2. a little background on supplements
Under current law, vitamins, supplements and herbs do People should be aware of these things and take meas-
not have to be evaluated by any regulatory agency, like the ures to reduce their risk of buying contaminated prod-
Food and Drug Administration (FDA), prior to their sale. ucts or ones without active ingredients. ey can do this
All they need to do is assert that the product is “generally by seeking out reputable sellers. Seek guidance from a
regarded as safe.” What this means is that studies are not trained alternative medicine practitioner, like an herbal-
required to show the e ectiveness and safety of these prod - ist or nutritionist who specializes in HIV, and gather
ucts. is leaves the consumer with little or no meaning ful information about the products you’re considering.
information about their bene ts or side e ects. Only taking the word of people selling the products does
Some manufacturers vaguely refer to “studies” in their not guarantee accurate information.
literature, but these are seldom more than very small, On their packages and even their websites, some
uncontrolled studies. Also, these products do not have to manufacturers claim their products have been tested for
be made according to the same Good Manufacturing Prac- active ingredients. Do a little research and see what you
tices established for making prescription meds. As a result, can learn. For example, some publications, like Con-
these products vary widely in terms of their active ingre- sumer Reports and other groups like www.consumerlab.
dients, and even between batches of the same product. In com, sometimes test supplements and list what is found
fact, studies show that some products on the market today in various brands. Even this, however, doesn’t tell you
contain no active ingredients whatsoever. whether you’ll bene t from using the product.
Herbal supplements can actually contain danger- Generally, if a company shows integrity in some of
ous chemicals, like arsenic and lead—both potentially its products tested by consumer groups, it’s a reasonable
deadly. Still others actually contain prescription meds. sign that they maintain similar standards for their other
However, the best manufacturers make a serious e ort products. According to researchers who evaluate these
to deliver the real product in the amounts claimed. But therapies, the quality products that undergo evaluation
due to the lack of industry regulations, there’s no simple by the manufacturer are, in general, not the ones you’ll
2 way to know who is telling the truth. nd at your average grocery store or pharmacy.
HERBS, SUPPLEMENTS AND HIV . JANUARY 2005 . PROJECT INFORM
what about side effects?
The biggest myth about complementary therapies is that they’re not toxic. Many people believe that
because something is “natural” or sold over the counter that it doesn’t have side effects. To the contrary,
many people with HIV experience side effects from complementary therapies.
For example, Chinese herbal remedies that contain deer antler can cause nausea, diarrhea and other stomach
upset. One man stopped all his anti-HIV meds to try to determine which had upset his stomach and quality of
life. It turned out that when he stopped his herbal therapy (with deer antler), his
problems cleared. It wasn’t the anti-HIV drugs causing the problems at all.
High doses of vitamin C can cause severe diarrhea. Taking too many
B-6 vitamins can lead to a complication that lands one in the hospital,
and excessive levels of vitamin A can be highly toxic to the liver. These
examples illustrate the need to be cautious when adding large doses of
vitamins to your diet.
Side effects from using herbs, vitamins and supplements may not
reveal themselves immediately. It may take several weeks after start-
ing a therapy for them to emerge. Keeping an accurate record of every
therapy you take, including when you start and stop them. Docu-
menting the onset of side effects may help sort out which one is
causing the problem. (For a list of herbs with known side effects,
see pages 6 & 7.)
TOLL FREE NATIONAL HIV/AIDS TREATMENT HOTLINE 1 800 822 7422 LOCAL AND INTERNATIONAL 415 558 9051 MONDAY FRIDAY 10 4 PACIFIC TIME
4. talking with your doctor
To lessen the chance of herb-drug and support their patients, in a non- to capture information about drug
interactions, experts encourage people judgmental way, about using these interactions and side e ects is to
to have more in-depth discussions therapies. And it may very well be record all the supplements you use
about complementary therapy with the patients who actually drive this in a complete drug history. It’s also
their doctors and pharmacists. is learning curve. important for patients, doctors and
may take some getting used to for However, patients also need to be pharmacists to keep up to date on
both patients and doctors alike. open and honest about what they’re the latest drug-herb and drug-vita-
Doctors may need to learn to listen using and considering. One way min interaction studies.
