BETA September 1997.
by Leslie Hanna
This article was inspired by a presentation jointly delivered by Carla Wilson, LAc, and Misha Cohen, OMD, LAc, at the National Conference on Women & HIV in May 1997. Carla Wilson is Executive Director and Misha Cohen is the Research and Education Director of Quan Yin Healing Arts Center, located in San Francisco, CA. Cohen is also the author of a book on Chinese medicine called The Chinese Way to Healing: Many Paths to Wholeness. Her second book, The HIV Wellness Sourcebook: an East/West Guide to Living with HIV/AIDS, is due out next May (1998).
Quan Yin Healing Arts Center (Quan Yin) is a nonprofit, alternative medical clinic that has treated thousands of HIV positive people since 1984. Quan Yin's mission is "to provide the best healthcare possible, regardless of ability to pay and social status." Staff include a Western medical doctor (MD), a registered nurse (RN), a doctor of Oriental medicine (OMD), an acupuncture clinical director, several licensed acupuncturists (LAc), 3 massage therapists and a Qi Gong (a specialized exercise program) instructor. All Chinese medicine practitioners have completed an HIV certification course that provides them with information about the most up-to-date Western and Eastern methods of treating HIV disease.
Currently, Quan Yin provides treatment to about 175 people a week. About 75 are in the HIV program, and approximately 23% of these are HIV positive women. Quan Yin offers other specialty programs related to chronic viral hepatitis, premenstrual syndrome (PMS), stress reduction and smoking cessation. Care is provided in Spanish and English.
In the U.S., Chinese medicine is considered alternative medicine. Most alternatives to Western medicine are collectively referred to as complementary and alternative medicine (CAM). CAM refers to a broad range of treatments, approaches and philosophies. CAM encompasses alternative systems of medical practice (e.g., Tibetan medicine), dietary systems (macrobiotics), "manual healing" techniques (massage therapy) and integrative mind/body approaches (biofeedback). In general, "alternative" tends to signify the use of some type(s) of CAM alone, for example, Chinese medicine instead of Western medicine. "Complementary" signifies the supplemental use of CAM in addition to conventional Western medicine, such as when an HIV positive person uses a Chinese herbal formula in addition to antiretroviral drugs for HIV infection.
The use of Chinese medicine or any other type of CAM is controversial in the U.S. CAM treatments are not taught in most U.S. medical schools and are not generally offered in doctors' offices or in hospitals. Furthermore, they are usually not reimbursed by third-party payers like insurance companies. The safety and efficacy of many CAM treatments have not been rigorously tested according to Western medical and scientific standards; thus, many Western healthcare practitioners such as medical doctors and registered nurses as well as the general public in the U.S. remain skeptical about CAM.
However, the popularity of CAM continues to rise in the U.S. According to recent articles in the medical literature (Archives of Family Medicine, Annals of Internal Medicine), approximately half of the adults in the U.S. use some type of CAM. (Worldwide, the World Health Organization reports that 80% of people use CAM.) The article in the Archives of Family Medicine states that 53% of CAM users report such use to their primary physicians, and the Annals of Internal Medicine article stresses the necessity for discussion of CAM between patients and their primary physicians. At the same time, practitioners of conventional medicine are becoming more familiar with CAM. In fact, the August 1997 issue of Nature Medicine reports that 80% of contemporary U.S. medical students are requesting more training in CAM practices.
Anecdotal data and data from other countries such as China and Germany indicate that some forms of CAM are effective for treating some medical conditions. For example, an herbal treatment called St. Johns Wort (Hypericum perforatus) was clinically tested and approved for the treatment of mild-to-moderate depression in Germany. Some types of CAM, like massage or meditation, involve little or no risk to a user. Others, such as herbal medicine, must be regarded differently. For example, the U.S. Centers for Disease Control and Prevention (CDC) has reported deaths associated with use of ephedrine or ma huang, an herb found in various teas and herbal formulations. In addition, especially for people with HIV who are taking powerful antiretroviral drug combinations, it is important to know that many herbs and vitamins, like many anti-HIV drugs, are metabolized by the liver and excreted by the kidneys. There may be powerful drug/herb interactions and stress on the body's metabolic and excretory systems.
