| Natural Medicines in the Clinical Management of HIV/AIDS |
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Antiretroviral Agents |
Immunostimulants |
Complications of HIV/AIDS
The Bottom Line |
References
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There are two types of retroviruses responsible for AIDS: HIV-1 and HIV-2. HIV-1 is most prevalent in North America. HIV-2 is more prevalent in Africa.
Here are some interesting facts about HIV:13788
- In the year 2000, 36.1 million people worldwide were living with HIV
- Approximately 1 to 1.6 million patients live with HIV/AIDS in North America
- There are about 42,000 new cases of HIV in the US each year:
- 60% of HIV cases are contracted by men who have sex with men
- 25% are contracted through injection drug users
- 15% are contracted through heterosexual contact
- Women comprise 17% of all HIV-infected people
- A woman with HIV during pregnancy has a 20% to 30% chance of passing it to her newborn in utero
- New York, California, and Florida report the highest number of AIDS cases in the U.S.
- Ontario has the highest number of cases of any province in Canada
The development and use of potent antiretroviral agents have helped cut mortality rates from HIV/AIDS by 70% since 1995. But there's a downside. The availability of effective treatments has led to a false sense of security. Young people are getting back into risky behaviors that can increase the risk of HIV transmission.
Experts agree that all patients with symptoms of HIV infection should receive antiretroviral treatment. Most experts would also treat asymptomatic patients with CD4 counts of < 350 cells/mm3.
For a comprehensive review of HIV/AIDS, including current CONVENTIONAL drug treatment guidelines, get our up-to-date course: "HIV/AIDS Drug Therapy Update."
| *Note: Many natural products are tried for HIV/AIDS, but very few have reliable evidence that they work. Inclusion in this list does NOT imply that these products are effective for HIV/AIDS.
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| | | | Antiretroviral Agents |  | |
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Antiretroviral drugs are divided into three classes: nucleoside and nucleotide reverse transcriptase inhibitors (NRTIs), nonnucleoside reverse transcriptase inhibitors (NNRTIs), and protease inhibitors. All of these drugs contribute to the inhibition of viral replication via slightly varied mechanisms. NRTIs and NNRTIs inhibit HIV reverse transcriptase, an enzyme responsible for viral replication early in the viral life cycle. The protease inhibitors block the activity of the HIV protease, an enzyme required for replication late in the viral life cycle.
Multi-agent combinations are essential for effectively reducing viral load to undetectable levels, increasing the CD4 lymphocyte counts, preventing the emergence of resistant HIV strains, preventing disease progression, and possibly prolonging survival.
Many patients are also trying natural products thought to have antiviral properties. In fact, as many as 35% of HIV patients try a natural product.13788
Don't be surprised when HIV patients ask about St. John's wort (Hypericum perforatum). We usually think of it as an herbal antidepressant...and many HIV patients use it for that indication. But researchers have found that a constituent in St. John's wort called hypericin can actually inhibit the HIV virus in vitro. Many assume this means it's effective for HIV in humans, but findings in humans have not been impressive. Hypericin does not seem to lower viral load or increase CD4 lymphocyte counts. In addition, hypericin can cause serious photosensitivity reactions.206
St. John's wort has also been associated with drug interactions. St. John's wort is a potent inducer of cytochrome P450 3A4 and p-glycoprotein. St. John's wort can reduce serum levels of protease inhibitors and NNRTIs by up to 57%.1290,1349,4837,7808 Subtherapeutic concentrations caused by St. John's wort can lead to therapeutic failure, development of viral resistance, and drug class resistance.
Tell HIV patients not to use St. John's wort. It's not likely to have any antiviral benefit...and it can make conventional antiretroviral medications ineffective through various drug interactions.
Patients try numerous other natural products due to suspected or purported antiviral effects. For example, reishi mushroom (Ganoderma lucidum) constituents have protease inhibitor activity in vitro.5479,5480 The bark of the Indian herb terminalia (Terminalia chebula) seems to inhibit HIV-1 reverse transcriptase.2518 Baicalin contained in the Chinese herb baikal skullcap (Scutellaria baicalensis) also inhibits HIV-1 reverse transcriptase.5541 Constituents in the chrysanthemum (Chrysanthemum morifolium) flower might also inhibit HIV replication.5545,8171 The antioxidant alpha-lipoic acid seems to reduce HIV replication by inhibiting reverse transcriptase.1280,3871 Other natural products with purported antiviral action are used...andrographis (Andrographis paniculata), elderberry (Sambucus nigra), epimedium (Epimedium grandiflorum), hyssop (Hyssopus officinalis), propolis, and thunder god vine (Tripterygium wilfordii). But none of these products have been studied in patients with HIV.