conclusion
ere are generally two schools of thought about using whether and how to better regulate the marketing of
vitamins. One is that people should take vitamin nutritional supplements and herbs.
supplements in pill form. e other is that people ere is a great di culty in evaluating herbs and
should simply improve their nutrition and increase herb-drug interactions because o en the active ingre-
their vitamin intake through better eating. Likely the dient in the products and its dose are not known.
best approach for people at risk for vitamin de cien- Although drug interaction studies for medications
cies is one that lies somewhere between these two typically take a matter of a week to ten days, drug-
approaches. herb interaction studies are expected to take much
It’s unknown if the body can really use vitamins longer. is is a more expensive process since people
that are delivered from pills. Some contend that will probably have to take herbs for a few weeks
in order for the body to optimally absorb and use before an e ect is seen.
vitamins they need to be delivered through better Even when the interactions are known for
4 nutrition, in foods where they exist in complex one particular product, it’s unclear how they
forms which may help the body to better will relate to similar products because of the
use the nutrients. lack of control over dosing. Because no
HERBS, SUPPLEMENTS AND HIV . JANUARY 2005 . PROJECT INFORM
Herbal remedies and other studies have determined the proper or
vitamins are sold as “food supple- best dose of many complementary
ments” and do not undergo the therapies, researchers face another
rigorous testing that prescription challenge in rst selecting the dose
meds do. ey’re not regulated and of herbs to use in studies. Fund-
may not reveal all of a product’s con- ing for these studies still remains a
tents on its label. ey also may not problem and a limitation to moving
contain the ingredient(s) listed or the forward rapidly. Many companies
amount(s) claimed. Don’t assume that that sell complementary therapies are
just because something is available over reluctant to fund studies which may
the counter or is “natural” that it doesn’t reveal their products are not useful, have
have side e ects or won’t interact nega - side e ects or have interactions with com-
tively with your other meds. mon meds. is information could hurt
In the US alone, it’s estimated that $20 billion their pro t margins. Pharmaceutical compa-
was spent on complementary therapies in 2001. nies are also unwilling to fund these studies
e use of these therapies has risen almost 400% in for many of the same reasons, and the FDA does not
the past eight years, and it’s estimated that half the require them.
people in the US use them. Currently, the industry Whatever the possible bene ts of herbs, vitamins
has done very little to document the safe and e ec- and supplements, there’s simply no meaningful
tive use of its products. It’s unlikely that it ever will. information to guide making decisions when using
e US government, through the NIH, has esta- them. Be aware that using them entails some risk.
blished two botanical centers to evaluate these types For more information on studies of herbs and vita-
of therapies. A third center will be funded shortly. mins conducted in HIV disease, see pages 8–12.
Every few years, new discussions are held about
TOLL FREE NATIONAL HIV/AIDS TREATMENT HOTLINE 1 800 822 7422 LOCAL AND INTERNATIONAL 415 558 9051 MONDAY FRIDAY 10 4 PACIFIC TIME
6. herbal side
Virtually any herb has the potential of causing side effects. For some, the Compound Q (Trichosanthes, Guaiougen,
risks are small and only occur when herbs are used in large quantities or for GLQ223, Chinese cucumber root)
long periods of time. For others, severe and life-threatening side effects have Severe neurologic side e ects (ranging
been seen even at very low doses with a single use. A good herbal practitioner from dizziness to coma) at very high doses,
low blood sugar, induces abortion. B
should discuss the potential risks of both side effects and herb-drug interac-
tions with you. However, this shouldn’t replace discussing these interactions Dandelion (Taraxacum)
and side effects with your doctor and pharmacist. Excessive gas, nausea and vomiting; skin
The following is a list of herbs and their known side effects. Those with FDA rashes, allergic reaction; increased urin-
ation (diuretic). Diuretic e ect is likely no
warnings or heightened safety concerns are highlighted in grey. This list is not more than what is seen with co ee. BC
comprehensive. If you don’t see the herb(s) you may be taking on this list, it does
not mean that there are no reported or possible side effects from using them. Many Devil’s Claw Root
resources exist on the internet and elsewhere providing even more comprehensive (Hapagophytum procumbens)
Induces abortion. C
information. One is www.personalhealthzone.com/herbsafety.html.
