THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 3, Number 2. 1997, pp. 169-172 Mary Ann Liebert, Inc.

GUEST EDITORIAL

HIV-Related Diarrhea: Urgent Need for a Reasoned Holistic Response

GEORGE M. CARTER

As an AIDS activist for the last 7 years, I and humiliating. Uncontrolled diarrhea related

found the article by Joyce K. Anastasi, to microsporidial, cryptosporidial, or other in-Nigel C. Dawes and Yong Ming Li, "Diarrhea fection can be lethal (Thea, 1993; Ma, 1989). and Human Immunodeficiency Virus: A Pos- This article offers no review of the literature sible Synergy for Clinical Practice," pp. with regard to herbal interventions. As I un-163-168, to be an interesting primer. However, derstand it, Chinese medicine is not only NOT after an epidemic of some 13-years duration, I restricted to acupuncture and moxibustion, but was also frustrated by it. I cannot comment in includes the whole garden to develop a dy-detail on the traditional Chinese medicine namic, integrative, and comprehensive ap-methods of diagnosis, but we learn very little proach to disease management. And that in-about management of HIV/AIDS-related diar- eludes herbs. Would tang-shen, astragalus, rhea from this particular Eastern perspective white atractylodes, Chinese yam, aconite, dried short of a diagnosis of a "spleen and/or kid- ginger, evodia, galangal or cinnamon bark ney yang deficiency." The few studies dis- help? Or not? That is a list from the Oriental cussed are inadequate. It remains uncertain Materia Medica (Hsu, 1993) under hypofunc-what the relevance of this diagnosis or the use tion of spleen and stomach with cold manifes-of acupuncture or moxibustion is in treatment tations. Under deficient kidney yang, Hsu lists of AIDS-related diarrhea. None of the acupunc- aconite, cinnamon, curculigo, deerhorn, epi-ture studies were done on people with HIV; midium [sic], morinda, cistanche and psoralea. many studies cited were animal studies. Stud- What about these? Are there any studies? ies in humans are given short shrift in terms of I believe diarrhea is a case where a good old describing what happened, who was treated. Western diagnosis is a critical component. Is it how they were treated, what the results were, induced by protozoa, bacteria, or viruses? and if those results were durable. Cryptosporidiosis, cytomegalovirus (CMV), or

Certainly, treating diarrhea vigorously Kaposi's Sarcoma (KS)? HIV-induced villous through appropriate diagnosis and intervention atrophy and crypt hyperplasia? Iatrogenic ef-is essential. This is not a revolutionary concept, fects of drugs? Is there more than one problem? But diarrhea, like the thousand different names Then apply appropriate intervention(s). The for snow, comes in a variety of forms and re- technology for such diagnoses is in serious suits from a number of problems. It can be need of improvement and as a result repeated, chronic or acute or explosive and watery. The sometimes unpleasant procedures and sample number and volume of stools may vary consid- collection must be undertaken for accurate di-erably. At the very least it can be debihtating agnosis.

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What does it mean to a person with HIV to factor-a (TNF-a) as well as interleukin-1-a (IL-tell them they have a spleen or kidney defi- la) and IL-6. Besides possibly being exacer-ciency? What practical tools are there? Did the bated by diarrhea, this immune dysregulation researchers try to contact practitioners to de- hastens GI tract deterioration and muscle wast-termine if they had any success or not? There ing (Aukrust, 1996; Roubenoff, 1996; Richter, are several traditional Chinese medicine prac- 1995; Aukrust, 1994; Malorni, 1993; Breen, titioners and groups who have been treating 1990). Many methods exist to deal with this, people with HIV/AIDS for years including the For TNF, the amino acid carnitine and the drug Immune Enhancement Project in San Francisco thalidomide (Synovir^^) may help. Carnitine (Young, 1996). enjoys the distinct advantage of being nontoxic