Since the beginning of the AIDS epidemic, people with HIV/AIDS have used different forms of CAM. Chinese medicine has consistently been one of the most popular alternative modalities. Despite a lack of controlled research studies (there have been a few, which will be explored in a later article), increasing numbers of women with HIV appear very interested in learning about Chinese medicine and other types of CAM. At the XI International Conference on AIDS in July 1996, Judith Berrier and colleagues from Mt. Sinai Medical Center in New York presented a novel survey of CAM use among women. They analyzed data drawn from nearly 1,300 participants in the Women's Interagency HIV Study (WIHS), a multicenter longitudinal study of the natural history of HIV infection in women. Over half of these women reported some use of CAM, but far less than half (30%) discussed CAM use with their primary healthcare provider. The investigators tentatively concluded that women with HIV may be more likely than men with HIV to try or to use CAM regularly, and may be more reluctant to discuss CAM use with health care providers.
In her presentation at the Women & HIV Conference, Misha Cohen noted that, "in this era of protease inhibitors, undetectable viral loads and increasing T-cells (for some people), questions have been raised as to the continuing need for CAM....CAM, especially Chinese medicine, is very important now to provide the immune support the body will need for extended years of drug treatments and to battle the onslaught of drug effects brought on by powerful new drugs. Chinese medicine has been especially effective as a total system for working with people with HIV, especially women."
Since information about Chinese medicine and other types of CAM applies to all adults with HIV, an upcoming issue of BETA will feature a comprehensive article on CAM that applies to both women and men with HIV. After some introductory information, this article will present a Chinese medical perspective on women with HIV. The article will provide women with HIV with an introduction to the Chinese medical system, its terminology and concepts, and information about how to access care.
The Chinese medical perspective on disease and health is foreign to Westerners, who nonetheless appear to be turning to Chinese medicine in increasing numbers. The philosophical underpinnings, the explanations for symptoms and diagnosis, and the treatments all may appear abstract, mystical and barely intelligible to a Westerner. One fundamental principle is that the whole individual is addressed. During the diagnostic procedure, the practitioner will, for example, examine and question the patient about her lifestyle in order to understand why her menstrual period may be heavier than usual.
Chinese medicine attempts to maintain health by harmonizing the body, mind and spirit. It is believed that immune strength derives from reinforcing the "normal" state of the body, which is naturally "intelligent" and full of vital energy, or Qi. Conceptually, Qi is regarded as being as vital and necessary to life as air. In fact, a person can learn through breathing exercises to breathe correctly, which makes more oxygen available to the bloodstream, and thereby strengthens the body's Qi. Much crossover exists between energetic and physiological effects.
The Chinese medical philosophy embraces the concept of the dialectical opposites of Yin and Yang. The body is considered a microcosm of the world; the correct balance of Yin and Yang will lead to good health as well as to a balanced environment. Far from being fixed entities, Yin and Yang are always in relationship to each other, in flux.
In addition to Qi and Yin and Yang, body fluids, especially Blood, and organ systems are important concepts. Each organ system governs particular body tissues, emotional states and activities. For example, the Kidney system manages fluid metabolism. Beyond that, in Chinese medicine, the Kidney system is responsible for reproduction, growth and regeneration. The bones, inner ear, marrow, teeth and lumbar area are all associated with the Kidney system. Frequent urination and low back pain may be associated with this system. The emotional state of fear, as well as will, are also associated with the Kidney system. (For more on organ systems and other philosophical underpinnings of Chinese medicine, see Cohen's book A Chinese Way to Healing: Paths to Wholeness.)
Fu Zheng therapy, which attempts to address the whole person to restore or maintain health, is thought to address well the needs of women with HIV. Fu Zheng therapy is believed to increase well-being and quality of life, to enhance the ability to fight pathogens and to minimize the need for drug treatment. In other words, the creation of wholeness and harmony will enable the body to heal itself. Some modalities of Chinese medicine such as acupuncture or exercise focus on balancing the body's energy, while others focus on improving the physical body by adding substances, such as herbs and food, which balance and change the body materially.
Diagnosis in Chinese medicine usually entails an extended period of time, during which the practitioner looks at and listens to the patient. Looking means closely observing the patient's size, age, patterns of facial wrinkles, expression, curvature of the spine and more. Close examination of the skin, especially around the orifices, and of any discolorations helps the practitioner "create a visual form of what is now manifesting on the surface," Cohen explains. The appearance of the tongue is very important in Chinese medicine. Size, swelling, cracks down the center and color all are believed to reflect the body's internal climate. Wilson says that some people with HIV who learn about Chinese medicine derive practical information that can help them self-monitor their health status by examining their tongues in the mirror each morning.