Dock Roots
Increased bowel movements, diarrhea. C
Akebia trifoliata caulis (Mu Tong) creased urine (diuretic), low blood sugar Echinacea
Kidney toxicity, kidney failure. is herb and may impact estrogen activity. BC Skin rash and insomnia. Allergic reaction.
contains aristolochic acid. In 2001 the May aggravate auto-immune disorders
FDA classi ed it as a Class 1 toxic sub- Calamus
Kidney toxicity. (like lupus). AB
stance and product recalls were started.
Cassava beans Ephedra
Aloe Vera (Carrisyn) Heart failure, stroke, increased blood
Severe diarrhea without proper prepar- May cause cyanide poisoning and death if
consumed in large quantities. C pressure.
ation, must be processed properly. Refrain
from ingesting aloe vera plant directly, or Chamomile Ganoderma (Ling-zhi, reishi)
use proper preparations. AB Belongs to ragweed family. People with Can inhibit blood clotting and trigger
allergies to ragweeds may experience al- hemorrhagic syndrome. AB
Apple seeds
May cause cyanide poisoning and death if lergic symptoms to chamomile. A Garlic (Allium sativum, Dasuan)
consumed in large quantities. C Chaparrel (Larrea divericata, Larrea Can inhibit blood clotting and interfere
tidentata, Creosote bush) with thyroid function. Diarrhea, vomiting,
6 Apricot Seeds nausea, weight loss, loss of appetite and
May cause cyanide poisoning (possibly Nausea, vomiting, diarrhea, cramps, skin
irritation, mouth sores and may promote skin rashes have been reported. AB
death) if consumed in large quantities. C
HERBS, SUPPLEMENTS AND HIV . JANUARY 2005 . PROJECT INFORM
tumor growth. e FDA issued a health Germander
Asarum sieboldii herba cum Radix (Xi Xin) warning in 1992 and many companies’ Inflammation of the liver (hepatitis),
Kidney toxicity, kidney failure. is herb voluntary removed chaparrel from their liver injury and death. Early symptoms
contains aristolochic acid. In 2001 the products or recalled products containing appear to resolve a er stopping the herb.
FDA classi ed it as a Class 1 toxic sub- chaparrel. Some may still exist on the Re-starting herb appears to result in im-
stance and product recalls were started. market, however. B mediate return of the problem. e risk
Astragalus (Huang-chi) Cherry pits or degree of liver injury is not appar-
Low blood pressure, low blood sugar and May cause cyanide poisoning and death if ently associated with dose or duration
increased urine production. May result in consumed in large quantities. C of use. E
dizziness and fatigue. AB Ginseng (Wuchaseng, Siberian,
Choke cherry pits
Atractylodes (Bai-zhu, Pai-chu) May cause cyanide poisoning and death if wjuia, ren-shen)
Liver toxicity, sedation, dehydration (di- consumed in large quantities. C Ginseng is touted the “most abused”
uretic), low blood sugar. AB or “mis-used” herb. Ginseng Abuse
Coconoosis Syndrome (GAS) is associated with its
Bitter almond seeds (Codonopsis pilosula, Tang-shen) long-term use. Various forms exist. Panax
May cause cyanide poisoning (possibly Low blood pressure. B and Eleutherococcus ginsengs produce
death) if consumed in very large quan- morning diarrhea, insomnia, nervous-
tities. C Coltsfoot
ness, depression, confusion, skin rashes
Liver toxicity, light sensitivity.
