In the early 1980s, Kaposi's sarcoma (KS), Pneumocystis carinii pneumonia (PCP), and other conditions became prevalent in homosexual men in United States cities; eventually, these opportunistic infections were recognized as the result of a profound acquired immunodeficiency. This acquired immunodeficiency syndrome, or AIDS, was soon understood to be a worldwide health problem. Currently, there are approximately 20 million people affected worldwide, 35% are heterosexual, and 1.2 million live in the United States. AIDS is caused by the human immunodeficiency virus (HIV), which attacks CD4 T lymphocytes. The infection results in cell death and impaired immune response. HIV most directly affects the central nervous, gastrointestinal, and pulmonary systems. A massive research effort has produced better treatments, resulting in longer survival and improved quality of life. But there is still no vaccine or cure for AIDS.

• Infection by HIV, a member of the lentivirus group of retroviruses. Seventy percent of transmission is through sexual contact. Parenteral transmission is mainly among intravenous drug users. Blood transfusions and blood products caused many infections, especially among hemophiliacs, but screening procedures have nearly eliminated this risk.
• Transmission to and from healthcare workers is also rare, due to increased precautions.
• Children, comprising fewer than 1% of cases, generally acquire the infection perinatally.

• Unprotected sex
• Anal intercourse
• Multiple sexual partners
• Intravenous drug use
• Occupational needlestick or other contact with infectious bodily fluids
• Exposure to contaminated blood products
• Children born to or breast-fed by HIV-infected mothers

Acute HIV Syndrome: generally, flu-like symptoms that occur in 50 to 80% of those who contract HIV within 2 to 6 weeks, including a combination of the following.

• Fever
• Pharyngitis
• Lymphadenopathy
• Myalgias and arthralgias
• Headache; retroorbital pain
• Malaise; lethargy
• Anorexia; weight loss
• Nausea, vomiting, diarrhea
• Erythematous maculopapular rash
• Mucocutaneaous ulcerations

Early Symptomatic Disease: generally occurs when the CD4 count is below 500/ml; sometimes called pre-AIDS or AIDS-related complex (ARC); there is a median latency phase of 10 years between the acute phase from initial contraction of HIV (see above) and early signs of infection.

• Generalized lymphadenopathy
• Oral and vaginal candidal infections
• Oral hairy leukoplakia
• Thrombocytopenia
• Herpes simplex, recurrent
• Herpes zoster
• Molluscum contagiosum
• Condylomata accuminata
• Repeated bacterial infections with common pathogens

Advanced stage HIV (AIDS): generally occurs when the CD4 count is below 200/ml and risk for development of opportunistic infections is greatly increased.

• Pneumonia, including Pneumocystis carinii (PCP) and bacterial
• Tuberculosis (often presents at higher CD4 counts)
• Extreme weight loss and wasting; exacerbated by diarrhea which is experienced in up to 90% of HIV patients worldwide
• Toxoplasma gondii– encephalitis, brain abscess, chorioretinitis, myocarditis
• Mycobacterium avium complex (MAC) – disseminated disease involving lung, bone marrow, liver; CD4 <= 100/ml
• Cryptococcus neoformans – meningitis, brain abscess, pneumonia, disseminated disease
• Cytomegalovirus – retinitis, esophagitis, colitis, pneumonia; CD4 <= 100/ml
• Diarrhea – Cryptosporidia, Isopora belli
• Syphilis
• Malignancies such as lymphoma, cervical cancer, and Kaposi's sarcoma
• Candida infections of trachea, esophagus, lungs

A broad topic that depends on the group of symptoms at the time of presentation, either with acute HIV syndrome, early signs of infection, or advanced stages of the disease.

Complete physical exam is necessary at the time of presentation and on a regular schedule to be determined by the HIV specialist; once the diagnosis is made, each patient should be referred to an infectious disease specialist with particular training or experience in HIV. Diagnosis should be suspected with any of the signs or symptoms mentioned earlier and considered in the case of an otherwise healthy individual who is experiencing frequent, unexplained infections with normal pathogens (e.g., recurrent respiratory infections or persistent sinusitis). During the exam, particular attention should be paid to evaluate for oral candidiasis, "cottage cheese and ketchup" appearance of retina, adenopathy, skin abnormalities, respiratory symptoms, abdominal tenderness, and signs of dementia.

