FACTORS AFFECTING HIV PROGRESSION

The human immunodeficiency virus (HIV) is a retrovirus that causes AIDS (acquired immune deficiency
syndrome). The retrovirus primarily attacks the immune defense system, making the body extremely
vulnerable to opportunistic infections. Opportunistic infections occur in individuals who are
immunocompromised (have weakened immune systems).

Background

The human immunodeficiency virus (HIV) is a retrovirus that causes AIDS (acquired immune deficiency
syndrome). The retrovirus primarily attacks the immune defense system, making the body extremely
vulnerable to opportunistic infections. Opportunistic infections occur in individuals who are
immunocompromised (have weakened immune systems).

HIV is transmitted from person to person via bodily fluids, including blood, semen, vaginal discharge, and
breast milk. It can be spread by sexual contact with an infected person, by sharing needles/syringes with
someone who is infected, through breastfeeding, during vaginal birth or, less commonly (and rare in
countries where blood is screened for HIV antibodies), through transfusions with infected blood. HIV has
been found in saliva and tears in very low quantities and concentrations in some AIDS patients. However,
contact with saliva, tears, or sweat has never been shown to result in HIV transmission.

Currently, there is no cure for HIV/AIDS. Patients receive antiretroviral drugs, which suppress the virus.
These drugs do not reduce the risk of transmitting the disease to someone else.

HIV can infect and kill many different types of cells in the body, but the primary targets are immune cells
called CD4 T-cells. The CD4 T-cells are white blood cells that help coordinate the immune system's
response to infection and disease. These cells express a molecule called CD4 on their surfaces, which
allows them to detect foreign substances, including viruses that enter the body. HIV binds to the receptors
on CD4 cells and enters the white blood cell. Once inside the cell, HIV begins replicating.

The first stage of HIV, known as the primary or acute infection, is the most infectious stage of the disease,
and it typically lasts several weeks. During this phase, the virus replicates rapidly, which leads to an
abundance of the virus in the bloodstream, and a drastic decline in the number of CD4 T-cells. The CD8 T-
cells (cells that kill abnormal or infected body cells) are then activated to destroy HIV-infected body cells
and antibodies are produced. An estimated 80-90% of HIV patients experience flu-like symptoms during
this stage.

The next stage, called clinical latency, may last anywhere from two weeks to 20 years. During this phase,
HIV is active in the lymph nodes, where large amounts of the virus become trapped. The surrounding
tissues, which contain high levels of CD4 T-cells, may also become infected. The virus accumulates in
infected cells and in the blood as free virus.

Patients progress to AIDS when their CD4 cell counts drop below 200 cells per microliter of blood. Healthy
individuals have a CD4 cell count between 600 and 1,200 cells per microliter of blood. Individuals with a
CD4 cell lower than 200 cells per microliter of blood have the greatest risk of developing opportunistic
infections.

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Many factors can affect how quickly HIV infection progresses to AIDS. Factors such as age, co-infections
(infection other than HIV), ethnicity, geographic location, genetics, infection route (how the disease was
transmitted), nutrition, pregnancy, stress, and whether or not the patient smokes or uses recreational drugs
can affect the rate at which an HIV patient develops AIDS. In addition, the healthcare provider's experience
treating HIV can influence how quickly the virus progresses.

RISK FACTORS

Age: Older patients: The older the HIV patient, the faster he/she is likely to progress to AIDS. The effect is
most apparent in patients older than 40. Researchers estimate that the risk of developing AIDS increases
27-55% every ten years.

According to a meta-analysis of 38 studies that involved more than 13,000 HIV patients, age and time since
diagnosis were significant factors in determining the rate of HIV progression. Patients who developed HIV
antibodies between the ages of 15 and 24 lived an average of 12.5 additional years. These patients
progressed to AIDS after an average of 11 years. Patients who developed HIV antibodies between the
ages of 45 and 54 lived an average of 7.9 additional years. These patients progressed to AIDS after an
average of 7.7 years.

While the exact reason for this is unknown, some researchers suggest that older patients have a decreased
ability to replace the CD4 T-cells that HIV infects and destroys. It is also unclear whether this is a result of
the thymus gland's inability to produce new CD4 T-cells. Others suggest that older patients may have lower
levels of chemokines, white blood cells that help fight off HIV.

Younger patients: HIV progression is also faster among patients who are younger than 13 years old,
especially newborn babies who are born with the virus. This is likely because the newborn's immune
system is not yet fully developed. Newborn babies do not begin to make their own antibodies (proteins that
detect and bind to foreign substances like viruses) until they are about six months old.

Co-infections: Cytomegalovirus (CMV): Many types of herpes viruses, including cytomegalovirus (CMV),
may increase the risk of developing AIDS. Herpes viruses produce proteins that may increase the speed at
which HIV replicates. Several studies have suggested that patients who have both HIV and CMV are likely
to develop AIDS quicker than those who only have HIV.

However, recent research has produced conflicting results, and the role of CMV as a possible co-factor
remains unknown. For instance, one study found that CMV only affected disease progression in individuals
who were already diagnosed with AIDS.