and high blood pressure. Ginsengs are
Black Tree Fungus
Comfrey [Symphytum officionale known to increase e ects of some anti-
Can inhibit blood clotting and trigger
(common comfrey), S. asperum (prickley depressants called Monoamine Oxidase
hemorrhagic syndrome. A
comfrey), and S. x uplandicum (Russian Inhibitors (MOIs). Women may experi-
Borage comfrey)] ence breast swelling or tenderness and
Liver toxicity. Liver toxicity: Vaso-occlusive disease, changes in menstrual cycle (amenorrhea)
fatal liver intoxi cation. In 2001 the FDA’s due to impact on estrogen. ABCD
Buckthorn Bark (Rhamnus) Center for Food Safety and Applied Nu-
Increased bowel movements, diarrhea. C trition sent letters to dietary supplement
Horsetail (Equisetum arvense)
Excitement, loss of appetite and muscle
Burdock (Arctium lappa) manufacturers advising that comfrey
control, diarrhea, labored breath, con-
Neurologic e ects, blurred vision, dry be removed from all nutritional health
vulsion, coma and death. C
mouth, constipation, bizarre behavior and products due to potentially serious and
speech (including hallucinations), in- life-threatening consequences of comfrey
ingestion. BE
TOLL FREE NATIONAL HIV/AIDS TREATMENT HOTLINE 1 800 822 7422 LOCAL AND INTERNATIONAL 415 558 9051 MONDAY FRIDAY 10 4 PACIFIC TIME
8. NIH study cautions use of
St. John’s Wort with anti-HIV drugs
A study conducted by the NIH St. John’s Wort (Hypericum perfo- One possible limitation of the
found a signi cant interaction ratum), and the protease inhibitor, nding is that it is not clear how it
between the popular herbal therapy, indinavir (Crixivan). Indinavir applies to the various forms of St.
blood levels were greatly decreased John’s Wort on the market. ere
when the two were used together, is no way of knowing its quality or
greatly reducing indinavir’s anti- how much St. John’s Wort is actu-
HIV activity. is can quickly lead ally present in the products. Di er-
to developing resistance to indina- ent brands may have a stronger or
vir. People commonly use St. John’s weaker e ect. Also, the methodol-
Wort as a mild anti-depressant. ogy of the study has not been fully
St. John’s Wort is also likely to described yet.
have the same e ect on other protease As this study shows, it’s very
inhibitors as well as NNRTIs. People possible for some herbal and nutri-
who take these drugs are advised tional supplements to lower the
not to use St. John’s Wort. Similar e ectiveness of anti-HIV drugs or
problems with drug interactions may other medications. People who use
occur between the herb and drugs complementary therapies should
used to treat other life-threatening ill- always discuss possible interactions
nesses, such as heart disease. with their doctors and pharmacists.
8
vitamin A (beta-carotene and retinoids)
HERBS, SUPPLEMENTS AND HIV . JANUARY 2005 . PROJECT INFORM
and anti-HIV drug interactions
In general, when used at reasonable doses on their own, fold less beta-carotene than advertised, and most were at
nutritional products like vitamin A supplements are least half as much than stated.
considered safe. New information suggests that when All forms of vitamin A (retinal, retinol, retinate and
used with other therapies, including anti-HIV drugs and beta-carotene) as well as all the products tested had
other nutritional products, interactions may occur that moderate (45–65%) to strong (65–100%) inhibitory
alter a product’s e ectiveness and safety. e ect on the p450 enzyme. erefore, these products (and
De ciencies in vitamin A (retinol, beta-carotene) have possible other nutritional health products) are very likely
been associated with advanced HIV disease. It remains to interact with anti-HIV drugs. However, human stud-
unclear if taking vitamin A supplements such as reti- ies are needed to understand the extent of these ndings.
noids or beta-carotene helps people with HIV beyond ese data suggest that there are possible, real vita-
correcting the de ciency. Moreover, questions remain as min-drug interactions with potentially harmful results
to whether or not vitamin A supplements cause vitamin- for people taking anti-HIV drugs. Much more informa-
drug interactions. tion is needed to fully understand the scope of these
A team in Canada set out to evaluate whether or not interactions and their impact on the e ectiveness and
di erent vitamin A supplements interact with the p450 side e ects of therapies. is information would also
enzyme. e team evaluated four tablets and two so gel be needed on how to modify doses of either therapy
capsules. All of the tested products had lower beta-carotene to reduce the risk of developing drug resistance and
content than stated on their labels. One product had ten- increase the chances of bene ting from both.