Boxwood (Buxus sempervirens) leaf extract is being investigated as a potential herbal antiviral for HIV. A specific extract of boxwood, known as SPV30, contains the constituents cyclobuxine D and buxamine. These constituents seem to have activity against HIV.4447 Preliminary clinical research suggests that taking this extract might slow progression to AIDS when used in asymptomatic patients with CD4 counts > 350 cells/mm3.5643 More evidence is needed about the long-term safety and effectiveness of boxwood extract before it can be recommended.
Blue-green algae (Nostoc ellipsosporum) is being investigated by researchers at the National Cancer Institute. A particular species of the algae, Nostoc ellipsosporum, contains an antiviral protein called cyanovirin-N (CV-N), which seems to have effects against HIV. CV-N has a unique mechanism. It binds to sites on the viral envelope, inactivating HIV and preventing viral entry into cells. Researchers postulate that CV-N might be used to adsorb and remove HIV from infected blood products.1375 While promising, it is too soon to recommend blue-green algae products for HIV.
Caution HIV patients about using blue-green algae. Some products are harvested from uncontrolled lakes and ponds and could be contaminated with pathogenic microorganisms. HIV patients can be more susceptible to infection from these contaminated products.
Surprisingly, some patients are using glucosamine sulfate and chondroitin sulfate as antiretroviral agents. These products are typically used for osteoarthritis. However, there's much research going on using these "sulfated saccharides" for people with HIV. Glucosamine is a sulfated MONO-saccharide and chondroitin is a sulfated POLY-saccharide. Some preliminary evidence suggests that some sulfated saccharides, including both chondroitin and glucosamine, can decrease HIV replication and prevent HIV from infecting lymphocytes in vitro.1263,1335,7642 Other research suggests that chondroitin sulfate might not have activity against HIV.8662 Clearly, more evidence is needed to determine what role, if any, these products might have in treating HIV.
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Question #1 | | What advice would be appropriate to give a HIV patient who is interested in trying St. John's wort? | | | | | | | | |
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Question #2 | | Which of the following herbal antivirals has been shown to reduce viral load in patients with HIV? | | | | | | | | |
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| | Immunostimulants | | |
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Conventional medical treatments for HIV focus on minimizing viral replication. So far there are no standard treatments that target immune function. But many complementary and alternative medicine practitioners consider this approach an important part of adjunct therapy.
One of the most interesting products used is a polysaccharide extracted from the shiitake mushroom (Lentinus edodes) called lentinan. When given parenterally, lentinan boosts natural killer cell, macrophage, and T-helper cell function. There is some clinical evidence that lentinan 2 mg IV once weekly in combination with didanosine (ddI) 400 mg daily can significantly increase CD4 counts in patients with HIV.1107 So far this effect has only been seen with IV lentinan, which is not available in North America.
| Practice Pearl |
| Tell patients that eating shiitake mushroom is not a substitute for IV lentinan. Shiitake mushrooms only contain about 0.02% of lentinan. It would take 10 grams of mushroom to provide 2 mg of lentinan. Excessive doses of the whole mushroom can cause serious side effects including eosinophilia, shiitake dermatitis, and photosensitivity.
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Coenzyme Q-10 is most often used for cardiovascular conditions like congestive heart failure, angina, hypertension, and others. But researchers are finding that patients with HIV can have low blood levels of coenzyme Q-10. Patients taking 200 mg of coenzyme Q-10 per day seem to have increased blood levels of IgG antibodies and of CD4 lymphocytes.2124,2125 Researchers speculate that this might help prevent opportunistic infections and increase survival, however, these important outcomes have not been studied. More evidence is needed before coenzyme Q-10 can be recommended for most HIV patients.
DHEA (dehydroepiandrosterone) is an adrenal hormone that is a precursor to both estrogen and testosterone. It is most often promoted to slow the aging process, or for erectile dysfunction. But it is now becoming popular among patients with HIV.