• HIV antibodies that generally appear 4 to 8 weeks following infection; enzyme-linked immunosorbent assay (ELISA) test is the standard for detecting HIV; 99.5% sensitive but not specific leading to false positives (can occur in the presence of autoantibodies, recent influenza vaccine, or hepatic disease); therefore, positive ELISA must be confirmed by Western blot
• CD4 T-cell lymphocyte count that indicates immune status
• HIV RNA levels for direct detection of the virus
• Arterial blood gas, for suspected PCP
• Stool sample for culture, ova, and parasites, cryptosporidium in the case of diarrhea
• Lumbar puncture may be warranted if CNS symptoms are present

Chest X ray for pneumonia, tuberculosis. Brain imaging if neurological symptoms are present.

Antiretroviral treatments attempt to slow progression of HIV infection to AIDS, while antibiotics and other therapies are used to treat or prevent opportunistic infections and other complications as they arise. Alternative treatments may be used to support the immune system, help in coping with disease symptoms and side effects from conventional treatments, and improve quality of life.

Appropriate treatment depends on the stage of the infection and presence or absence of opportunistic infections; HIV positive patients are best followed by a specialist in this disease process who will determine the best and most current medical regimen. Antiretrovirals, such as zidovudine (AZT), 200 mg orally tid, or lamivudine, 150 mg orally bid, are generally prescribed, together with protease inhibitors such as indinavir, 800 mg orally tid. These medications have significant side effects, and when to begin administering them to asymptomatic patients is a matter for careful consideration. When prescribing for complications, interactions and contraindications must be carefully considered as well, as HIV/AIDS patients may have a number of medical problems at any one time and are usually taking multiple medications. Compliance with the prescribed regimen is important to avoid encouraging resistant viral strains. The following are a few examples of the most common regimens for prophylaxis.

Prophylaxis:

• PCP: trimethoprim–sulfamethoxazole (TMP/SMX) or pentamidine; started at CD4 < 200/ml
• MAC: clarithromycin 500 mg po bid or azithromycin 1200 mg po q week or rifampin 300 mg po qd; started at CD4 < 100/ml
• Toxoplasmosis: TMP/SMX 1 DS tablet qd
• Cryptococcal meningitis: fluconazole 200 mg qd; may start at CD4 < 50/ml
• Candidiasis: fluconazole 200 mg qd; although, primary prophylaxis generally not indicated
• Cytomegalovirus: ganciclovir 1 g po tid with food

Many people with HIV turn to complementary and alternative therapies to reduce symptoms of the virus, lessen side effects from medications, and improve overall health and well being. Surveys show that:

• 52 to 68% of HIV-positive patients take vitamins, herbs, or supplements
• 64% do aerobic exercise, while 33% do other forms of exercise such as yoga or strength training
• 22 to 54% obtain bodywork such as massage, energy healing, or acupuncture
• 38 to 56% use prayer or other forms of spiritual practice
• 42% attend group support
• 33 to 46% practice meditation or other forms of relaxation, such as breathing exercises

Despite these statistics, only 26% of medical doctors ask patients about these practices; 63% of physicians, though, admit that they would like to know if their HIV positive patients are using such alternatives and believe that these practices are helpful.

As mentioned earlier, weight loss has historically been a serious problem for the HIV population. Treatment with protease inhibitors has lessened the amount of weight loss, but reduction of muscle mass remains a significant concern. Working with a registered dietitian can help prevent both weight loss and muscle breakdown.

An article published in November 1999 supports the use of certain supplements for those with HIV, particularly for help in maintaining body weight. In a well-designed study comparing the use of a daily supplement regimen including the amino acid glutamine (40 g per day), vitamin C (800 mg), vitamin E (500 IU), beta-carotene (27,000 IU), selenium (280 mcg), and N-acetylcysteine (2400 mg) to placebo, subjects taking the supplements gained significantly more weight after 12 weeks than those who took the placebo.

Vitamins C and E may reduce the oxidative stress of HIV and reduce viral load; this was suggested by a study published in the journal AIDS in September 1998, although it was not definitively proven. If true, it would support the fact that many people with HIV seem to have lower levels of antioxidants such as vitamins C and E in their blood than those without HIV. Related to vitamin C, grapefruit juice may enhance the absorption of protease inhibitors. The antioxidant selenium (100 to 400 mcg per day) and a vitamin B complex (75 to 100 mg per day) may also be useful to reduce physiologic stress of HIV. Cobalamin (vitamin B₁₂) levels are occasionally low with HIV, in which case B₁₂ injections may be required.