TOLL FREE NATIONAL HIV/AIDS TREATMENT HOTLINE 1 800 822 7422 LOCAL AND INTERNATIONAL 415 558 9051 MONDAY FRIDAY 10 4 PACIFIC TIME
10. amounts of selenium vitamin E, vitamin A and
in various foods: anti-HIV therapies
Previous reports suggest that vitamin E levels
Micro- % Daily are decreased in people living with HIV. Also,
Food grams Value
low levels of vitamin E have been associated
Brazil nuts, dried, unblanched, 1 oz 840 1,200 with increased risk of disease progression.
Tuna, canned in oil, drained, 3.5 oz 78 111 Researchers in the United Kingdom sought
Beef / calf liver, 3 oz 48 69 to evaluate vitamin E levels among 33 people
before and six weeks a er starting anti-HIV
Cod, cooked, dry heat, 3 oz 40 57
therapy. ey compared levels to those seen in
Noodles, enriched, boiled, 1 c 35 50
otherwise healthy HIV-negative people. ose
Macaroni & cheese (box mix), 1 c 32 46 taking multivitamins were not eligible.
Turkey, breast, oven roasted, 3.5 oz 31 44 Investigators found that before starting anti-
Macaroni, elbow, enriched, HIV therapy, vitamin E levels were lower (21
boiled, 1 c 30 43 µmol/l) among people with HIV compared to
Spaghetti w/ meat sauce, 1 c 25 36 HIV-negative people (30 µmol/l). Contrary to ear-
Chicken, meat only, 1/2 breast 24 34 lier reports, people with AIDS had slightly higher
Beef chuck roast, lean only, vitamin E levels (24 µmol/l) than people with
oven roasted, 3 oz 23 33 HIV who did not have AIDS (19 µmol/l). A er
Bread, enriched, whole wheat, six weeks of therapy, vitamin E levels normalized
2 slices 20 29 among people with HIV (28 µmol/l) compared to
Oatmeal, 1 c cooked 16 23 the HIV-negative people (26 µmol/l).
Egg, raw, whole, 1 large 15 21 Vitamin A levels were also evaluated. No
10
Bread, enriched, white, 2 slices 14 20 di erences were seen in vitamin A levels either
before or six weeks a er starting anti-HIV ther-
Rice, enriched, long grain,
HERBS, SUPPLEMENTS AND HIV . JANUARY 2005 . PROJECT INFORM
apy. Moreover, vitamin A levels were in normal
cooked, 1 c 14 20
healthy ranges, roughly equivalent to those seen
Cottage cheese, low-fat 2%, 1/2 c 11 16
in HIV-negative people, both before and a er
Walnuts, black, dried, 1 oz 5 7 therapy. Further, no di erences were seen in
Cheddar cheese, 1 oz 4 6 vitamin A levels between healthy HIV-positive
people and those with AIDS.
is study suggests that for people tak-
ing anti-HIV therapy, vitamin E supplements
are likely not necessary. Moreover, vitamin A
de ciencies were not noted with HIV infec-
tion, regardless of stage of disease. It remains
unknown if vitamin E supplements will bene t
people not on anti-HIV therapy.
www.projectinform.org
i Go online around the clock and get connected to treatment
information in the privacy of your own home!
TOLL FREE NATIONAL HIV/AIDS TREATMENT HOTLINE 1 800 822 7422 LOCAL AND INTERNATIONAL 415 558 9051 MONDAY FRIDAY 10 4 PACIFIC TIME
11. HERBS, SUPPLEMENTS AND HIV . JANUARY 2005 . PROJECT INFORM
vitamin supplements and HIV in women
(implications for everyone)
Vitamin deficiencies have been seen in people even at early stages of HIV infection. This has led to an
interest in using multivitamins, particularly in resource poor settings and those where malnutrition is
a problem. A study in Tanzania, Africa among HIV-positive pregnant women showed that using multi-
vitamins led to fewer deaths of unborn children, increased birth weights and fewer pre-term births.