Population studies suggest that DHEA levels might correlate with severity of disease...patients with more severe disease have lower DHEA levels. There is also in vitro evidence that DHEA can mildly inhibit HIV replication. But taking DHEA does not consistently increase CD4 counts.3865,3866,3867 Don't recommend DHEA.
Remind patients that DHEA is a potent hormone, with many hormone-related side effects...acne, hair loss, voice deepening, insomnia, liver dysfunction, etc.
| Practice Pearl |
| Watch for drug interactions in patients taking DHEA. DHEA can inhibit cytochrome P450 3A4 and might INCREASE levels of drugs: alprazolam (Xanax), amitriptyline (Elavil), buspirone (BuSpar), citalopram (Celexa), diazepam (Valium), felodipine (Plendil), fexofenadine (Allegra), itraconazole (Sporanox), ketoconazole (Nizoral), lansoprazole (Prevacid), lovastatin (Mevacor), ondansetron (Zofran), phenytoin (Dilantin), prednisone (Deltasone, etc), sertraline (Zoloft), sildenafil (Viagra), simvastatin (Zocor), and many others.
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Some patients with HIV have low levels of L-carnitine. L-carnitine plays a role in programmed cell death (apoptosis), which is thought to be the primary cause of lymphocyte loss in HIV. Researchers are treating some patients with a daily infusion of 6 grams of L-carnitine. L-carnitine seems to reduce lymphocyte apoptosis and increases CD4 counts after 3 months of treatment, but L-carnitine does NOT seem to lower viral load in the blood.798,3632,8049 The effects of long-term use are not known and the benefits of ORAL supplementation remain unknown.
Thymus extract is sometimes suggested for boosting immune function. The thymus gland plays an important role in white blood cell maturation. The theory is that extracts of thymus gland from cows might boost white blood cell levels in humans. There is some preliminary evidence that a specific extract of calf thymus called thymomodulin can boost CD4 lymphocyte levels in patients with HIV.1178 But discourage patients with HIV from using these products...they might not be safe. Since thymus extract comes from cows, there is concern about potential contamination from diseased animals or animal parts. The biggest concern involves potential contamination with prions known to cause bovine spongiform encephalopathy (BSE, "mad cow disease"). It is important to keep in mind that there are no reports of BSE or other disease transmission to humans from dietary supplements containing glandular or organ material. The risk of potential disease transmission is thought to be low. Theoretically, HIV patients could be at higher risk of infection and might be susceptible to contracting illness from potential contaminants.
| Practice Pearl |
| Help patients avoid products containing glandular (or other) animal parts. Tell them to be cautious about the following ingredients: adrenal extract, orchic extract, thymus factors, liver factors, and numerous others. You can use the Natural Medicines Comprehensive Database to find out which products contain animal materials. We've included an Editor's Comment for all brand name products containing animal parts as ingredients.
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Several other products with suspected immunostimulant properties are tried...astragalus (Astragalus membranaceus), cat's claw (Uncaria tomentosa), echinacea (Echinacea angustifolia), American ginseng (Panax quinquefolius), Panax ginseng, larch arabinogalactan (Larix occidentalis), and numerous others. But these have not been studied in patients with HIV/AIDS.
Using agents that strengthen immune function in combination with antivirals makes sense, but little is known about the long-term safety and benefits of immunostimulants.
For now, don't recommend this approach. Advise patients not to rely on immunostimulants ALONE to treat HIV with current antiretroviral regimens...there's no reliable evidence these products lower the viral load in blood.
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Question #3 | | Which of the following is TRUE about DHEA? | | | | | | | | |
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| | Complications of HIV/AIDS | | |
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Opportunistic Infections
Along with CD4 counts and viral load, the development of opportunistic infections is an indicator of the severity of HIV infection and often marks the onset of AIDS. Opportunistic infections can include Pneumocystis carinii pneumonia, Candida albicans, cytomegalovirus, herpes simplex, Cryptococcus, Mycobacterium, and others.
Conventional treatments, such as antibiotics and antifungals, are often used prophylactically in patients at risk for these infections. Patients are also trying natural remedies to prevent these complications.
You will likely get questions about garlic (Allium sativum) supplements. Garlic is popular among patients with HIV for several reasons. Garlic has antimicrobial effects including in vitro activity against cytomegalovirus, herpes simplex virus, and Candida albicans.4769,4808 There is also some evidence that garlic might stimulate immune function and boost lymphocyte activity.8018 Since garlic seems to lower cholesterol levels, some patients are using it to reduce the high lipid levels that can occur from taking protease inhibitors.
