Randomized, placebo-controlled trial of Chinese herb therapy for HIV-1-infected individuals

Aikeqing decreases viral loads in SHIV89.6-infected Chinese rhesus macaques

BACKGROUND

Aikeqing (AKQ) has been shown in clinical studies to improve quality of life of HIV/AIDS patients, but anti-HIV activity has not been determined. The SHIV-infected macaque is an important animal model for testing antiviral drugs. This study aimed to determine the anti-HIV activity of AKQ in chronically SHIV89.6-infected Chinese rhesus macaques.

METHODS

Nine Chinese rhesus macaques were inoculated intravenously with SHIV89.6 virus. At 11 weeks post-infection, the animals were arbitrarily divided into three groups: high-dose (AKQ 1.65 g/kg; n = 3), low-dose (AKQ 0.55 g/kg; n = 3), and control (water 1 mL/kg; n = 3). Treatment was administered by the intragastric gavage route once-daily for 8 weeks. Blood (5 mL) was collected biweekly. Viral loads were analyzed by real-time quantitative RT-PCR assays, and T cell counts were monitored by FACS analyses throughout the treatment.

RESULTS

AKQ induced a persistent decline (P = 0.02) in plasma viral loads during treatment in the high-dose group compared with their baseline levels, and cessation of the therapy caused viral load rebound to the pretreatment levels. No significant difference (P = 0.06) was found in the plasma viral loads during treatment in the low-dose group. The CD4(+) T cell counts and CD4/CD8 ratios remained at stable high levels during the treatment period.

CONCLUSION

AKQ reduced plasma viral loads in the SHIV89.6-infected Chinese rhesus macaque model.

Health related quality of life: is it another comprehensive evaluation indicator of Chinese medicine on acquired immune deficiency syndrome treatment?

Health related quality of life (HRQOL) can better reflect changes in acquired immune deficiency syndrome (AIDS) patients and inform economic evaluation of AIDS treatment services, and the assessment of HRQOL can help us to detect problems that may influence the progression of the disease, hence HRQOL has become a particularly important assessment indictor for HIV comprehensive interventions. Being a multi-angle, multi-level, and diversified complex intervention, roles of Chinese medicine (CM) in AIDS treatment have been recognized and accepted by more and more patients, and HRQOL has been widely used to evaluate the comprehensive management effects of CM on AIDS. In this article, the authors analyze the definition and measurement of HRQOL, measurement of HRQOL of HIV/AIDS patients and effects of CM on AIDS, and give some reasonable advices for the usage of the scale of HRQOL. The authors hold that some new HRQOL instruments specific for CM treatment of AIDS should be developed and further prospective studies should be carried out to demonstrate the practicality, reliability and validity of HRQOL as an evaluation indictor for CM treatment of AIDS.

Traditional Chinese Herbal Medicines for Treating HIV Infections and AIDS

To assess the effects of TCHM on patients with HIV infection and AIDS, we reviewed eleven randomized placebo-controlled trials involving 998 patients. Due to the limited number of RCTs for included trials and the small sample size of each study, we are not able to draw firm conclusions concerning TCHM therapy in treating patients with HIV infection and AIDS. However, some high-quality clinical studies do exist. Studies of diarrhea and oral candidiasis, which are challenging symptoms of AIDS, were demonstrated to have positive effects. Study of peripheral leukocytes, which are a side effect of antiretroviral drugs, suggested that an integrated treatment approach may be of benefit. The overall methodological quality of the trials was adequate; however, randomization methods should be clearly described and fully reported in these trials according to the Consolidated Standards of Reporting Trials (CONSORT).

A potential in vitro and in vivo anti-HIV drug screening system for Chinese herbal medicines