Doses of vitamins frequently used in the case of HIV:

• Vitamin C 1000 mg per day
• Vitamin E 400 to 800 IU per day
• Selenium 100 to 400 mcg per day
• Vitamin B complex 75 to 100 mg per day

In a study in Uganda, 154 patients with HIV who received individualized herbal treatments for herpes zoster, improved more quickly than 55 patients who received standard treatment with the drug acyclovir. Both groups got better, but the group receiving the individualized herbal remedies experienced reduced pain and resolution of the blisters more quickly than the group receiving acyclovir.

Although the use of herbs is standard in traditional Chinese medicine, and despite some promising in vitro and animal studies, human research in the United States of traditional Chinese medicinal herbs to help reduce levels of circulating HIV in the bloodstream have been inconclusive, showing no definitive help but no obvious harm.

In vitro studies of St. John's wort suggest that it may also be helpful against HIV. St. John's wort given to people with the virus, however, led to such intolerable side effects in one study that very few people were willing to complete the study. In addition, recent data from an article published in February 2000 shows that St. John's wort may lower levels of indinavir.

In vitro studies of other herbs in the treatment of HIV, including licorice root, Calendulus officinalis flowers, and ginseng, have yielded intriguing results. Ginseng has also shown some possible benefits in human studies. More research is necessary, however, before drawing definitive conclusions about these herbal remedies for HIV. Please see the individual monographs about these herbs for additional information.

In addition, echinacea and astragalus, two substances touted to enhance immune function in people with HIV, should not be used because these herbs may actually enhance replication of the HIV virus.

While no known published scientific research supports the use of homeopathy for HIV or AIDS specifically, a licensed, certified homeopathic doctor would assess an individual's constitutional type and severity of disease to select the correct remedy and potency as an adjunct to standard medical therapy.

Exercise is another way to help develop a general sense of well-being, improve mental attitude, decrease depression, diminish weight loss, and increase lean body mass. Resistance or weight training is particularly useful to increase strength and enhance lean body mass.

Patients with HIV have used acupuncture to improve general well being, alleviate symptoms such as fatigue, insomnia, headache, and night sweats, as well as to minimize side effects from medications.

A small study published in 1999 showed that acupuncture used for people with peripheral neuropathy, an occasional side effect from some antiretrovirals, improved nerve function for all of the participants both subjectively and objectively. Each individual reported feeling less pain, increased strength, and improved sensation; these feelings were confirmed by measurable improvement in nerve function.

As mentioned earlier, diarrhea can be a major problem for people with HIV throughout the world. In China, acupuncture and moxibustion (a heat treatment performed by the acupuncturist over points where the needles are placed) are included as standard treatment for HIV-related diarrhea.

Massage may enhance the immune system and decrease anxiety as demonstrated in a study of newborns specifically. Other forms of stress reduction have shown improved CD4 counts in additional populations.

Patients must be seen regularly to evaluate disease progression and monitor for complications; the schedule for this process as well as evaluation of CD4 count and viral load are generally determined by the HIV specialist.

Safe-sex practice or abstinence helps prevent transmission of HIV. Needle-exchange programs have the potential for reducing cases among intravenous drug users. Healthcare workers should always follow universal precautions.

While 70 to 80% of patients recover fully from P. carinii pneumonia, respiratory failure is a possibility. Other complications may include hydrocephalus from cryptococcal meningitis, and blindness from cytomegalovirus. Please see earlier sections for more detailed information on opportunistic infections.

Zidovudine and certain other antiretroviral medications administered to pregnant patients with HIV reduces the likelihood of transmission to the child. A decision must be made, based on the patient's condition, whether to postpone treatment until after the first trimester to reduce the risk to the fetus. Efavirenz should be avoided throughout pregnancy due to teratogenic effects. Likewise the possible teratogenic effects of other medications must be weighed against the advisability of postponing more aggressive combination treatment for the mother until after the first trimester. HIV-positive women should not breast-feed because of the risk of transmission.

Allard JP et al. Effects of vitamin E and C supplementation on oxidative stress and viral load in HIV-infected subjects. AIDS. 1998;13:1653-1659.

Anastasi JK, Dawes NC, Li YM. Diarrhea and HIV: Western and Eastern perspectives. J Altern Comp Med. 1997;2:163-168.

Auerbach J, Oleson T, Solomon G. A behavioral medicine intervention as an adjunctive treatment for HIV-related illness. Psychology and Health. 1992;6:325-334.

Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, Mass: Integrative Medicine Communications; 1998:119-120, 134, 169-170.

Dubin J. HIV Infection and AIDS. Emergency Medicine Online. 1998. Accessed at www.emedicine.com/emerg/topic253.htm on February 13, 1999.

Dworkin BM. Selenium deficiency in HIV infection and the acquired immunodeficiency syndrome (AIDS). Chem Biol Interact. 1994;91:181-186.

Elion RA, Cohen C. Complementary medicine and HIV infection. Primary Care. 1997;4:905-919.

Ernst E. Complementary AIDS therapies: the good, the bad and the ugly [editorial]. Int J STD AIDS. 1997;5:281-285.

Fairfield KM, Eisenberg DM, Davis RB, Phillips RS. Patterns of use, expenditure and perceived efficacy of complementary and alternative therapies in HIV-infected patients. Arch intern Med. 1998;158:2257-64.

Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998; 1110-1111, 1814-1840.

Fawzi WW, Mbise RL, Hertzmark E, et al. A randomized trial of vitamin A supplements in relation to mortality among human immunodeficiency virus-infected and uninfected children in Tanzania. Pediatr Infect Dis J. 1999;18:127-133.

Galantino ML, Elseokoro ST, Findley TW, Condoluci D. Use of noninvasive electroacupuncture for the treatment of HIV-related peripheral neuropathy: a pilot study. J Altern Comp Med. 1999;5(2):135-142.

Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal Medicines. Montvale, NJ: Medical Economics Co; 1998:626-627, 866-867, 903-904, 1138-1139, 1174-1175.

Hayashi K, Hayashi T, Kojima I. A natural sulfated polysaccharide, calcium spirulan, isolated from Spirulina platensis: in vitro and ex vivo evaluation of anti-herpes simplex virus and anti-human immunodeficiency virus activities. AIDS Res Hum Retroviruses. 1996;12:1463-1471.

Homsy J, Katabira E, Kabatesi D, et al. Evaluating herbal medicine for the management of Herpes zoster in human immunodeficiency virus-infected patients in Kampala, Uganda. J Altern Comp Med. 1999;5(6):553-565.

Lissoni P, Vigore L, Rescaldani R, et al. Neuroimmunotherapy with low-dose subcutaneous interleukin-2 plus melatonin in AIDS patients with CD4 cell number below 200/mm³: a biological phase-II study. J Biol Regul Homeost Agents. 1995;9:155-158.

MacIntyre RC, Holzemer WL. Complementary and alternative medicine and HIV/AIDS. Part II: selected literature review. J Assoc Nurses AIDS Care. 1997;8(2):25-38.

Nerad JL, Gorbach SL, et al. Nutritional aspects of HIV infection. Infect Dis Clin North Am. 1994;8:499-515.

Noyer CM, Simon D, Borczuk A, Brandt LJ, Lee MJ, Nehra V. A double-blind placebo-controlled pilot study of glutamine therapy for abnormal intestintal permeability in patients with AIDS. Am J Gastroenterol. 1998;93:972-975.

Patarca R, Fletcher MA. Massage therapy is associated with enhancement of the immune system's cytotoxic capacity. Int J Neurosci. February 1996;84:205-217.

Piscitelli S, Burstein AH, Chaitt D, et al. Indinavir concentrations and St. John's wort [letter]. Lancet. 2000;355:547-548.

Remacha AF, Cadafalch J. Cobalamin deficiency in patients infected with the human immunodeficiency virus. Semin Hematol. 1999;36:75-87.

Rouben R, McDermott A, Weiss L, Suri J, Wood M, Block K, Gorbach S. Short-term progressive resistance training increases strength and lean body mass in adults infected with HIV. AIDS. 1999;2:231-239.

Shabert JK, Winslow C, Lacey JM, Wilmore DW. Glutamine antioxidant supplementation increases body cell mass in AIDS patients with weight loss: a randomized, double-blind controlled trial. Nutrition. 1999;11:860-864.

Weber R et al. Randomized, placebo-controlled trial of Chinese herb therapy for HIV infected individuals. J Acquir Immun Defic Syndr. 1999;1:56-64.

Wynia MK, Eisenberg DM, Wilson IB. Physician-patient communication about complementary and alternative medical therapies: a survey of physicians caring for patients with human immunodeficiency virus. J Altern Comp Med. 1999;5:447-456.