Based on the theory that CMV and other herpes viruses may increase HIV replication, researchers have
evaluated the effect of anti-herpes treatment in HIV patients. Based on the results of several studies, it has
been suggested that high doses of the anti-herpes drug acyclovir (Zovirax©) may increase survival time in
HIV patients, particularly in those who have advanced HIV. However, other studies have found no effect of
acyclovir treatment on survival time in HIV patients. Further research is warranted in order to make a firm
conclusion.

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Hepatitis C virus (HCV): Hepatitis C virus (HCV) appears to cause a rapid progression of both HIV and
HCV-related diseases. Despite modern-day antiretroviral therapy (ART), patients infected with both HIV
and HCV still have a greater risk of death than those only infected with HIV.

According to recent research, HCV's impact on HIV progression varies, depending on the genetic makeup
of HCV. Also, patients who are infected with several different genetic types of HCV are likely to experience
even faster HIV progression. Some researchers suggest that ART may decrease the impact HCV has on
HIV progression.

Herpes virus type 6: Herpes virus type 6 (HHV-6) has also been suggested as a possible factor in HIV
progression. The virus infects CD4 T-cells and produces a protein that may make increase the rate at
which HIV replicates inside the white blood cells. However, one study evaluated long-term non-progressed
HIV patients who had herpes viruses and based on their results, the researchers suggested that HHV-6,
HHV-7, and HHV-8 are not co-factors in HIV progression.

T -lymphocyte virus: According to some studies, co-infection with the retrovirus human T-lymphocyte virus
type 1 (HTLV-1) may increase the risk of an HIV-infected patient developing AIDS.

Ethnicity and location: It has been suggested that Africans living in the United Kingdom develop AIDS
and die more quickly than non-Africans. However, recent research does not support this claim. According
to a review of more than 1,050 HIV-infected Africans and 992 HIV-infected non-Africans diagnosed with the
disease between 1982 and 1995, there was not a significant difference in survival rates between the two
groups. The Africans lived an average of 82 months, while the non-Africans lived an average of 78 months.
The researchers also reported no significant difference in the CD4 cell counts or rates of progression.

The researchers suggested that it was highly likely that the African patients studied were infected with a
different strain of HIV (called HIV-2) than the one that normally infects homosexual men and injection-drug
users in Europe and North America (called HIV-1). If HIV-2 does not cause HIV progression quicker outside
of Africa, this suggests that environmental factors, such as lack of access to antiretroviral therapy (ART)
and treatment for opportunistic infections, lead to the faster progression rates in Africa.

Other research suggests that HIV progression rates among individuals living in Uganda are similar to those
in developed countries. The researchers estimated that the average time from HIV exposure to an AIDS
diagnosis was 9.4 years.

However, some studies suggest that a common genetic mutation among Africans may increase the
patient's risk of developing HIV, and increase the rate of disease progression.

Another study conducted in the United States found no difference in viral load levels (number of HIV viral
particles in the blood) among different racial groups, after controlling for access to medical care, socio-
economic status, and CD4 cell counts.

Gender: Based on several studies in both adults and children, it appears that gender does not affect the
risk of HIV disease progression. In general, women have a lower viral set-point than men. The viral set-
point is the point at which HIV replication slows and is suppressed by the body's white blood cells.
However, this lower set-point does not appear to influence the rate of HIV disease progression.

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Genetics: Receptors: Patients who have certain genetic mutations or variations may have CD4 cells that
are either more or less susceptible to HIV infection. This may occur in patients who either lack the co-
receptors CCR5 or CXCR4, or they express them in a different way.

For instance, one meta-analysis found that a variation of the CCR5 co-receptor, called CCR5-©"32,
reduced the risk of HIV patients developing AIDS by 31%, and lowered the risk of death by 39%.

Another study showed that patients who had mutations on their CCR5 receptors called 356T were more
susceptible to HIV infection. This mutation, according to researchers, may also increase the rate of disease
progression.

Chemical messengers: Genetic variation in chemical messengers called cytokines and chemokines may
also impact the rate of HIV progression. These chemical messengers signal the white blood cells to move
towards an area of infection. According to one study that evaluated 337 slow and fast progressors, genetic
variations of two types of cytokines called interleukin-4 and interleukin-10 led to an increased rate of
disease progression.

In addition, a low copy number of the gene for a chemokine called CCL3L1 has been associated with a
significantly increased risk of HIV progression.

Human leukocyte antigens (HLA): Researchers have also demonstrated a relationship between the genetic
makeup of human leukocyte antigens (HLA) and HIV progression. HLA are proteins found in the
membranes (outside surface) of nearly every cell in the body. These antigens are found in especially high
concentrations on the surface of white blood cells. In healthy individuals, HLA antigens help the body's
immune system distinguish between self and non-self (foreign or invading) substances.

Several studies suggest that a diverse range of HLA variations decreases the rate of HIV disease
progression. Researchers have discovered that HIV adapts to the most frequent HLA genes in the body.
Therefore, individuals who have rare gene types usually have a slower disease progression.

Specific genes that are associated with slow or rapid HIV progression have been identified. According to
researchers, patients who have HLA class I genes A1, B14, B44, B27, B5701, and C8 are more likely to
experience slow or non-progressive HIV, while patients who have HLA class I genes A29, B22, B54, B55,
and B56 are more likely to experience rapid progression.

