutic options and
offer guidance in making informed choices (see
Resources, below).
Help clients talk with their medical teams about
complementary therapy

Unreported use of complementary therapies can adversely
influence the results of traditional treatment. All healthcare professionals should routinely ask patients about their
use of complementary therapies, and counselors should
urge clients to confide the facts to members of their healthcare teams. Regardless of treatment, regular monitoring of
disease progression with CD4 cell count assessment and
viral load testing is essential.
Work with clients to make lists of questions for their
healthcare providers and, if necessary, act as an intermediary to pave the way for constructive discussion of
complementary care. It may be useful for members of
treatment teams to talk with the nontraditional practitioners, both to encourage patient confidence and to
establish a team approach.

Resources

Libraries
Books, magazines, and scientific journals can be found
in public libraries and more specialized university and
medical libraries, many of which are open to the public. The Index Medicus catalogues articles in medical
journals worldwide. This information is available
on line from the National Library of Medicine
(http://www.nlm.nih.gov).
The World Wide Web
Other websites include
Office of Alternative Medicinehttp://altmed.od.nih.gov
Immunet and AIDS Treatment Newshttp://www.aids.org
AIDS Treatment Data Networkhttp://204.179 .124.69 /network
The Body: An AIDS and HIV Information Resource-

http://www.thebody.com
Beacon Clinic-http://www.beaconclinic.org
Health A to Z-http://www.healthatoz.com
AIDS Research Information Centerhttp://www.critpath.org/aric
The Alternative Medicine Home Pagehttp://www.pitt.edu/-cbw/altm.html
AIDS/HIV Internet Resource Centerhttp://members.aol.com/healwell/aids.htm
Internet Grateful Med-http://igm.nlm.nih.gov
Hotlines
AIDS Health Fraud Hotline: (888) 332-1820
(6 PM-9 PM, EST, M-F)
California AIDS Fraud Task Force: (800) 459-4503
(will take out-of-state calls)

H1\fEc 0 atl ine
Candidiasis is the most common HIV-related fungal infection. Prior to the availability of maximally suppressive ART; as many as
90% of HIV-infected individuals could be expected to have at least one episode. Candidiasis is caused by the excessive growth of one
of several yeastlike organisms of the family Candida. Candida can be found on the mucosa/ tissues and in the gastrointestinal (GI)
tracts of most healthy people and is usually harmless. For people with compromised immune systems, Candida can cause infections
that are disagreeable and sometimes painful but usually not life threatening. Its greatest significance is as a sentinel disease-o~en
the first sign that something is amiss with the immune system.
On an emotional level, recurrent candidiasis can be very frustrating for the patient, affecting pleasure derived from food and sexual
activity. Clinicians should be aware of the potential psychological effects, such as stress, associated with this condition.

Infection and Disease
Candida is one of the many organisms
that normally colonize in the human
body without causing harm. The Candida
population is usually regulated by white
blood cells and other immune defenses
and by components in saliva and other
bodily fluids, especially benign bacteria
that inhabit the GI and genital tracts.
When something occurs that upsets this
balance, however, Candida proliferates.

The most common type of Candida seen in
HIV-infected individuals is Candida albicans.
Less frequently observed species include
Candida tropicalis, Candida parapsilosis,
Candida kruseii, and a closely related
organism, Torulopsis glabrata. These tend
to infect people in whom prior therapy
has resulted in drug resistance.
Recent therapy with broad-spectrum
antibiotics is a common factor in the
development of Candida infection. Such
treatment leads to the elimination not
only of the bacteria causing the illness
being treated but also of the benign bacteria
that ordinarily help keep Candida in
check. Candidiasis is also associated with
diabetes, whose characteristic high blood
sugar provides Candida with a particularly
nourishing
environment.
Usually,
though, candidiasis is a sign of immune
dysfunction. It is frequently observed in
patients with cancer who are on immunesuppressing therapies and patients who
have received transplants and are taking
antirejection drugs. Candidiasis is

especially prevalent among HIV-infected
individuals. HIV-infected women, infants,
and children are particularly vulnerable.
A first episode of candidiasis may occur
long before other symptoms are observed
or HIV is suspected. As HIV disease progresses, the likelihood that one will
develop candidiasis increases as other
risk factors come into play. Antibiotics
prescribed as prophylaxis for other Ols,
for example, may put patients at risk for
candidiasis. Xerostomia (dry mouth),
commonly observed in HIV-infected
patients, promotes the growth of
oropharyngeal candidiasis. The risk of
both occurrence and recurrence is
heightened as CD4 cell counts decline.
'J}lpesi, Signsi, and Symptoms
Candida can be cultured from the saliva,
mucous membranes, and GI tracts of
most people, healthy or ill, and can be
found in the reproductive organs and urinary tracts of many women. It can also be
found in food, soil, and hospital environments and can affect tissues of the
mouth, throat, esophagus, and vagina.
Candida can cause a systemic infectionalthough this is rare-affecting the blood
and vital organs. Signs and symptoms
vary depending on the site of infection.

