Complementary and Holistic Medicine
Janet Konefal
Jessica Lillisand
Complementary and alternative medicine (CAM) can be defined as “those practices that aren’t part of the politically dominant medical system of a country.”1 In the United States, this means those practices that are not usually taught in medical schools; not available in most hospitals, clinics, and private practices; and often not reimbursed by insurance or otherwise routinely accessible.1 This encompasses an amazingly wide range of practices, including, but not limited to, the following general categories:
Alternative medical systems are comprehensive systems of care that may have evolved from a non-Western philosophical tradition, such as Traditional Chinese Medicine (TCM) or Ayurveda, or that may have evolved concurrently with conventional Western medical approaches, such as homeopathy and naturopathy. The essential element of these systems is a complete methodology for treatment based on an underlying theory or philosophy.
Mind-body interventions involve a variety of techniques designed to promote the mind’s capacity to affect body functions and symptoms. This includes a wide array of practices, from cognitive-behavioral therapy to meditation and prayer.
Biologically based therapies use substances found in nature, such as herbs, foods, vitamins, and other dietary supplements.
Manipulative and body-based methods involve hands-on manipulation and/or movement of one or more parts of the body—for example, chiropractic or osteopathic manipulation or massage.
Energy therapies involve the use of energy fields of two basic types—biofield and bio- electromagnetic. Biofield therapies affect energy fields, which hypothetically surround and permeate the body. Examples of these are Qigong, Reiki, and Therapeutic Touch. Bioelectromagnetic-based therapies use electromagnetic fields such as pulsed fields, magnetic fields, or alternating current or direct current fields in unconventional and not yet scientifically validated ways.
The debate that has surrounded the uses of CAM health care practices has been politically charged for many years, because in the early years there were few, if any, scientifically valid studies demonstrating the efficacy of these therapies. CAM has been criticized because most of the information about its effectiveness has been anecdotal and gathered from treatments that are generally individualized, rather than standardized, thus not lending themselves to the requirements of the scientific method. Even though much of Western medicine was itself developed from anecdotal information, the current standard for evaluation of a Western
medical treatment is a double-blind, placebo-controlled trial. In recent years, there has been an increasing effort to apply the scientific method to the evaluation of CAM practices, with mixed results. A number of factors have contributed to the difficulty of this endeavor. For example, many alternative practices, such as massage therapy, do not lend themselves to the possibility of a double-blind design. Also, pure substances, a requirement of a controlled drug trial, are often not available, or are undesirable for treatment.
medical treatment is a double-blind, placebo-controlled trial. In recent years, there has been an increasing effort to apply the scientific method to the evaluation of CAM practices, with mixed results. A number of factors have contributed to the difficulty of this endeavor. For example, many alternative practices, such as massage therapy, do not lend themselves to the possibility of a double-blind design. Also, pure substances, a requirement of a controlled drug trial, are often not available, or are undesirable for treatment.
As an indication of the slowly changing relationship of CAM to the mainstream medical world, in 1992 the National Institute of Health (NIH) became involved in CAM research and by 1998 established the National Center for Complementary and Alternative Medicine, or NCCAM with a budget of $123 million. NCCAM has defined its 5-year (2000 to 2005) plan, with priorities in the areas of research, training of practitioners, expanding outreach, and facilitating integration. These recent developments are evidence of a dramatic expansion of interest in CAM.
The list of what is considered to be CAM continually changes because complementary and alternative therapies, because they are proven to be safe and effective, are adopted into conventional practices and, at the same time, new and complementary approaches to health care are constantly emerging. For example, scientists have found that folic acid prevents certain birth defects and that a regimen of vitamins and zinc can prevent age-related macular degeneration (AMD), and thus these are now used in mainstream or conventional medicine.
Even within the class of CAM practices, there is also some confusion about correct terminology. Complementary medicine refers to practices that are used in conjunction with conventional medicine. For example, aromatherapy is a complementary therapy that may be used to lessen a patient’s discomfort following surgery. Alternative medicine is also used in place of conventional medicine. For example, the practice of using a special diet to treat cancer as an alternative to undergoing surgery, radiation, or chemotherapy recommended by a conventional doctor. Integrative medicine, on the other hand, combines mainstream medical practices with CAM therapies for which there is some valid scientific evidence of efficacy and safety.
The focus of this chapter is on complementary medicine, specifically with regard to its use with patients with human immunodeficiency virus (HIV) disease and AIDS. Patients with HIV or AIDS typically receive conventional treatment. However, more and more, persons living with HIV disease or AIDS are seeking CAM treatments for symptoms and side effects from the antiretroviral drug therapies they receive, as well as for the disease itself. Most of these treatments are designed to augment, not replace, the conventional treatments patients with HIV disease and AIDS receive.