Tell HIV patients to steer clear of garlic supplements. There's no reliable evidence that they help. And there is a lot of concern about drug interactions. Garlic can induce drug metabolism by cytochrome P450 3A4...and decrease saquinavir (Invirase, Fortovase) levels by about 50%.7027 Levels of other protease inhibitors and NNRTIs are probably also affected by garlic.
| Practice Pearl |
| Even though garlic supplements can decrease HIV drug levels, casual garlic consumption in food probably does not have this effect. But discourage patients from eating large amounts (1-2 cloves/day) of raw garlic for extended periods of time.
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Probiotics are becoming popular for AIDS-related infectious diarrhea. Probiotics are a group of organisms that make up the normal flora of the GI tract. They are found in fermented foods like yogurt and in encapsulated dietary supplements. They can include species such as Lactobacillus, Bifidobacteria, Saccharomyces boulardii, and others. The theory is that probiotics can latch on to the intestinal mucosa and colonize it. This colonization then prevents infectious organisms from binding to the mucosa. Some probiotics also produce chemicals (e.g., lactic acid) that can inhibit growth of pathogenic organisms.
Probiotics can be very helpful in some cases of antibiotic-associated diarrhea, traveler's diarrhea, and rotaviral diarrhea in children. But there is little evidence to support their use in HIV-related infectious diarrhea. There is preliminary evidence that the species Saccharomyces boulardii might help.4347
Warn patients not to self-treat with probiotics. Since HIV patients with infectious diarrhea are often severely immunocompromised, they are at increased risk of pathogenic colonization from probiotics. Monitor patients taking probiotics closely for signs of systemic infection.
| Practice Pearl |
| Choose probiotics wisely. There can be a wide variation in the potency of probiotic supplements. Make sure products are labeled to contain "live and active" organisms.
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Patients might be asking about bovine colostrum. Colostrum is the milky fluid produced by mammals during the first few days after giving birth. It normally contains some antibodies and researchers are producing a "hyperimmune" colostrum that contains specific antibodies for fighting certain diseases. This is done by first immunizing cows with a pathogen (e.g., Cryptosporidium). The cow then generates antibodies to the pathogen. The colostrum produced from the immunized cow will then contain extra high levels of pathogen-specific antibodies. There's growing evidence that hyperimmune bovine colostrum can effectively treat AIDS-related infectious diarrhea.4905,4906,4907,4908 Researchers are using 10-20 grams daily in divided doses for 10-21 days.
HIV Wasting
HIV wasting syndrome develops in many AIDS patients as a result of HIV infection itself or because of opportunistic infections. Patients often have diarrhea, weakness, severe weight loss, and nutritional deficiencies.
Many HIV patients become nauseated and have a loss of appetite. Some patients develop painful aphthous ulcers that make eating difficult. Severe HIV infection can also cause malabsorption of nutrients.
Appetite stimulants or anabolic agents are often tried to boost calorie intake and weight gain.
Another approach is using medium chain triglycerides (MCTs). MCTs are semisynthetic fatty acids that are one-half to one-third as long as normal fatty acids (i.e., 6-12 carbon atoms instead of the usual 18-20). An MCT-based diet is substituted for a normal diet. MCTs are better absorbed in some patients with malabsorption problems because of their shorter length. Using this diet in patients with HIV wasting might decrease diarrhea and the amount of fat in stools. But evidence so far suggests that MCTs are not effective for increasing body weight.11730
There is also interest in using alternate food sources like whey protein. Whey protein is a cheese by-product that provides carbohydrates, minerals, albumin, and amino acids. Body builders use it to help them bulk up.
There is preliminary evidence that consuming 8-84 grams per day of whey protein can help HIV patients gain 7-15 pounds over a three month period. Whey protein also seems to decrease diarrhea and boost CD4 and CD8 cell counts.4926,4932,4935,4936
| Practice Pearl |
| Warn patients allergic to milk or milk products to avoid whey protein...it can also cause a similar reaction.