Chinese herbal medicines are often applied as an alternative therapy for viral diseases. However, the development of anti-HIV herbal drugs has proceeded slowly, partly because of the lack of a high-throughput system for screening these drugs. The present study evaluated 16 herbal medicines for anti-HIV activities in vitro and in vivo. Herbal medicines were first screened for the ability to regulate C-X-C receptor 4 (CXCR4) and C-C receptor 5 (CCR5) promoter activities. A single-round pseudotyped HIV-luciferase reporter virus system (HIV-Luc) was used to identify potential anti-HIV mechanisms. CD4+ T cells from healthy volunteers were examined for changes in CXCR4 and CCR5 levels. HIV-1 replication was evaluated by ELISA. Spica Prunellae and Herba Andrographitis were found to down-regulate the activities of both the CXCR4 and CCR5 promoters. Also, Spica Prunellae and Herba Andrographitis (>1000 μM) inhibited HIV-1 in a dose-dependent manner. CXCR4 and CCR5 levels were reduced in CD4+ T cells from healthy volunteers (p<0.05). Spica Prunellae and Herba Andrographitis (EC₅₀: 3.18 and 5.49 μg/mL, respectively) could suppress cell fusion and decrease p24 antigen. In conclusion, the data demonstrated that Spica Prunellae and Herba Andrographitis possessed anti-HIV-1 capabilities, perhaps through the inhibition of the CXCR4 and CCR5 promoters and HIV-1 replication.

Traditional medicines, HIV, and related infections: workshop 2C

Traditional medicines are an integral part of health care worldwide, even though their efficacy has not been scientifically proven. HIV-infected individuals may use them singularly or in combination with conventional medicines. Many in vitro studies have proven the anti-HIV, anti-Candida, and anti-herpes simplex virus potential of traditional plants and identified some of the mechanisms of action. Very few in vivo studies are available that involve a small number of participants and show controversial results. In addition, knowledge is limited of the role of traditional medicines in the enhancement of the immune system. The use of traditional medicines with antiretroviral drugs (ARVs) has created a problem because drug interactions compromise the efficacy of ARVs. Several currently popular plants have been studied in the laboratory for their interaction with ARVs, with disadvantageous results. Unfortunately, no clinical trials are available. The science of traditional medicines is relatively new and is at present being modernized worldwide. However, there are still ethical issues regarding traditional medicines that need to be addressed-for example, regulations regarding quality control and standardization of medicines, regulation and education of healers who deliver these medicines, and unregulated clinical trials. The workshop addressed the following questions about traditional medicine and their use in HIV infection: What are the mechanisms of action of anti-HIV traditional medicines? Should traditional medicines be used in conjunction with ARV? Do traditional medicines enhance the immune system? Should medicinal plants be used for the control of oral infections associated with HIV? What are the ethical issues surrounding the use of traditional medicines for the treatment of HIV and associated infections?

HIV and depression--a systematic review of interventions

HIV-positive individuals are more likely to be diagnosed with major depressive disorder than HIV-negative individuals. Depression can precede diagnosis and be associated with risk factors for infection. The experience of illness can also exacerbate depressive episodes and depression can be a side effect to treatment. A systematic understanding of which interventions have been tested in and are effective with HIV-seropositive individuals is needed. This review aims to provide a comprehensive understanding of evaluated interventions related to HIV and depression and provide some insight on questions of prevalence and measurement. Standard systematic research methods were used to gather quality published papers on HIV and depression. From the search, 1015 articles were generated and hand searched resulting in 90 studies meeting adequacy inclusion criteria for analysis. Of these, 67 (74.4%) were implemented in North America (the US and Canada) and 14 (15.5%) in Europe, with little representation from Africa, Asia and South America. Sixty-five (65.5%) studies recruited only men or mostly men, of which 31 (35%) recruited gay or bisexual men. Prevalence rates of depression ranged from 0 to 80%; measures were diverse and rarely adopted the same cut-off points. Twenty-one standardized instruments were used to measure depression. Ninety-nine interventions were investigated. The interventions were diverse and could broadly be categorized into psychological, psychotropic, psychosocial, physical, HIV-specific health psychology interventions and HIV treatment-related interventions. Psychological interventions were particularly effective and in particular interventions that incorporated a cognitive-behavioural component. Psychotropic and HIV-specific health psychology interventions were generally effective. Evidence is not clear-cut regarding the effectiveness of physical therapies and psychosocial interventions were generally ineffective. Interventions that investigated the effects of treatments for HIV and HIV-associated conditions on depression generally found that these treatments did not increase but often decreased depression. Interventions are both effective and available, although further research into enhancing efficacy would be valuable. Depression needs to be routinely logged in those with HIV infection during the course of their disease. Specific data on women, young people, heterosexual men, drug users and those indiverse geographic areas are needed. Measurement of depression needs to be harmonized and management into care protocols incorporated.