Prevalence of CAM use in HIV/AIDS
Although there is some debate over the extent to which it is happening, there is no question that patients with HIV disease or AIDS have also increasingly been seeking CAM treatments. This trend came about largely after 1996, when the efficacy of highly active antiretroviral therapy (HAART) was first presented, and patients with HIV disease and AIDS began to view their illness as something that might become a chronic controllable condition. Initially, lack of understanding of the disease motivated interest in CAM. Taking high doses of vitamin C was one of the first types of CAM that was widely used by those with HIV infection and AIDS. Dinitrochlorobenzene (DNCB), a chemical used in developing color photographs, applied to the skin in the hopes of stimulating cellular immunity, was another treatment that was used in the early years of the disease. Others included dextran sulfate, hypericin (St. John’s wort), hyperthermia, ribavirin, and compound Q. Most of these therapies have fallen out of favor in recent years. Since the advent of a broad array of new antiretroviral drugs, CAM use has dramatically changed. Many individuals who are HIV-positive or have AIDS
and who use CAM today do so to reduce the side effects of prescribed medications, improve or sustain well-being, or increase their energy. CAM is therefore more likely now to be used in a more complementary fashion. Today, many patients with HIV disease or AIDS are also interested in CAM as a way to treat conditions that do not respond to HAART, such as wasting syndrome.
and who use CAM today do so to reduce the side effects of prescribed medications, improve or sustain well-being, or increase their energy. CAM is therefore more likely now to be used in a more complementary fashion. Today, many patients with HIV disease or AIDS are also interested in CAM as a way to treat conditions that do not respond to HAART, such as wasting syndrome.
The use of CAM in patients with HIV disease or AIDS was recently extensively studied by Standish et al.,2 who reported on 1,675 HIV-positive individuals and found that they had used 1,600 different types of CAM and 1,210 CAM substances, visited 119 types of CAM providers, and used 282 CAM therapeutic activities. Most of the participants in this study were using CAM in conjunction with antiretroviral drug therapy (63%) and thus could be characterized as using integrated medicine. Only 3.5% of the subject pool reported seeing only alternative providers. The most frequently used modalities were biologically based therapies such as vitamins and herbal supplements (63%). Massage therapists (49%), acupuncturists (45%), nutritionists (37%), and psychotherapists (35%) were also employed, and the activities most commonly used were aerobic exercise (63%), prayer (58%), massage (53%), and meditation (46%).
CAM use is also associated with several sociodemographic variables. A study by Gore- Felton et al.3 concluded that HIV-positive women and Whites were both four times more likely to use CAM. CAM use is also higher among homosexuals, persons with a college education, persons with greater incomes, and persons with poorer health status.4
Reasons for CAM use in HIV/AIDS
It appears that HIV-positive individuals turn to CAM for a variety of reasons. Some of these reasons include, but are not limited to, the desire to take an active role in one’s own health care, the treatment of side effects caused by conventional medications, and the desire to improve general well-being and stress levels, boost immunity, and lower viral load.
Individuals with HIV infection or AIDS generally use the same types of CAM as the population as a whole, with therapies such as acupuncture, massage, herbs, and nutritional supplementation used most frequently. In a study by Sparber et al.,5 postdiagnosis therapies that were increasingly used were imagery, relaxation, spiritual, herbal, weight gain, acupuncture, massage, and high-dose vitamins. However, many different techniques are employed by those with HIV infection or AIDS in the treatment of a variety of conditions. The following sections discuss these methods and the symptoms they are used to treat, as well as the efficacy of the treatments, both as perceived and as tested.
Biologically Based Systems
By far the most commonly used CAM modality for patients with HIV disease or AIDS is biologically based systems. This includes herbs, foods, vitamins, and other dietary supplements. Herbs are used by naturopaths, herbalists, homeopaths, acupuncturists, and practitioners of Ayurvedic, Chinese, and Native American medicine. Chinese herbs in particular are often used in combination, such as Composition A, to provide a tonic for general health or to cure a specific ailment. The study by Gore-Felton et al.3 found that 50% of their sample reported that they took more one or more multivitamins, 17% reported taking mineral supplements, 12% reported using Chinese herbs, and 12% reported using botanicals. One of the most common reasons that patients with HIV disease or AIDS take herbs is to support the immune system and help it repair damage caused by the virus. Unfortunately, herbal remedies have not generally been rigorously or effectively studied for use with these patients. Most of the knowledge about herbal immune therapies, therefore, comes from herbs that were previously used for cancer. Some herbs that are used as immune therapies include ginseng, greater celandine, cat’s claw, atractylodes, astragalus, ashwagandha, and shatvari, shitake, and maitake mushrooms.