Researchers have not yet discovered exactly how HLA affects HIV progression. It has been suggested that
HLA molecules directly limit HIV's ability to replicate. Other researchers suggest that the HLA molecules
that are associated with slow progression may help the immune cells identify HIV quicker and help
stimulate a more rapid immune response.

Multi-drug transporter gene: The multi-drug resistance transporter 1 (MDR1) gene has been associated
with an increased risk of rapid HIV progression. However, the scientific evidence of this association is
controversial.

The MDR1 gene produces P-glycoprotein (P-gp), which is a drug transport molecule that protects the
body's cells from toxic chemicals like HIV antiretrovirals by removing them from the cells.

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While some researchers suggest that P-gp may influence how susceptible a patient's immune cells are to
HIV infection, the results of a new study do not support this claim. The researchers evaluated the type and
amount of MDR1 in the T-cells of HIV-negative subjects. The cells were then exposed to HIV in the
laboratory. MDR1 and P-gp did not influence the cells' vulnerability to HIV infection.

Other: The human protein called APOBEC3G is an antiviral protein that prevents HIV from replicating
inside the body. The protein changes HIV's DNA molecules, which inhibits viral replication. However, HIV
produces viral infectivity factor (Vif), which inhibits APOBEC3G's activity.

According to one study that evaluated more than 3,070 HIV patients, variations in the APOBEC3G gene
may influence the rate of HIV disease progression. The researchers found that one variant called H186R,
common among African Americans, was associated with a rapid drop in CD4 cell counts.

Infection route:It has been suggested that infection route (how the disease was transmitted) may impact
the rate of HIV progression in patients. For instance, HIV can be spread by sexual contact with an infected
person, by sharing needles/syringes with someone who is infected, through breastfeeding, during vaginal
birth or, less commonly (and rare in countries where blood is screened for HIV antibodies), through
transfusions with infected blood. However, research results are conflicting.

Some studies have found faster rates of disease progression among HIV-infected patients who were
infected via blood transfusion. However these studies may not have considered the age of the blood
transfusion recipients. Patients who are infected at an older age are more likely to experience a faster
disease progression.

While it has also been suggested that patients who acquire the disease via injection-drug use are more
likely to experience a faster disease progression, there is conflicting scientific evidence. More studies are
necessary before any firm conclusions can be made.

Nutrition:According to several studies, patients who have deficient levels of vitamin A, vitamin B12, or zinc
are more likely to experience a rapid decline of CD4 cell counts. This is because the body's white blood
cells need sufficient levels of these vitamins in order to grow and maintain health.

Researchers believe that poor absorption of nutrients, diarrhea, and inadequate calorie and protein
consumption contribute to HIV progression. For instance, researchers found that poor nutrition in Zambia
was the best predictor of death in both HIV-negative and HIV-positive children.

Several studies have shown that multivitamin supplementation can slow the rate of HIV disease
progression and death. However, HIV patients who have gastrointestinal problems may have a difficult time
absorbing these essential vitamins into the bloodstream. Some HIV patients may need to take vitamins that
are injected or in a form that will dissolve in the mouth and be absorbed across the mucus membranes.

Pregnancy: The majority of studies suggest that pregnancy does not increase the rate of HIV disease
progression. However, there is scientific evidence that the patient's viral load (number of HIV viral particles
in the blood) increases gradually from delivery until 12 weeks after delivery, even in women receiving
consistent antiretroviral therapy.

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Recreational drug use: The majority of studies suggest that recreational drug use does not play a role in
HIV disease progression. However, some studies are contradictory.

According to one study involving nearly 1,150 HIV-positive women (40% of whom used cocaine, heroin,
methadone, or injection-drugs), there appears to be no association between drug use and CD4 cell
percentage, viral loads, or death (of any cause). However, HIV patients who used drugs were more likely to
develop other infections, especially herpes, tuberculosis, and recurrent pneumonia. Patients who develop
these infections may then have an increased risk of progressing to AIDS.

Alcohol: Alcohol abuse appears to be prevalent among HIV patients. One study found that 41% of HIV-
infected patients met the criteria for alcoholism, as defined by a score of five or higher on the Michigan
Alcoholism Screening Test (MAST) survey. Recent studies have shown that HIV-infected patients with a
history of alcohol problems, who are receiving highly active antiretroviral therapy (HAART) and are
currently drinking, have greater HIV progression than those who do not drink.

In vitro studies suggest that Alcohol may block a chemical messenger in the immune system and stimulate
the expression of CCR5 co-receptor, which HIV uses to infect cells. This in turn may lead to increased rates
of HIV replication. However, human studies have not shown an association between alcohol consumption
and HIV progression.

Cocaine: Cocaine use may affect HIV disease progression either directly or indirectly. Some studies have
suggested that cocaine may increase the rate of HIV replication and suppress cytokines (chemical
messenger that stimulate the immune response). These factors may enable HIV to infect more immune
system cells.