Oropharyngeal candidiasis is the most
common 01 associated with HIV. It
affects the portion of the pharynx at the
back of the mouth. General symptoms, if
any, include altered taste sensation,

mouth pain or burning, and pain or
difficulty in swallowing. Any or all of
these can interfere with nutrition, a
serious liability for HIV-infected people.
There are four main categories of oropharyngeal candidiasis. Pseudomembranous
candidiasis (also called "thrush") appears as
painless white spots on the tongue, gums,
inner cheeks, and throat. The spots can be
easily scraped away, exposing reddened
and sometimes bleeding areas beneath
them. In contrast, the white spots or patches
of the less common chronic hyperplastic
candidiasis (or leukoplakia), which form
on the tongue and inner cheeks, cannot be
scraped away. Acute atrophic candidiasis
(also called erythematous candidiasis) is
characterized by red patches on the
tongue, inner cheeks, and gums. Chronic
atrophic candidiasis (also called angular
cheilitis) is characterized by painful red or
white cracks at the corners of the mouth.
Esophageal candidiasis occurs when
infection spreads from the mouth and
throat to the esophagus, typical in more
advanced HIV disease. This is one of the
most common GI infections associated
with AIDS and may affect women and
blacks more frequently than whites.
Those at greatest risk have low CD4 cell
counts and high viral loads.
Symptoms include ulcers and erosion of
the esophagus, chest pains, and pain or
difficulty in swallowing, which may be
severe enough to compromise nutritional
(continued on back page)

H1yFront1 ioe
H·l·V

N·E·W·S

B·R·l·E·F·S

■

According to recent data from the National Center for Health Statistics, the AIDS mortality rate in the United States
decreased by 46.4% in 1997, falling to its lowest level since 1987. There were 16,865 AIDS-related deaths in 1997,
compared with 31,130 deaths in 1996. Despite the encouraging news, the United States had the highest HIV/ AIDSrelated mortality rate of 11 industrialized countries.
The number of new HIV infections remained stable at about 40,000. Some researchers are particularly concerned that,
although the decline in AIDS mortality shows great strides in treatment, prevention efforts have not been similarly successful.
■

The Centers for Disease Control and Prevention (CDC) has finished a draft document concerning partner notification in
HIV cases. Some critics say it comes too late, as many states have already begun passing their own laws, many of which
do not parallel the policies outlined by the CDC.
The new CDC guidelines-4 years in the making-recommend developing a comprehensive program that w ould
offer long-term counseling for both sexual and needle-sharing partners, support for clients who choose to notify their
partners, and help in seeking medical evaluation and treatment.
■

As of year-end 1995, the AIDS rate among prisoners in the United States was six times higher than that in the general
population. Although new inmates in federal and most state prisons are not routinely tested for HIV, in part because of
the difficulty of maintaining patient confidentiality, fears about the safety of guards and the high rate of HIV and AIDS
could change this policy.
The US House of Representatives has approved legislation that would require all federal inmates serving at least 6
months to be tested for HIV within 4 months of entering the prison system. Inmate testing would also be mandated if
their bodily fluids come into contact with corrections officers. Results of the tests would be made available to the facility
administrator and the tested inmate.
■

Nationwide, laws that affect HIV-infected people are being passed in response to public fears about the spread of AIDS.
At least 29 states have made it a criminal offense to transmit HIV knowingly. Other laws mandate partner notification
and HIV testing in certain populations, including pregnant women and prison inmates, and permit good Samaritans
and nonmedical personnel to inquire about the HIV statuses of the people they assist.
Many public health officials are worried that the trend toward criminalization will deter HIV-infected people from
seeking help.
SOURCE: CDC National AIDS Clearinghouse. Copyright 1998, Information Inc., Bethesda, MD.