Herbs are also taken as antimicrobial therapies, to prevent AIDS-related infections or to treat mild infections. These herbs include garlic, goldenseal, neem, propolis, sanguinaria, and tea tree. Various herbs have also been found to have some moderate anti-HIV impact, usually in combination. Herbal combinations have several benefits, including fewer side effects than drug “cocktails” and less likelihood that the virus will mutate to evade the attack. Herbs such as bitter melon, curcumin, glycyrrhizin, and SPV-30 have been used to treat HIV with some claimed effectiveness. However, although a few small clinical trials have been done on antiretroviral herbs, no herbal treatment has been found to be as effective as antiretroviral drugs in stopping the replication of HIV. Herbs are also used to treat HIV-related conditions, such as ginkgo for dementia, aloe vera for skin problems, St. John’s wort for depression, marijuana for wasting, greater celandine for Kaposi’s sarcoma, and lemon balm for insomnia and herpes simplex. Patients with HIV and AIDS produce high levels of free radicals; herbs such as ginger, ginkgo, milk thistle, and turmeric can be used for their antioxidant properties. Herbs are also used to treat the side effects of antiretroviral drug therapy, though they must be used carefully because dangerous herb—drug interactions can occur that might weaken the effectiveness of treatment, increase side effects, or cause drug resistance. For short-term side effects, herbs such as ginger or marijuana for nausea, and peppermint or psyllium husks for diarrhea can be used. High cholesterol and triglyceride values, seemingly associated with the use of antiretroviral drugs, are also being treated with herbs such as garlic, ginger, ginseng, and guggul.
Herbs are also taken as antimicrobial therapies, to prevent AIDS-related infections or to treat mild infections. These herbs include garlic, goldenseal, neem, propolis, sanguinaria, and tea tree. Various herbs have also been found to have some moderate anti-HIV impact, usually in combination. Herbal combinations have several benefits, including fewer side effects than drug “cocktails” and less likelihood that the virus will mutate to evade the attack. Herbs such as bitter melon, curcumin, glycyrrhizin, and SPV-30 have been used to treat HIV with some claimed effectiveness. However, although a few small clinical trials have been done on antiretroviral herbs, no herbal treatment has been found to be as effective as antiretroviral drugs in stopping the replication of HIV. Herbs are also used to treat HIV-related conditions, such as ginkgo for dementia, aloe vera for skin problems, St. John’s wort for depression, marijuana for wasting, greater celandine for Kaposi’s sarcoma, and lemon balm for insomnia and herpes simplex. Patients with HIV and AIDS produce high levels of free radicals; herbs such as ginger, ginkgo, milk thistle, and turmeric can be used for their antioxidant properties. Herbs are also used to treat the side effects of antiretroviral drug therapy, though they must be used carefully because dangerous herb—drug interactions can occur that might weaken the effectiveness of treatment, increase side effects, or cause drug resistance. For short-term side effects, herbs such as ginger or marijuana for nausea, and peppermint or psyllium husks for diarrhea can be used. High cholesterol and triglyceride values, seemingly associated with the use of antiretroviral drugs, are also being treated with herbs such as garlic, ginger, ginseng, and guggul.
Standish et al.2 reported that the most commonly used CAM substances in their 2001 survey were vitamins and herbs, including multivitamin supplements, vitamin C, vitamin E, garlic, beta-carotene, and vitamin B12. Substances such as ginseng,Echinacea, and acidophilus were also employed at a high rate. Vitamin C is a powerful antioxidant, useful for increasing immune function and neutralizing free radicals. Vitamin C has been shown in vitro to suppress HIV replication in CD4 cells, but there is a dearth of rigorously controlled studies conducted to test its true efficacy. A daily multivitamin has also been shown to reduce the risk of AIDS and lower CD4 count in HIV-positive men.6 One of the downsides to using vitamin and mineral supplements in high dosages is possible gastrointestinal distress, along with several other, nutrient-specific side effects. For example, high dosages of zinc carry the risk of impaired immune function. Whole food supplement extracts reduce the risks of high dosage.
Alternative Medical Systems
Alternative medical systems, such as TCM and Ayurveda, also use herbs as a key part of their treatment of HIV disease. TCM has become a popular complementary treatment for patients with HIV disease and AIDS. Unlike Western herbs, Chinese herbs are generally combined, using herbs that complement and balance one another, thus reducing risk of toxicity. However, TCM also employs a wide range of therapies in addition to herbal medicine, including acupuncture, massage, bone adjustment, dietary therapy, and energy therapies such as Qigong. Acupuncture points may be affected by needles, heat, finger pressure, suction, scraping, and laser and electrical stimulation. The points may also be stimulated using massage to affect the energetic system manually. Dietary therapy in TCM is extensive and complex and is not discussed in detail here. However, when a practitioner of TCM is consulted for treatment of HIV disease, most of these therapies will be employed in a synergistic way.