Developing a self-report outcome measure for complementary and alternative medicine

OBJECTIVE

Our objective was to develop a pilot measure of subjective outcomes of complementary and alternative medicine (CAM). Current options for assessing subjective outcomes in CAM are either too burdensome or fail to represent diverse outcomes. A single measure specifying common, patient-reported outcomes of CAM would be of value.

DESIGN

We conducted a three-phase instrument development study. In phase I, 30 CAM-receiving patients and 12 CAM practitioners completed a battery of standardized measures. Participants identified those standardized items relevant to CAM outcome and suggested additional outcome issues. In phase II, 20 CAM-receiving patients completed a Q-sort to determine which items from phase I were most relevant to CAM outcome. In phase III, five experts reviewed the items from phase II for content validity.

SETTING

An integrative medicine clinic at a private, Midwest US hospital.

PARTICIPANTS

CAM patients, practitioners, and researchers and an outcomes measurement specialist.

RESULTS

In phase I, 30 standardized items were judged relevant to CAM outcome, and 8 additional items were suggested. In phase II, 29 of the 38 phase I items were deemed at least "moderately relevant" to CAM outcome. In phase III, experts added 15 items, dropped 9 items, and altered 3 items. The 35 resulting items were classified into content domains, forming a testable, pilot version of the instrument.

Issues surrounding the use of herbal therapies for AIDS in endemic regions

Herbal preparations are rampantly used in the treatment of AIDS in endemic regions. Despite beneficial effects from the use of some plant preparations, the issues that still have to be addressed comprise the interaction between herbal preparations and antiretrovirals, lack of conclusive clinical trials of widely used plants, and ethical issues surrounding the practices of traditional healers. The burden presented by AIDS requires an urgent need for closer collaboration among scientists, medical practitioners and traditional systems of medicine to evaluate promising herbal preparations rigorously, and develop policies and guidelines for the judicious use of herbs with proven clinical benefit.

Pilot validation of a self-report outcome measure of complementary and alternative medicine

BACKGROUND

We previously developed a multidomain, self-report outcome measure relevant to a wide range of complementary and alternative medical (CAM) therapies. We report the results of a pilot study to validate the measure.

METHODS

Fifty-two patients (60% female, mean age, 53 years) seeking services from CAM providers completed a battery of measures prior to a scheduled visit. The battery included the Positive and Negative Affect Schedule, items from the Brief Pain and Fatigue Inventories, ratings of global quality of life (QOL) and change in physical health, and our pilot measure consisting of six hypothesized subscales (pain, fatigue, physical/functional ability, personal control, existential issues, and general QOL). Internal reliability, item convergence and discrimination, construct, and concurrent validity were assessed.

RESULTS

Pilot measure domains appeared to be internally reliable with five of six alpha coefficients exceeding 0.70. Multitrait scaling analyses demonstrated that most items converged on the domains that they were hypothesized to represent, although item discrimination was demonstrated for the pain domain only. Correlations with standardized assessments of pain, fatigue, and global QOL showed evidence of construct validity. All domain scores differentiated patients classified high versus low in global QOL (P < .01) and four (pain, fatigue, physical/functional ability, and general QOL) differentiated patients who perceived recent changes in their physical health (improvement vs decline; P < .05).

CONCLUSION

These results provide preliminary psychometric data for a pilot measure of CAM outcomes, though further testing is warranted.

Efficacy of group psychotherapy to reduce depressive symptoms among HIV-infected individuals: a systematic review and meta-analysis