Inhaled nitrates (poppers): It has been suggested that inhaled nitrates (poppers) may suppress the immune
system. However, human and animal studies that have evaluated this association have produced
inconclusive results. Further research is necessary to fully understand the relationship between inhaled
nitrates and HIV.

Injection-drug use: Some researchers believe that DNA damage caused by injection-drug use may result in
faster HIV replication and greater potential for viral mutations. This may ultimately lead to an increased risk
of developing neurological diseases and resistance to antiretroviral drugs. However, more research is
necessary to verify these claims.

HIV patients sharing needles may re-expose themselves to HIV, which may increase the rate of HIV
disease progression. These patients also have an increased risk of developing other infections.

Marijuana: Marijuana may aggravate symptoms of HIV-induced mental impairment, especially memory
loss, in patients who have advanced HIV.

Methamphetamine (meth): Methamphetamine (meth) may increase the risk of HIV disease progression.
According to the results of one study, methamphetamine users who were receiving antiretroviral therapy
(ART) were more likely to have higher viral loads than non-users. However, there appeared to be no
significant difference in methamphetamine users who did not receive antiretroviral therapy. The

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researchers concluded that the impact on viral load may be the result of poor treatment adherence rather
than a direct affect of the drug.

Researchers have found that both methamphetamine abuse and HIV infection may cause impaired
cognitive (mental) functions. Patients may experience difficulties learning new information, solving
problems, concentrating and quickly processing information. The researchers suggest that
methamphetamine abuse and HIV infection significantly reduce the size of certain brain structures, which
may be associated with impaired cognitive functions. Co-occurring methamphetamine abuse and HIV
infection has shown to cause a greater impairment than each condition alone.

Repeated exposure to HIV: There is some scientific evidence suggesting that repeated exposure to HIV
increases the rate of HIV disease progression.

One study involving 937 HIV-infected men who received little or no antiretroviral therapy found that the
patients who had unprotected receptive anal intercourse experienced more rapid declines in their CD4 cell
counts than men who did not engage in unprotected sex. The men who reported having unprotected sex in
the last year were twice as likely to experience a CD4 cell drop as those who did not. The researchers
found that the more people the patient had unprotected, receptive anal sex with, the greater the risk of CD4
cell count decline. However, the researchers could not determine whether the CD4 cell count decrease was
the result of re-infection with HIV or exposure to other sexually transmitted infections or diseases.

Smoking: The majority of studies suggest that smoking does not influence the rate of HIV disease
progression. However, there is good scientific evidence that HIV patients who smoke tobacco are more
likely to develop certain opportunistic infections and diseases. Opportunistic infections occur in individuals
who have weakened immune systems.

Candidiasis (thrush): In general, smokers are more likely to develop a yeast infection of the mouth called
oral candidiasis (thrush) than non-smokers. More research is necessary to determine whether the same is
true for HIV-positive patients.

One study found that even though smoking increased the amount of Candida albicans (yeast that causes
the disease) in the mouths of HIV patients, it did not appear to increase the risk of developing thrush.

Another study found that smoking increased the risk of developing thrush, bacterial pneumonia, and
another mouth infection called oral hairy leukoplakia in HIV-positive men. Patients who smoked the most
had the greatest risk of developing these infections.

Emphysema: In addition, smokers who have HIV are more likely to develop emphysema than non-smokers.
Emphysema is a chronic lung disease characterized by shortness of breath. Researchers conducted a
study involving HIV-positive and HIV-negative people who smoked for 12 years or more. The researchers
found that 37% of the HIV-positive patients showed evidence of emphysema, while none of the HIV-
negative patients had signs or symptoms of the disease. HIV-positive patients also had higher levels of
cytotoxic CD8 T-cells in their lungs tissues indicating that these immune cells may have caused some of
the lung damage.

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Kidney disease: Some research suggests that HIV patients who smoke are more likely to develop kidney
disease than those who do not.

Lung cancer: HIV patients who smoke tobacco are more likely to develop lung cancer than HIV patients
who do not. This is because the smoke contains more than 4,000 different chemicals and many of these
chemicals have been shown to be cancer-causing substances.

Lung infection: Smokers typically have slightly higher CD4 cell counts than non-smokers. However,
analyses of immune cells in the lung fluid show that the CD4 and CD8 percentages and cytokine activity
are significantly lower in smokers than non-smokers. Therefore, smokers have an increased risk of
developing lung infections. For instance, a review of 598 HIV patients found that smokers were three times
more likely to develop Pneumocystis jiroveci pneumonia (formerly called Pneumocystis carinii pneumonia
or PCP) than non-smokers. Patients who smoked the most were at the greatest risk of developing lung
infections.

Smoking and pregnancy: HIV-infected pregnant women who smoke may have a greater chance of
transmitting the disease to their babies during vaginal delivery, according to one study. However, the study
was conducted between 1988 and 1990, before antiretroviral therapy was introduced as a treatment during
pregnancy. Currently, antiretroviral therapy is given to pregnant women to reduce the risk of passing the
disease. One-third of the patients who smoked in the study transmitted HIV to their babies, compared to
less than one-fourth of women who did not smoke. Researchers have suggested that nicotine may cause
the membranes surrounding the fetus to rupture prematurely, which increases the time the infant may be
exposed to HIV-infected blood during delivery.