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The amino acids L-glutamine and L-arginine plus hydroxymethylbutyrate (HMB) are also tried to treat patients with HIV-wasting. HMB is a metabolite of the amino acid leucine. These products seem to slow degradation of muscle protein. Using a combination of L-glutamine 14 grams, L-arginine 14 grams, and HMB 3 grams daily for 8 weeks can increase weight by almost 7 pounds in patients with AIDS.1909
HIV-related Neuropathy
Some clinicians are trying acetyl-L-carnitine for HIV-related neuropathy. In the body, it is converted to the amino acid L-carnitine. Researchers are using it for diabetic neuropathy. It is not known if it helps for HIV-related neuropathy. If it does help, chances are only those patients with L-carnitine deficiency will benefit.
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Question #4 | | What advice would be appropriate for an HIV patient who is considering taking garlic? | | | | | | | | |
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Question #5 | | Which of the following products is NOT correctly matched with the safety concern? | | | | | | | | |
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Question #6 | | True or False. Like calcium and other minerals, taking whey protein might decrease absorption of some other drugs such as quinolone or tetracycline antibiotics? (HINT: Click here to review the whey protein monograph, Interactions with Drugs section to help find the answer). | | | | |
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| | The Bottom Line | | |
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Preventive measures are the key. Counsel patients to avoid risky sexual behavior...use condoms and avoid illicit IV drug use. Encourage needle exchange programs to reduce the risk of HIV exposure. Health care workers should wear protective equipment such as gloves, masks, and goggles when possible to avoid exposure to body fluids.
Antiretroviral therapy can be very effective for patients with HIV. Compliance is the key to successful therapy. Do what you can to help simplify drug regimens and encourage adherence to treatment. Follow this link to read more about why compliance with antiretroviral therapy is so important: "HIV medication compliance," Pharmacist's Letter/Prescriber's Letter Detail-Document #170107.
Many patients will ask about alternative therapies. The science supporting herbs and supplements for HIV is just developing. Preliminary evidence looks promising for some interventions, but most have little or no clinical evidence in humans.
Certain products are worth considering for complications of HIV...probiotics and bovine colostrum for infectious diarrhea...whey protein, L-glutamine, L-arginine, and HMB for HIV wasting.
Make sure patients avoid St. John's wort and garlic because they can decrease the effectiveness of standard antiretroviral treatments.
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Question #7 | | Which of the following products is appropriately matched with its use or mechanism of action? | | | | | | | | |
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Question #8 | | Which of following would be appropriate to consider for HIV wasting? | | | | | | | | |
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Recommendation Chart for Natural Medicines Used for HIV/AIDS *
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| | KEY: | | Consider recommending this product.
| | | | | | Don't recommend using this product.
| | | | | | Recommend against using this product.
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* These proposed recommendations are based solely on the Safety and Effectiveness
Ratings contained in Natural Medicines Comprehensive Database. This assumes use
of high-quality, uncontaminated products and the use of typical doses. Keep in
mind that some products are never appropriate for some patients due to
concomitant disease states, potential drug interactions, or other clinical
factors. Use your clinical judgment before recommending any product.
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| References