Depressed mood is highly prevalent among HIV-infected individuals. Some but not all studies have found group psychotherapy to be efficacious in this population. We performed a systematic review and meta-analysis of double-blinded, randomized controlled trials to examine efficacy of group psychotherapy treatment among HIV infected with depressive symptoms. We used PubMed, the Cochrane database, and a search of bibliographies to find controlled clinical trials with random assignment to group psychotherapy or control condition among HIV infected patients with depressive symptoms. The principal measure of effect size was the standard difference between means on validated depression inventories. We identified 8 studies that included 665 subjects: 5 used cognitive behavioral therapy (CBT), 2 used supportive therapy, and 1 used coping effectiveness training. Three of the 8 studies reported significant effects. The pooled effect size from the random effects model was 0.38 (95% confidence interval [CI]: 0.23-0.53) representing a moderate effect. Heterogeneity of effect was not found to be significant (p = 0.69; I(2) = 0%). Studies reporting use of group CBT had a pooled effect size from the random effects model of 0.37 (95% CI: 0.18-0.56) and was significant. Studies reporting the use of group supportive psychotherapy had a pooled effect size from the random effects model 0.58 (95% CI: -0.05-1.22) and was nonsignificant. The results of this study suggest that group psychotherapy is efficacious in reducing depressive symptoms among, HIV-infected individuals. Of note, women were nearly absent from all studies. Future studies should be directed at addressing this disparity.

The use of herbal medicines in early drug development for the treatment of HIV infections and AIDS

This review systematically assesses the beneficial and harmful effects of herbal medicines in people with HIV infection and AIDS. Based on a Cochrane review and updated searches, the author identifies the available evidence on herbal medicines compared with placebo or antiretroviral drugs in patients with HIV infection, HIV-related disease or AIDS. There are ten randomised controlled trials, involving 571 individuals with HIV infection or AIDS, that met the inclusion criteria. Some herbal medicines, such as IGM-1 seem to be effective in symptom improvement, but generally no significant effect on antiviral or immunity enhancement among reviewed herbs was seen. Combined treatment of Chinese herbal medicine, SH and antiretroviral agents showed increased antiviral benefit compared with antiretrovirals alone. These findings suggest beneficial effects from some of the tested herbs but more evidence from larger studies are needed to support this evidence in the future.

Efficacy of antidepressant medication among HIV-positive individuals with depression: a systematic review and meta-analysis

Depression is highly prevalent among HIV-positive individuals yet some, but not all, have not found antidepressant medication to be efficacious in this population. We performed a systematic review and meta-analysis of double-blinded, randomized controlled trials to examine efficacy of antidepressant treatment among HIV-positive depressed individuals and evaluate whether the results are generalizable to women and minorities. We used PubMed, the Cochrane Database, a search of bibliographies, and consultation with experts to find double-blinded, controlled clinical trials with random assignment to antidepressants or control condition for which HIV-positive patients met standard diagnostic criteria for depression. The principal measure of effect size was the standard difference between means on the Hamilton Depression Score (HDS). We identified 7 studies that included 494 subjects. Three of the 7 studies reported significant antidepressant effects. The pooled effect size from the random effects model was 0.57 (95% confidence interval [CI]: [0.28-0.85]). Heterogeneity across studies was significant (Q, 13.22; p = 0.07; I(2) = 47.1%). When stratified by placebo response, the pooled effect size for placebo response greater than 33% was 0.20 (-0.11-0.52) and not significant while the pooled effect size for placebo response greater than 33% was 0.80 (0.52-1.08) and was significant. Placebo response explained nearly 62% of the variance in effect sizes across studies. Women were nearly absent from and minorities were underrepresented in the studies investigated. Antidepressant medication is efficacious in treating depression among depressed, HIV-positive individuals. However, the underrepresentation of women and minorities limits the generalizability of these findings and suggests that future studies be directed to address this disparity.

Herbal medicines for treating HIV infection and AIDS

BACKGROUND

HIV-infected people and AIDS patients often seek complementary therapies including herbal medicines due to reasons such as unsatisfactory effects, high cost, non-availability, or adverse effects of conventional medicines.

OBJECTIVES

To assess beneficial effects and risks of herbal medicines in patients with HIV infection and AIDS.

SEARCH STRATEGY

Electronic searches included the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, LILACS, Science Citation Index, the Chinese Biomedical Database, TCMLARS; plus CISCOM, AMED, and NAPRALERT; combined with manual searches. The search ended in December 2004.

SELECTION CRITERIA

Randomized clinical trials on herbal medicines compared with no intervention, placebo, or antiretroviral drugs in patients with HIV infection, HIV-related disease, or AIDS. The outcomes included mortality, HIV disease progression, new AIDS-defining event, CD4 cell counts, viral load, psychological status, quality of life, and adverse effects.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently and assessed the methodological quality of trials according to randomization, allocation concealment, double blinding, and drop-out.