Stress: According to researchers, severe stress can increase the rate of HIV disease progression. Patients
who had severe and frequent stress over a two-year period were four times more likely to experience HIV
disease progression, according to one study. However, levels of stress that are common to everyday life
did not affect the rate of disease progression.

In addition, psychological distress has also shown to increase the rate of HIV disease progression, but did
not lead to a shorter survival time, according to one cohort study. The researchers concluded that patients
who experienced psychological distress were more likely to develop an AIDS-defining illness within two
years. When HIV patients develop an AIDS-defining illness, this means their condition has progressed to
AIDS.

Experience of healthcare providers:Studies have shown that patients who receive medical care from
healthcare providers who have experience in treating HIV and AIDS patients are more likely to live longer
than those who receive care from less-experienced doctors. One study found that AIDS patients who
received care from the most experienced doctors were 43% more likely to survive than patients who
received care from the least-experienced doctors.

Another study, conducted by the same researcher, found that patients who received care from experienced
healthcare providers were more likely to receive primary care and special services, as well as better access
to laboratory and pharmacy services.

INTEGRATIVE THERAPIES

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Note : Integrative therapies should not be used in place of antiretroviral therapy. Patients should consult
their healthcare providers before taking any herbs or supplements because they may interact with
treatment.

Unclear or conflicting scientific evidence :

Aloe vera : Clear gel from the pulp of Aloe vera leaves has been used on the skin for thousands of years to
treat wounds, skin infections, minor burns and other skin conditions. Although aloe has been suggested as
a possible treatment for HIV, further research is needed before a firm conclusion can be made.

Avoid if allergic to aloe or other plants of the Liliaceae family (garlic, onions, tulips). Avoid injecting aloe. Do
not apply to open skin, surgical wounds or pressure ulcers. Avoid taking by mouth with diarrhea, bowel
blockage, intestinal diseases, bloody stools or hepatitis. Avoid with a history of irregular heartbeat
(arrhythmia), electrolyte imbalances, diabetes, heart disease or kidney disease. Avoid taking by mouth if
pregnant or breastfeeding.

Antineoplastons :Antineoplastons are substances found in human blood and urine. A small preliminary
study reported increased energy and weight in patients with HIV, as well as a decreased number of
opportunistic infections, and increased CD4 cell counts. These patients were treated with antineoplaston
AS2-1. However, this evidence cannot be considered conclusive. Currently, there are drug therapy
regimens available for HIV with clearly demonstrated effects (highly active anti-retroviral therapy), and
patients with HIV are recommended to consult with their physicians about treatment options.

Avoid if allergic or hypersensitive to antineoplastons. Use cautiously with high medical or psychiatric risk.
Use cautiously with an active infection due to a possible decrease in white blood cells. Use cautiously with
high blood pressure, heart conditions, chronic obstructive pulmonary disease, liver disease/damage or
kidney disease/damage. Avoid if pregnant or breastfeeding.

Beta sitosterol : Beta-sitosterol is found in plant-based foods, such as fruits, vegetables, soybeans, breads,
peanuts and peanut products. It is also found in bourbon and oils (such as olive oil, flaxseed and tuna). Due
to data that suggest immune modulating effects of beta-sitosterol and beta-sitosterolglucoside, these
sterols have been studied in combination in the treatment of HIV. Larger populations of patients with HIV
should be evaluated in randomized controlled trials to draw any conclusions.

Avoid if allergic or hypersensitive to beta-sitosterol, beta-sitosterolglucoside or pine. Use cautiously with

asthma or breathing disorders, diabetes, primary biliary cirrhosis (destruction of the small bile duct in the
liver), ileostomy, neurodegenerative disorders (like Parkinson's disease or Alzheimer's disease), diverticular
disease (bulging of the colon), short bowel syndrome, celiac disease and sitosterolemia. Use cautiously
with a history of gallstones. Avoid if pregnant or breastfeeding.

Bitter melon : Laboratory studies have shown that a protein in bitter melon called MAP30 may have antiviral
activity. However, this has not been studied in humans. Further research is needed before a firm
conclusion can be made.

Avoid if allergic to bitter melon or members of the Curcurbitaceae (gourd or melon) family. Avoid ingesting
bitter melon seeds. Avoid with glucose-6-phosphate dehydrogenase deficiency. Use cautiously with

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diabetes, glucose intolerance or with hypoglycemic agents due to the risk of hypoglycemia. Avoid if
pregnant or breastfeeding.

Chiropractic : Chiropractic care focuses on how the relationship between musculoskeletal structure (mainly
the spine) and bodily function (mainly nervous system) affects health. There is not enough reliable scientific
evidence to conclude the effects of chiropractic techniques on CD4 cell count or quality of life in patients
with HIV/AIDS.

Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that cause
decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding disorders or
migraines. Use cautiously with the risk of tumors or cancers. Avoid with symptoms of vertebrobasilar
vascular insufficiency, aneurysms, unstable spondylolisthesis or arthritis. Avoid with agents that increase
the risk of bleeding. Avoid in areas of para-spinal tissue after surgery. Avoid if pregnant or breastfeeding
due to a lack of scientific data.