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| | 206 | Gulick RM, McAuliffe V, Holden-Wiltse J, et al. Phase I studies of hypericin, the active compound in St. John's Wort, as an antiretroviral agent in HIV-infected adults. AIDS Clinical Trials Group Protocols 150 and 258. Ann Intern Med 1999;130:510-4. | | 798 | Moretti S. Effect of L-carnitine on human immunodeficiency virus-1 infection-associated apoptosis: a pilot study. Blood 1998;91:3817-24. | | 1107 | Gordon M, Guralnik M, Kaneko Y, et al. A phase II controlled study of a combination of the immune modulator, lentinan, with didanosine (ddI) in HIV patients with CD4 cells of 200- 500/mm3. J Med 1995;26:193-207. | | 1178 | Valesini G, Barnaba V, Benvenuto R, et al. A calf thymus acid lysate improves clinical symptoms and T-cell defects in the early stages of HIV infection: second report. Eur J Cancer Clin Oncol 1987;23:1915-9. | | 1263 | Jurkiewicz E, Panse P, Jentsch KD, et al. In vitro anti-HIV-1 activity of chondroitin polysulphate. AIDS 1989;3:423-7. | | 1280 | Baur A, Harrer T, Peukert M, et al. Alpha-lipoic acid is an effective inhibitor of human immuno-deficiency virus (HIV-1) replication. Klin Wochenschr 1991;69:722-4. | | 1290 | Piscitelli SC, Burstein AH, Chaitt D, et al. Indinavir concentrations and St. John's wort. Lancet 2000;355:547-8. | | 1335 | Bagasra O, Whittle P, Heins B, Pomerantz RJ. Anti-human immunodeficiency virus type 1 activity of sulfated monosaccharides: comparison with sulfated polysaccharides and other polyions. J Infect Dis 1991;164:1082-90. | | 1349 | Mayer G, Kroger M, Meier-Ewert K. Effects of vitamin B12 on performance and circadian rhythm in normal subjects. Neuropsychopharmacology 1996;15:456-64. | | 1375 | Blue-Green Algae Protein Is a Promising Anti-HIV Microbicide Candidate. www.medscape.com/reuters/prof/2000/03/03.16/dd03160g.html (Accessed 16 March 2000). | | 1909 | Clark RH, Feleke G, Din M, et al. Nutritional treatment for acquired immunodeficiency virus-associated wasting using beta-hydroxy beta-methylbutyrate, glutamine, and arginine: a randomized, double-blind, placebo-controlled study. JPEN J Parenter Enteral Nutr 2000;24:133-9. | | 2124 | Folkers K, Langsjoen P, Nara Y, et al. Biochemical deficiencies of coenzyme Q10 in HIV-infection and exploratory treatment. Biochem Biophys Res Commun 1988;153:888-96. | | 2125 | Suzuki S, Hinokio Y, Ohtomo M, et al. The effects of coenzyme Q10 treatment on maternally inherited diabetes mellitus and deafness, and mitochondrial DNA 3243 (A to G) mutation. Diabetologia 1998;41:584-8. | | 2518 | el-Mekkawy S, Meselhy MR, Kusumoto IT, et al. Inhibitory effects of Egyptian folk medicines on human immunodeficiency virus (HIV) reverse transcriptase. Chem Pharm Bull (Tokyo) 1995;43:641-8. | | 3632 | Cifone MG, Alesse E, Di Marzio L, et al. Effect of L-carnitine treatment in vivo on apoptosis and ceramide generation in peripheral blood lymphocytes from AIDS patients. Proc Assoc Am Physicians 1997;109:146-53. | | 3865 | Dyner TS, Lang W, Geaga J, et al. An open-label, dose-escalation trial of oral dehydroepiandrosterone tolerance and pharmacokinetics in patients with HIV disease. J Acq Immun Def Synd 1993;6:459-65. | | 3866 | Henderson E, Yang JY, Schwartz A. Dehydroepiandrosterone (DHEA) and synthetic DHEA analogs are modest inhibitors of HIV-1 IIIB replication. AIDS Res Hum Retroviruses 1992;8:625-31. | | 3867 | Christeff N, Gherbi N, Mammes O, et al. Serum cortisol and DHEA concentrations during HIV infection. Psychoneuroendocrinol 1997;22:S11-8. | | 3871 | Packer L, Witt EH, Tritschler HJ. Alpha-Lipoic acid as a biological antioxidant. Free Rad Biol Med 1995;19:227-50. | | 4347 | Saavedra J. Probiotics and infectious diarrhea. Am J Gastroenterol 2000;95:S16-8. | | 4447 | Atta-ur-Rahman, Choudhary MI, Naz S, et al. New steroidal alkaloids from the roots of buxus sempervirens. J Nat Prod 1999;62:665-9. | | 4769 | Weber ND, Andersen DO, North JA, et al. In vitro virucidal effects of Allium sativum (garlic) extract and compounds. Planta Med 1992;58:417-23. | | 4808 | Sasaki J, Kita T, Ishita K, et al. Antibacterial activity of garlic powder against Escherichia coli O-157. J Nutr Sci