However, trends were noted that children born to HIV in breast milk, higher rates of mother-to-
HIV-positive mothers who took multivitamins dur- child HIV transmission, lower CD4+ cell counts
ing pregnancy were more likely to be infected with and more rapid disease progression. Four hundred
HIV. Because of this, another study was started in women took either placebo or vitamin A at the dose
Kenya to examine the impact of using daily multivi- recommended by the World Health Organization
tamins (or placebo) and evaluate its impact on vagi- for correcting symptomatic vitamin A de ciencies in
nal and cervical presence of HIV. women of child-bearing potential. e study found
e use of multivitamins was associated with that the supplements had no e ect whatsoever on
slightly higher CD4+ and CD8+ cell counts and no vaginal presence of HIV, blood levels of HIV, or
overall changes in HIV levels in the blood. However, CD4+ or CD8+ cell counts.
it was also associated with increased vaginal presence ese ndings held true even among the 59% of
of HIV, with about 1/2 log higher levels of HIV in women with notable vitamin A de ciencies at the
vaginal swabs. e percentage of vaginal cells with start of the study. ey suggest that while vitamin
HIV was higher among those taking daily multi- A de ciencies may be associated with poorer out-
vitamins (31%) than those on placebo (17%). e comes in passing HIV from mother to child and of 11
di erences were less striking in cervical cells. HIV disease in general, supplements are unlikely to
Researchers speculate that using daily multivita- address these problems. As with the other study, this
mins among women is unlikely to protect them study did not evaluate using supplements together
from HIV disease progression and may increase the with anti-HIV therapy.
chances of passing HIV onto others. e results are
perhaps more relevant to places where anti-HIV
therapies are not available or to those who choose
not to use them together with multivitamins. e use
of multivitamins was linked to improved markers of
immune health (slight increases in both CD4+ and
CD8+ cell counts). It remains unknown whether the
increased vaginal presence of HIV from using mul-
tivitamins would be controlled while using anti-HIV
therapy. ( e women in this study were not on anti-
HIV therapy.)
Another Kenyan study found that vitamin A
de ciencies in blood were associated with increased
vaginal presence of HIV during pregnancy, increased
TOLL FREE NATIONAL HIV/AIDS TREATMENT HOTLINE 1 800 822 7422 LOCAL AND INTERNATIONAL 415 558 9051 MONDAY FRIDAY 10 4 PACIFIC TIME
12. zinc deficiencies and HIV
De ciencies in dietary zinc have been associated with gests that, in general, improving a person’s diet results in
decreased immune function and possibly increased HIV more normalized zinc levels.
reproduction. Drug users are at particular risk for zinc e study also showed that people with lower zinc levels
de ciencies for a number of reasons. ese include poor had somewhat lower CD4+ cell counts and were more
diets, poor absorption of nutri- likely to have counts below 200. It would be rash to sug-
ents and poor processing of gest, however, that low zinc levels are the cause of lower
nutrients by the body. CD4+ cell counts and not merely an e ect of disease
A team in Florida examined progression. In general this study is encouraging in that
the nutritional and immuno- it shows that simply improving diet, without supple-
For more
treatment
logic status of 118 HIV-posi- ments, leads to increased zinc levels in the blood and
information, call tive injection drug users. ey better immune status. Another study is ongoing to see
Project Inform’s found that people whose diets if zinc supplements will result in improved blood levels
toll-free National included foods with higher lev- of zinc and to see if it has any e ect on HIV or immune
HIV/AIDS els of zinc showed higher levels markers.
Treatment of zinc in their blood. is sug-
Hotline at
1-800-822-7422.
12
HERBS, SUPPLEMENTS AND HIV . JANUARY 2005 . PROJECT INFORM
Yes, I want to help Project Inform remain at the forefront of HIV treatment information!
PARTNERS IN HOPE
Enclosed is my donation of: $35 $50 $100 $250 $500 $1,000 $2,500 Other $_______
Enclosed is my donation of: $_____ per month for _____ months.
(circle one) In Honor of / In Memory of: _________________________________________________________
Please send me information on making a bequest or planned gi .
ADDRESS PAYMENT
Circle One: CHECK AMEX MC VISA DISCOVER
Dr./Mr. / Ms. / Mrs.
This is a new address.
Credit Card # Exp. Date
Address
City State Zip Print Name Shown on Card Day Phone
Email Phone Signature FACT
TOLL FREE NATIONAL HIV/AIDS TREATMENT HOTLINE 1 800 822 7422 LOCAL AND INTERNATIONAL 415 558 9051 MONDAY FRIDAY 10 4 PACIFIC TIME