Coenzyme Q10 : Coenzyme Q10 (CoQ10) is produced by the body, and it is necessary for basic
functioning of cells. CoQ10 levels decrease with age. There is limited evidence that natural levels of CoQ10
in the body may be reduced in people with HIV/AIDS. There is no reliable scientific research showing that
CoQ10 supplements have any effect on this disease.

There are currently no documented cases of allergy associated with Coenzyme Q10 supplements, although
rash and itching have rarely been reported. Stop use two weeks before surgery/dental/diagnostic
procedures with bleeding risk and do not use immediately after these procedures. Use cautiously with
history of blood clots, diabetes, high blood pressure, heart attack or stroke. Use cautiously with
anticoagulants (blood thinners), antiplatelet drugs, blood pressure drugs, blood sugar drugs, cholesterol
drugs or thyroid drugs. Avoid if pregnant or breastfeeding.

DHEA : DHEA (Dehydroepiandrosterone) is a hormone that is secreted by the adrenal glands. Although
some studies suggest that DHEA supplementation may be beneficial in patents with HIV, results from
different studies do not agree with each other. There is currently not enough scientific evidence to
recommend DHEA for this condition, and other therapies are more proven in this area.

Avoid if allergic to DHEA. Avoid with a history of seizures. Use cautiously with adrenal or thyroid disorders.
Use cautiously if taking anticoagulants, or drugs, herbs or supplements for diabetes, heart disease,
seizures or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and
do not use immediately after these procedures. Avoid if pregnant or breastfeeding.

Flaxseed : Flaxseed and flaxseed oil/linseed oil are rich sources of the essential fatty acid alpha-linolenic
acid (omega-6). While flaxseed has been used to treat HIV, no strong evidence supports its use, and no
recommendation can be made without further research.

Flaxseed has been well tolerated in studies for up to four months. Avoid if allergic to flaxseed, flaxseed oil
or other plants of the Linaceae family. Avoid with prostrate cancer, breast cancer, uterine cancer or
endometriosis. Avoid ingestion of immature flaxseed pods. Avoid large amounts of flaxseed by mouth and
mix plenty of water or liquid. Avoid flaxseed (not flaxseed oil) with history of esophageal stricture, ileus,
gastrointestinal stricture or bowel obstruction. Avoid with history of acute or chronic diarrhea, irritable bowel

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syndrome (IBS), diverticulitis or inflammatory bowel disease (IBD). Avoid topical flaxseed in open wounds
or abraded skin surfaces. Use cautiously with history of a bleeding disorder or with drugs that increase the
risk of bleeding (such as anticoagulants and non-steroidal anti-inflammatories). Use cautiously with high
triglyceride levels, diabetes, mania, seizures or asthma. Avoid if pregnant or breastfeeding.

Healing Touch : Healing touch (HT) is a combination of hands-on and off-body techniques to influence the
flow of energy through a person's biofield. Data from small preliminary studies are insufficient to support
any recommendations for or against use of HT in HIV/AIDS. Studies of better design are needed before
any conclusions can be reached.

HT should not be regarded as a substitute for established medical treatments. Use cautiously if pregnant or
breastfeeding.

L-carnitine : L-carnitine may be beneficial in AIDS treatment by increasing proliferation of mononuclear cells
and increasing CD4 counts. Additional study is needed to make a firm recommendation

Avoid if allergic or hypersensitive to carnitine. Use cautiously with peripheral vascular disease, high blood
pressure, alcohol-induced liver cirrhosis and diabetes. Use cautiously in low birth weight infants and
individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers or
calcium channel blockers. Avoid if pregnant or breastfeeding.

Meditation : Various forms of meditation have been practiced for thousands of years throughout the world,
with many techniques originating in Eastern religious practices. A common goal is to attain a state of
"thoughtless awareness" of sensations and mental activities occurring at the present moment. More studies
are needed to establish how meditation may be useful as an adjunctive therapy in HIV/AIDS patients.

Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their
primary mental healthcare professionals before starting a program of meditation, and they should explore
how meditation may or may not fit in with their current treatment plans. Avoid with risk of seizures. The
practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or
therapies, and it should not be used as the sole approach to illnesses.

Melatonin : Melatonin is a neurohormone produced in the brain. There is a lack of well-designed scientific
evidence to recommend for or against the use of melatonin as a treatment for AIDS. Melatonin should not
be used in place of more proven therapies, and patients with HIV/AIDS should be treated under the
supervision of their healthcare professionals.

Based on available studies and clinical use, melatonin is generally regarded as safe in recommended
doses for short-term use. There are rare reports of allergic skin reactions after taking melatonin by mouth.
Use cautiously with bleeding disorders, seizure disorders or if taking drugs that increase the risk of
bleeding.

Mistletoe : Once considered a sacred herb in Celtic tradition, mistletoe has been used for centuries for high
blood pressure, epilepsy, exhaustion, anxiety, arthritis, vertigo (dizziness) and degenerative inflammation of
the joints. Treatment of HIV patients with mistletoe has been done in Europe since the beginning of the
AIDS epidemic. Treatment seems to be tolerable with minimal side effects reported. Mistletoe may assist in

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inhibiting disease progression. However, not all mistletoe preparations have shown equal effects. Further
study is needed before a firm conclusion can be made.