The different combinations of nucleoside as well as normalizing TNF. If the TNF level is analogs and protease inhibitors are providing normal, supplementation will not further re-some relief for people from such constitutional duce it (De Simone, 1993). Carnitine may help symptoms and indeed, some of my friends are in formation of adenosine triphosphate (ATP) clearly alive today because such drugs have and appropriate fatty acid shuttling, reducing been developed. But the drugs themselves are triglyceride levels (and thus help restore glu-a big culprit in diarrhea (particularly riton- tathione). Omega-3 fatty acids may help to avir/Norvir® [Horn, 1996; Cameron, 1996] and lower inflammatory prostaglandin secretion nelfinavir/Viracept® [DeNoon, 1996]). Indi- (PGE2) that has been associated with various navir/Crixivan® causes not only kidney stones opportunistic infections like toxoplasmosis (Horn, 1996), but a peculiar bloating and gas- (Delemarre, 1995) among others, trointestinal (GI) distress is commonly reported The level of glutathione, an important intra-by users (anecdotal reports). Many individuals cellular antioxidant and detoxifier, is low in have turned to using 3 0 ^ 0 g of glutamine of a many people with HIV/AIDS (Droge, 1994, day to help restore damaged GI tract tissue. 1993; Staal, 1992; Buhl, 1989). Restoring intra-Does this offset diarrhea? Does it have an ad- cellular glutathione may help improve cellular verse impact on drug absorption? Anecdotally, organ function, particularly liver, lungs, kid-some are reporting good results—but of course ney, and eyes. Improving glutathione levels such reports are scientifically inadequate. We may help improve the body's ability to off-don't know because the clinical studies have set drug-related GI tract damage, fight other not been done. enteric pathogens, and further reduce damage

Others (ReSEARCH Alliance) have found Al- to the GI tract that induces or exacerbates di-hcin (garlic extract) useful to treat cryp- arrhea (see Carr, 1995; Cunningham-Rundles, tosporidiosis (Searchlight, 1996). Still others 1994; Loguercio, 1993; Mathelier-Fusade, 1993). have used bovine colostrum or whey protein Methods for increasing intracellular glu-for general diarrhea or cryptosporidiosis tathione are varied and probably a combined (Baruchel, 1994; Shield, 1993; Doyle, 1993; Plet- approach is most practical, including N-acetyl-tenberg, 1993; Rump, 1992; Voss, 1991). Where cysteine (NAC; Droge, 1996), a-lipoic acid are the combination treatment studies for cryp- (Thioctic; Han, 1995), and whey protein. Whey tosporidiosis, possibly including a drug like ni- is getting some good results in children with tazoxanide? This, however, is a question for of- HIV/AIDS. Dr. Sylvain Baruchel at Montreal ficials at the National Institutes of Health who Children's Hospital has conducted some pre-vigorously maintain a stance favoring phar- liminary studies and achieved positive results maceutical interests over rigorous research into in weight gain and increased intracellular glu-nonpatentable substances. tathione production (Baruchel, 1996). The

An often overlooked model is that of oxida- Herzenbergs' group at Stanford have shown tive stress induced by the ongoing host battle that people with lower glutathione levels suf-with HIV—a battle that occurs principally in fer faster progression and that NAC can help the lymphatic, GI, lung, and central nervous to offset this (Herzenberg, 1996). system tissues. This results in increased levels There is a dark side not explored here. As the of inflammatory cytokines like tumor necrosis pharmaceutical industry has its unfortunate

GUEST EDITORIAL 171

share of chicanery, so indeed does the alterna­tive industry. Some are proposing potentially seriously dangerous herbal protocols including the use of Artemisia (frequently without dis­tinguishing between A. absinthium and A. an­nua). One individual suggests doses far higher than traditional use and for long periods based on a highly dubious hypothesis that flukes cause AIDS and asserts that she has "cured" AIDS with this method, citing a transformation from p24[ + ]-positive to p24-negative as proof (Clark, 1993). This is most certainly not evi­dence of a cure. Aside from the anecdotal re­ports by holistic physicians and people in the community of the damage this herbal combi­nation has done to some people, it eclipses an understanding of the vermifugic properties of these herbs and their possibly more judicious use where a definitive diagnosis is obtained.

I can only hope that this editorial will spur not only further vigorous study but a renewed recognition that the AIDS crisis is far from over. The drugs are not a cure. And globally, mil­lions of people living with HIV will never have access to them. The alternative community needs to demand of its practitioners and pro­ponents the highest level of commitment, ex­pertise, and effort. There is a revolution occur­ring that is drawing upon the best of disparate healing modalities, west, east, south and north. We must be active, scientifically, spiritually, and politically, in forging this relationship into an exceptional synergy.

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George M. Carter Member, ACT UP/NY

Director Treatment Information Development Direct AIDS Alternative Information

Resources (DAAIR) 31 East 30th St. #2A New York, NY 10016