Vitaminol (Tokyo) 1999;45:785-90. | | 4837 | de Maat M, Hoetelmans R, Mathot R, et al. Drug interaction between St. John's wort and nevirapine. AIDS 2001;15:420-1. | | 4905 | Greenberg PD, Cello JP. Treatment of severe diarrhea caused by Cryptosporidium parvum with oral bovine immunoglobulin concentrate in patients with AIDS. J Acquir Immune Defic Syndr Hum Retrovirol 1996;13:348-54. | | 4906 | Plettenberg A, Stoehr A, Stellbrink HJ, et al. A preparation of bovine colostrum in the treatment of HIV-positive patients with chronic diarrhea. Clin Invest 1993;71:42-5. | | 4907 | Rump JA, Arndt R, Arnold A, Bendick C, et al. Treatment of diarrhea in human immunodeficiency virus-infected patients with immunoglobulins from bovine colostrum. Clin Invest 1992;70:588-94. | | 4908 | Nord J, Ma P, DiJohn D, et al. Treatment with bovine hyperimmune colostrum of cryptosporidial diarrhea in AIDS patients. AIDS 1990;4:581-4. | | 4926 | Bounous G, Baruchel S, Falutz J, et al. Whey proteins as a food supplement in HIV-seropositive individuals. Clin Invest Med 1993;16:204-9. | | 4932 | Salomon SB, Jung J, Voss T, et al. An elemental diet containing medium-chain triglycerides and enzymatically hydrolyzed protein can improve gastrointestinal tolerance in people infected with HIV. J Am Diet Assoc 1998;98:460-2. | | 4935 | Vergel NR, Salvato P, Mooney M. Anabolic steroids, resistance exercise and protein supplementation effect on lean body mass in HIV+ patients. Int Conf AIDS 1998;12:557 (abstract # 32185). | | 4936 | Voss T, Rowe B, Graf L, et al. Management of HIV-related weight loss and diarrhea with an enteral formula containing whey peptides and medium-chain triglycerides. Int Conf AIDS 1991;7:223 (abstract # WB2165). | | 5479 | Singh AB, Gupta SK, Pereira BM, et al. Sensitization to Ganoderma lucidum in patients with respiratory allergy in India. Clin Exp Allergy 1995;25:440-7. | | 5480 | Min BS, Nakamura N, Miyashiro H, et al. Triterpenes from the spores of Ganoderma lucidum and their inhibitory activity against HIV-1 protease. Chem Pharm Bull (Tokyo) 1998;46:1607-12. | | 5541 | Huang KC. The pharmacology of Chinese herbs. 2nd ed. New York, NY: CRC Press LLC. 1999;385-6, 400-1. | | 5545 | Huang KC. The Pharmacology of Chinese Herbs. 2nd ed. New York, NY: CRC Press, LLC 1999:113-114, 417. | | 5643 | Durant J, Chantre P, Gonzalez G, et al. Efficacy and safety of Buxus sempervirens L. preparations (SPV30) in HIV-infected asymptomatic patients: a multicentre, randomized, double-blind, placebo-controlled trial. Phytomedicine 1998;5:1-10. | | 7027 | Piscitelli SC, Burstein AH, Welden N, et al. The effect of garlic supplements on the pharmacokinetics of saquinavir. Clin Infect Dis 2002;34:234-8. | | 7642 | Bagasra O, Whittle P, Heins B, Pomerantz RJ. Anti-human immunodeficiency virus type 1 activity of sulfated monosaccharides: comparison with sulfated polysaccharides and other polyions. J Infect Dis 1991;164:1082-90. | | 7808 | Schulz V. Incidence and clinical relevance of the interactions and side effects of Hypericum preparations. Phytomedicine 2001;8:152-60. | | 8018 | Lamm DL, Riggs DR. The potential application of allium sativum (garlic) for the treatment of bladder cancer. Urol Clin North Am 2000;27:157-62. | | 8049 | Famularo G, De Simone C, Cifone G. Carnitine stands on its own in HIV infection treatment. Arch Intern Med 1999;159:1143-4. | | 8171 | Wang HK, Xia Y, Yang ZY, et al. Recent advances in the discovery and development of flavonoids and their analogues as antitumor and anti-HIV agents. Adv Exp Med Biol 1998;439:191-225. | | 8662 | Ylisastigui L, Bakri Y, Amzazi S, et al. Soluble glycosaminoglycans Do not potentiate RANTES antiviral activity on the infection of primary macrophages by human immunodeficiency virus type 1. Virology 2000;278:412-22. | | 11730 | Gibert CL, Wheeler DA, Collins G, et al. Randomized, controlled trial of caloric supplements in HIV infection. J Acquir Immune Defic Syndr 1999;22:253-9. | | 13788 | Dong BJ. HIV/AIDS: Drug therapy update. Continuing Education Course #09007 Pharmacist's Letter/Prescriber's Letter 2005;7:05007. |
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