Avoid if allergic or hypersensitive to mistletoe or to any of its constituents. Anaphylactic reactions (life
threatening, shock) have been described after injections of mistletoe. Avoid with acute, highly febrile,
inflammatory disease, thyroid disorders, seizure disorders or heart disease. Use cautiously with diabetes,
glaucoma or with cholinergics.

Prayer/distant healing : Prayer can be defined as a "reverent petition," the act of asking for something while
aiming to connect with God or another object of worship. Limited study of prayer in patients with AIDS
reports fewer new AIDS-related illnesses and hospitalizations. However, due to methodological problems,
these results cannot be considered conclusive.

Prayer is not recommended as the sole treatment approach for potentially serious medical conditions, and
it should not delay the time it takes to consult with a healthcare professional or receive established
therapies. Sometimes religious beliefs come into conflict with standard medical approaches and require an
open dialog between patients and caregivers.

Psychotherapy : Psychotherapy is an interactive process between a person and a qualified mental health
professional. The patient will explore thoughts, feelings and behavior to help with problem solving.
Psychotherapy, especially supportive psychotherapy, may reduce depression in HIV-positive patients. It
may also help with treating substance abuse when used in combination with prescription medicine.
Supportive-expressive group therapy may also have concomitant improvements in CD4 cell count and viral
load. More research is needed in this area, especially to determine the best type of psychotherapy.

Psychotherapy cannot always fix mental or emotional conditions. Psychiatric drugs are sometimes needed.
In some cases symptoms may get worse if the proper medication is not taken. Not all therapists are
qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions
because some forms of psychotherapy may stir up strong emotional feelings and expression.

Relaxation therapy : Relaxation techniques include behavioral therapeutic approaches that differ widely in
philosophy, methodology and practice. Mental health and quality-of-life improvements have been seen in
preliminary studies of HIV/AIDS patients. These findings suggest the need for further, well-controlled
research.

Avoid with psychiatric disorders like schizophrenia/psychosis. Jacobson relaxation (flexing specific
muscles, holding that position, then relaxing the muscles) should be used cautiously with illnesses like
heart disease, high blood pressure or musculoskeletal injury. Relaxation therapy is not recommended as
the sole treatment approach for potentially serious medical conditions, and it should not delay the time to
diagnosis or treatment with more proven techniques.

Selenium : Selenium is a mineral found in soil, water and some foods. Selenium supplementation has been
studied in HIV/AIDS patients, and some reports associate low selenium levels with complications, such as
cardiomyopathy. It remains unclear if selenium supplementation is beneficial in patients with HIV,
particularly during antiretroviral therapy.

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Avoid if allergic or sensitive to products containing selenium. Avoid with history of non-melanoma skin
cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal
research reports that large doses of selenium may lead to birth defects.

Shiitake : Shiitake mushrooms were originally grown on natural oak logs found in Japan. Today, they are
available in the United States. These mushrooms are large, black-brown and have an earthy rich flavor.
Based on preliminary studies, lentinan may increase CD4 counts and may qualify in future multi-drug
studies in HIV patients. Further well-designed studies are needed to confirm these results. Side effects
have been reported and more proven therapies are recommended at this time.

Avoid if allergic or hypersensitive to shiitake mushrooms. Avoid if pregnant or breastfeeding.

Thymus extract : Thymus extracts for nutritional supplements are usually derived from young calves.
Preliminary evidence found no improvement in HIV progression to AIDS or immunostimulation, although
some immunological activity was noted in a non-randomized controlled trial. Additional study is needed in
this area.

Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously
due to potential for exposure to the virus that causes "mad cow disease." Avoid use with an organ
transplant or other forms of allografts or xenografts. Avoid if receiving immunosuppressive therapy or
hormone therapy. Avoid with thymic tumors, myasthenia gravis (neuromuscular disorder) or untreated
hypothyroidism. Avoid if pregnant or breastfeeding. Thymic extract increases human sperm motility and
progression.

Traditional Chinese medicine (TCM) : Traditional Chinese medicine (TCM) is a broad term that refers to
many different treatments and traditions of healing. They share a common heritage of technique or theory
rooted in ancient Chinese philosophy (Taoism) that dates back over 5,000 years. TCM herbs are a popular
complementary therapy in HIV/AIDS. However, study results conflict. More studies are needed before the
potential benefits of TCM herbs in HIV/AIDS can be established.

Chinese herbs can be potent and may interact with other herbs, foods or drugs. Consult a qualified
healthcare professional before taking. There have been reports of manufactured or processed Chinese
herbal products being tainted with toxins or heavy metal or not containing the listed ingredients. Herbal
products should be purchased from reliable sources. Avoid ma huang, which is the active ingredient in
ephedra. Avoid ginseng if pregnant or breastfeeding.

Turmeric : Turmeric is a perennial plant native to India and Indonesia, and it is often used as a spice in
cooking. Several laboratory studies suggest that curcumin, a component of turmeric, may have activity
against HIV. However, reliable human studies are lacking in this area.