The fundamental aim of Ayurvedic treatments is the balance of the tridosha, which is the name for the combination of the forces, or humours, that make up the body: vata (wind), kapha (phlegm), and pitta (bile). Ayurveda aspires for optimal health by balancing the factors that influence the mind, body, and spirit. Oil baths and massage are often employed, as well as the use of several Ayurvedic herbs, including guggul and ashwaganda, for the treatment of HIV disease. Homeopathy is a more Western, and more recent, medical system that also employs a holistic approach to care. Homeopathic remedies are highly individualistic and are
chosen by matching a cure to the unique characteristics of the person being treated. Homeopathic remedies are often very dilute, highlighting homeopathy’s second key principle— that the more dilute a remedy is, the stronger it is. Very little has been published about the effects of and experiences with homeopathy by HIV-positive people, but a recent publication in The Lancet concluded that the effects of homeopathy could not be attributed to placebo effect. Flower essences are also used in homeopathy. They are designed to address emotional and mental states, and may be useful in the treatment of anxiety and depression in HIV- positive individuals. Both homeopathy and flower essences are too subtle to interact with prescription medications and are safe for use in the HIV-positive patient.
chosen by matching a cure to the unique characteristics of the person being treated. Homeopathic remedies are often very dilute, highlighting homeopathy’s second key principle— that the more dilute a remedy is, the stronger it is. Very little has been published about the effects of and experiences with homeopathy by HIV-positive people, but a recent publication in The Lancet concluded that the effects of homeopathy could not be attributed to placebo effect. Flower essences are also used in homeopathy. They are designed to address emotional and mental states, and may be useful in the treatment of anxiety and depression in HIV- positive individuals. Both homeopathy and flower essences are too subtle to interact with prescription medications and are safe for use in the HIV-positive patient.
Naturopathy, a more Western approach, involves the use of the body’s natural abilities to heal itself. Naturopaths use a wide variety of approaches, including but not limited to acupuncture, dietary recommendations, herbal remedies, homeopathy, TCM, exercise therapy, and counseling. The goal for a naturopathic practitioner is to evoke a lifestyle change in patients by teaching proper diet, exercise, relaxation, and eating techniques.
Manipulative, or Body-Based, Techniques
Another commonly used modality in HIV and AIDS therapy is manipulative, or body-based, CAM. This includes practices such as massage, acupuncture, and chiropractic manipulation. Standish et al.2 reported that 52.5% of respondents used massage, 45.4% used acupuncture, 12.1% used acupressure, 25.7% used chiropractic manipulation, and 8.6% used spinal manipulation. American practices of acupuncture incorporate medical traditions from China, Japan, Korea, and other countries. Acupuncture has been claimed to affect the immune response dramatically in the treatment of patients with HIV disease, including the ability to reduce fever, increase production of antibodies, and increase resistance to disease. Although there are no similar studies of its effectiveness in patients with HIV disease, it has been shown to increase CD4+ cells in cancer patients. Acupuncture has also been used to treat generalized symptoms such as fatigue and pain and localized symptoms such as neuropathy.
Massage is also a widely used therapy for patients’ HIV disease and AIDS. Massage is the manipulation of body tissues by a therapist. The tissues that are manipulated can be muscles, such as with Swedish massage, or bones and joints, such as with chiropractic massage and osteopathy. Considerable research on touch therapies such as massage have indicated positive results in the treatment of HIV-positive individuals. Therapeutic massage has been used to treat a variety of physical symptoms, including chronic pain, peripheral neuropathy, stress, and fatigue. A 1996 study demonstrated that HIV-positive adults receiving a 45-minute massage five times a week for 1 month showed an increase in natural killer cell production and activity, as well as a decrease in anxiety and depression.7 Massage techniques are used in the treatment of discomfort relating to Kaposi’s sarcoma and associated lesions and to ease difficulty breathing after bouts of Pneumocystis jiroveci (formerly carinii) pneumonia (PCP) by reducing muscular and chest tension. Massage has also been effective in increasing circulation, improving lymphatic drainage, and relieving pain or restriction following opportunistic infections or serious HIV infection symptoms. These benefits are in addition to the psychoneuro- logic benefits of increased mood and improved outlook and self-esteem that touch can give.
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