UPDATE
Progressive Multifocal L.eukoencephalopathy
The Summer 1998 issue of HIV Frontline focused on progressive multifocal leukoencephalopathy (PML), an
HIV-related condition for which there is no specific treatment. A letter in the September 17, 1998, issue of the New
England Journal of Medicine cites a case in which 10 patients who had not previously received protease inhibitors
began maximally suppressive ART within 90 days of the onset of PML symptoms. Neurologic conditions improved
markedly in six of the patients, remained unchanged in three, and worsened in one. In half of the patients, JC virus,
which causes PML, was undetectable as much as 1 year after PML was diagnosed. The authors of AIDS Clinical
Trials Group Study 243 responded that they had observed similar results.

HIVfrogtlioe
H W -Flelated Conditions Focus
status. Sometimes, however, esophageal
candidiasis is asymptomatic.
Vaginal candidiasis, familiar to many
women as yeast infection (also known
as monilia), is extremely common in
HIV-infected women. Recurrent bouts
frequently precede oral candidiasis as
an early warning sign of immune dysfunction. After ruling out other causes
(eg, diabetes, pregnancy, or use of
broad-spectrum antibiotics, oral contraceptives, corticosteroids, and other
immunosuppressives), a clinician may
suggest an HIV test for a woman who
has recurrent vaginal candidiasis.
Symptoms include itching; burning
pain; a creamy, cheeselike vaginal discharge; redness with visible white
patches on the labia, vulva, and vaginal tissues, and pain during urination.
Despite the frequency of mucosal
infections with Candida and the
increasing prevalence of candidemia
(bloodstream infection) in hospitalized AIDS patients, visceral infection,
or systemic candidiasis (eg, infection
of the liver, kidneys, or other internal
organs), remains rarely reported.
The heart, kidneys, lungs, eyes, central
nervous system, blood, joints, and
bones are all subject to infection.
Symptoms vary depending on which
organ is affected.
Risk factors for systemic candidiasis
include advanced HIV disease, neutropenia (low white cell count), total parenteral
nutrition (or other therapies requiring
the use of a central venous catheter),
injection drug use, and prophylaxis with
antifungal and/or broad-spectrum antibiotic drugs. Another risk factor is time
spent in a hospital, since illnesses related
to Candida are usually nosocomial
(hospital-acquired) infections.

on:

Cendkliasls

(conttnued from page 6)

Diagnosis

Prevention

Candidiasis is generally diagnosed via
clinical signs. If the condition does not
respond to treatment in a reasonable
amount of time, a culture or biopsy of
lesions may be taken to distinguish
between candidiasis and hairy leukoplakia (associated with Epstein-Barr
virus) or histoplasmosis, both of which
affect HIV-infected people. For esophageal candidiasis, this involves inserting an endoscope down the throat and
scraping the lesions.

Candidiasis is not generally regarded as a
communicable disease. It is an individual's
vulnerability to the organism that is
responsible for an infective episode.
People with active outbreaks should
avoid oral or vaginal contact with others.

n-eatment
Candidiasis is treated with a variety of
antifungal agents, including nystatin,
clotrimazole, fluconazole, ketoconazole, itraconazole, and amphotericin
B. These are available in various forms:
lozenges and swish-and-swallow liquids for oropharyngeal disease; ointments, pills, and suppositories for
vaginal disease; pills, suspensions, and
intravenous preparations for more
severe or refractory disease.
For a first or mild occurrence, clotrimazole or nystatin will probably be tried.
For more severe episodes, oral therapy
with fluconazole or itraconazole is usually successful. Ongoing prophylaxis
with oral azoles is usually reserved for
patients who have frequent recurrences
after initial therapy because of concern
with the emergence of azole-resistant
Candida species. Amphotericin B is
used intravenously when nothing else
proves effective.
A 10- to 14-day course of treatment usually clears up the condition, though
recurrence is common. Drug resistance
and worsening immune status are factors
in recurrence, but so is the ubiquitous
nature of Candida. There is some suggestion
that poor oral hygiene contributes to
recurrence, as dental cavities may
provide a hiding place for the organism.

Since it is virtually impossible to avoid
exposure to Candida, the best hope
for prevention is improvement of
immune function. There is evidence
that reduced viral loads and increased
CD4 cell counts associated with multidrug antiretroviral regimens may
lower the incidence of candidiasis.
For patients with recurrent disease,
especially when it interferes with food
intake or causes extreme discomfort,
prophylactic fluconazole may be
considered. The risk of resistance,
however, as well as the considerable
expense, must be taken into account.
Good oral hygiene, including regular
dental care, is advised.
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