MAIN RESULTS

Nine randomized placebo-controlled trials involving 499 individuals with HIV infection and AIDS met the inclusion criteria. Methodological quality of trials was assessed as adequate in five full publications and unclear in other trials. Eight different herbal medicines were tested.A compound of Chinese herbs (IGM-1) showed significantly better effect than placebo in improvement of health-related quality of life in 30 symptomatic HIV-infected patients (WMD 0.66, 95% CI 0.05 to 1.27). IGM-1 appeared not to affect overall health perception, symptom severity, CD4 count, anxiety or depression (Burack 1996a). An herbal formulation of 35 Chinese herbs did not affect CD4 cell counts, viral load, AIDS events, symptoms, psychosocial measure, or quality of life (Weber 1999). There was no statistical difference between SPV30 and placebo in new AIDS-defining events, CD4 cell counts, or viral load (Durant 1998) although an earlier pilot trial showed positive effect of SPV30 on CD4 cell count (Durant 1997). Combined treatment of Chinese herbal compound SH and antiretroviral agents showed increased antiviral benefit compared with antiretrovirals alone (Sangkitporn 2004). SP-303 appeared to reduce stool weight (p = 0.008) and abnormal stool frequency (p = 0.04) in 51 patients with AIDS and diarrhoea (Holodniy 1999). Qiankunning appeared not to affect HIV-1 RNA levels (Shi 2003), Curcumin ineffective in reducing viral load or improving CD4 cell counts (Hellinger 1996), and Capsaicin ineffective in relieving pain associated with HIV-related peripheral neuropathy (Paice 2000). The occurrence of adverse effects was higher in the 35 Chinese herbs preparation (19/24) than in placebo (11/29) (79% versus 38%, p = 0.003) (Weber 1999). Qiankunning was associated with stomach discomfort and diarrhoea (Shi 2003).

AUTHORS' CONCLUSIONS

There is insufficient evidence to support the use of herbal medicines in HIV-infected individuals and AIDS patients. Potential beneficial effects need to be confirmed in large, rigorous trials.

Essais cliniques des médicaments à base de plantes : revue bibliographique

BACKGROUND

The importance of traditional medicine, one of the fundamentals of the cultural heritage of African, Asian and South American peoples, is evident in that such medicine is practised by more than 80% of these populations.

METHODS

To analyse the methodology of clinical trials using medicinal plants, we reviewed articles published on this topic between 1980 and 2000.

RESULTS

Forty-eight clinical trials were identified. Most were carried out in developed countries. Standard methodological principles were applied in almost all the trials: randomisation (85.4%), comparison (87.5%) versus placebo (95.2%), and blinded design (81.3%). The duration of the studies was short. Sample sizes were generally small, ranging from 30 to 99 subjects; statistical tests were used in 90% of the trials. Adverse effects were infrequently collected.

CONCLUSION

Most clinical trials included in this survey were conducted in accordance with WHO guidelines. Respect for methodological principles and the implementation of a legislative framework are important in obtaining credibility and international recognition of the traditional pharmacopoeia.

Herbal medicine use and quality of life among people living with HIV/AIDS in northeastern Thailand

Many people living with HIV/AIDS (PHA) use herbal medicine as one of alternative therapies, where curative options are limited. This study aimed to examine the association between the herbal medicine use and quality of life (QOL) among PHA in northeastern Thailand. Participants were 132 HIV-positive Thai adults who attended the PHA's self-help group meetings from June to July 2002. Health-related QOL scores were measured by self-administered questionnaire from the Medical Outcomes Study-HIV Health Survey. Dimensions of physical function (PF) and mental health (MH) in QOL were assessed. Additional data were collected on herbal medicine use, socio-demographic, psychosocial and HIV-related characteristics. The herbal medicine users had significantly better MH scores than the non-users, while the herbal medicine use was not statistically associated with PF scores. When stratified, herbal medicine users with the following characteristics had significantly better MH scores than the non-users: female, widowed, having no income, reporting any HIV-related symptom, having no instrumental support or receiving subsidies. In conclusion, herbal medicine use was associated with better MH especially among socially vulnerable PHA. This study suggests that herbal medicine has a potential to improve the MH aspect of QOL among socially vulnerable PHA who cannot easily receive antiretroviral therapy in Thailand.