Avoid if allergic or hypersensitive to turmeric (curcumin), yellow food colorings or plants belonging to the
Curcuma or Zingiberaceae (ginger) families. Use cautiously with history of bleeding disorders, immune
system deficiencies, liver disease or gallstones. Use cautiously with blood-thinners (e.g. warfarin). Use
cautiously if pregnant or breastfeeding.

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Vitamin A : Vitamin A is a fat-soluble vitamin, which is derived from two sources - retinoids and carotenoids.
Retinoids are found in animal sources (such as the liver, kidney, eggs and dairy products). Carotenoids are
found in plants like dark or yellow vegetables and carrots. The role of vitamin A in the prevention,
transmission, or treatment of HIV is controversial and not well established. A clear conclusion cannot be
formed based on the available scientific research.

Avoid if allergic or hypersensitive to vitamin A. Vitamin A toxicity can occur if taken at high dosages. Use
cautiously with liver disease or alcoholism. Smokers who consume alcohol and beta-carotene may have an
increased risk for lung cancer or heart disease. Vitamin A appears safe in pregnant women if taken at
recommended doses. Use cautiously if breastfeeding because the benefits or dangers to nursing infants
are not clearly established.

Zinc : Zinc formulations have been used since Ancient Egyptian times to enhance wound healing. Patients
with HIV/AIDS, especially in those with low zinc levels, may benefit from zinc supplementation. Some low
quality studies cite reduction in infections, enhanced weight gain and immune system function, including
increased CD4 and CD8 cells. However, other low quality studies conflict with these findings. Further
research is needed before a conclusion can be drawn.

Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since
studies have not been done on its safety or effectiveness. While zinc appears safe during pregnancy in
amounts lower than the established upper intake level, caution should be used since studies cannot rule
out the possibility of harm to the fetus.

Fair negative scientific evidence :

Ozone therapy : Ozone molecules are composed of three oxygen atoms. Ozone exists high in the earth's
atmosphere and absorbs radiation from the sun. Reports of using ozone for medicinal purposes date to the
late 19th Century. Laboratory studies have shown HIV virus to be sensitive to ozone, but no high-quality
human studies exist. A preliminary study measured the safety and effectiveness of ozone-treated blood in
the treatment of HIV infection and immune disease. Ozone therapy was not shown to enhance immune
activation or diminish HIV virus.

Autohemotherapy has been associated with transmission of viral hepatitis, and with a possible case of
dangerously lowered blood cell counts. Insufflation of the ear carries a risk of tympanic membrane ("ear
drum") damage, and colon insufflation may increase the risk of bowel rupture. Consult a qualified health
professional before undergoing any ozone-related treatment

St John's wort : St. John's wort is a perennial herb that grows up to 32 inches tall and is commonly found in
many parts of the world, including eastern North America and the Pacific coast. Anti-viral effects of St.
John's wort have been observed in laboratory studies, but were not found in one human study. Multiple
reports of significant adverse effects and interactions with drugs used for HIV/AIDS, including protease
inhibitors (PIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs), suggest that patients being
treated for HIV/AIDS should avoid this herb. Therefore, there is evidence to recommend against using St.
John's wort in the treatment of patients with HIV/AIDS.

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Avoid if allergic or hypersensitive to plants in the Hypericaceae family. Rare allergic skin reactions like itchy
rash have been reported. Avoid with immunosuppressant drugs (like cyclosporine, tacrolimus or myophenic
acid). Avoid with non-nucleoside reverse transcriptase inhibitors or protease inhibitors. Avoid with organ
transplants, suicidal symptoms or before surgery. Use cautiously with history of thyroid disorders. Use
cautiously with drugs that are broken down by the liver, with monoamine oxidase inhibitors (MAOI) or
selective serotonin reuptake inhibitors (SSRIS), digoxin, or birth control pills. Use cautiously with diabetes
or with history of mania, hypomania or seasonal affective disorder. Avoid if pregnant or breastfeeding.

AUTHOR INFORMATION

This information has been edited and peer-reviewed by contributors to the Natural Standard Research
Collaboration (www.naturalstandard.com).

• AIDSmap Treatment & Care. www.aidsmap.com.

• Kitahata MM, Van Rompaey SE, Dillingham PW, et al. Primary care delivery is associated with
greater physician experience and improved survival among persons with AIDS. J Gen Intern Med.
2003 Feb;18(2):95-103.
• Leserman J, Jackson ED, Petitto JM, et al. Progression to AIDS: the effects of stress, depressive
symptoms, and social support. Psychosom Med. 1999 May-Jun;61(3):397-406.
• Liu KL, Peters V, Weedon J, et al. l. Sex differences in morbidity and mortality among children with
perinatally acquired human immunodeficiency virus infection in New York City. Arch
PediatrAdolesc Med. 2004 Dec;158(12):1187-8.
• Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com.
• The Body: The Complete HIV/AIDS Resource. www.thebody.com.
• Weisser M, Rudin C, Battegay M, et al. Does pregnancy influence the course of HIV infection?
Evidence from two large Swiss cohort studies. J Acquir Immune DeficSyndr Hum Retrovirol. 1998
Apr 15;17(5):404-10.

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