Listening, or inquiry, is very important in Chinese medical diagnosis. An interview of each individual is central to Chinese medicine, and may include "unusual" questions such as: What time do you awaken in the morning? Do you have night sweats early in the night or toward morning? Do you dream heavily? Taking a patient's pulse is another pivotal diagnostic technique and way of "listening" to what is happening with an individual.
According to Wilson, Chinese medicine is a complete system, with its own understanding of physiology and pathology, and its own forms of diagnosis and treatment. It has been used for thousands of years in Asia and for hundreds of years in various parts of the West. Wilson stated that diagnostic procedures and theory developed over the course of thousands of years and involved millions of subjects, and that Chinese medical textbooks represent compilations of thousands of hours of debate among the most reputable physicians in China. For instance, it could take up to months or years to determine the physiological effects of a single herb, effects which had to be reproducible in all people with the same syndromes. Says Wilson, "this process is similar to what happens in contemporary Western clinical trials. It was not a simple matter for an herb to become included in a book of medicine." The same principles continue to be used to this day when prescribing and practicing Chinese medicine.
A number of modalities are included in Chinese medicine, including acupuncture, moxibustion, herbal formulas, dietary therapy, exercise and massage. All of these are commonly used by women for a variety of medical problems.
Many techniques, not all of which use needles, are associated with acupuncture. Generally, acupuncture is the art of inserting fine metal needles into certain points on the body in order to control the body's energy or Qi flow. Practitioners stimulate the needles manually or electrically. Acupuncture is relatively painless, and may be accompanied by sensations of heaviness, warmth, or movement of energy at the point of insertion or along channels or energy lines. Acupuncture has long been known for its success in relieving pain. Another benefit is the ability of acupuncture to help the body rebalance its energy patterns in order to heal itself of organic symptoms and syndromes.
Wilson noted that acupuncture was first licensed in Hawaii, followed by New Mexico, California and Florida. Today, 30 states license or register acupuncturists. In other states, acupuncture remains legally prohibited or unregulated. A national campaign is being waged to develop licensure in those states as well as a national certification program. In California, acupuncturists are required to pass a state board examination that is regulated by the medical board of acupuncture.
Moxibustion is a form of heat therapy. It involves the burning of a common herb, mugwort or moxa, which is held over certain areas of the body for stimulation or for warmth. The herb is usually rolled into a cigar shape, lit so that a coal forms at one end, and held over the body. In China, family members often assist with moxibustion. Moxibustion can also refer to the traditional use of heat packs which are placed strategically on the body. Moxibustion may be used alone or in conjunction with acupuncture, and may be prescribed for home use. With moxibustion as with acupuncture, certain points are considered useful for stimulating appetite and others for ameliorating neuropathies (nerve damage).
Chinese herbal medicine is a vast subject, involving thousands of distinct medicines. In the U.S., students learn to use 300-500 herbs while attending very strict training programs. Thorough training and cautious use is warranted in the area of herbal medicine because herbal substances are essentially drugs in that they have specific organic effects. They are not recommended for casual use. Herbs may produce therapeutic effects and side effects, and there may be individual sensitivities, as with pharmaceutical drugs. As of 1997, California is the only state that requires herbal medicine training for passing state licensure examinations. In other states, licensed acupuncturists may or may not have studied herbs as well as acupuncture.
Currently, regulations regarding the use of herbs are being rewritten in some states. Persons interested in seeing an acupuncturist or herbalist should ask a potential practitioner what type of herbal training she or he has had. The practitioner also should have additional training in HIV and AIDS treatment. For instance, a National AIDS and Chinese Medicine Conference held each year offers courses for acupuncturists. In the setting of HIV infection, ingestion of certain herbs has been linked to near-fatal reactions. Sherwood Gorbach, MD, from Tufts University School of Medicine, identified 10 such herbal substances: chaparral, comfrey, germander, GordoloboYerba tea, Kombucha tea, margosa oil, mistletoe, pennyroyal (squawmint) oil, skullcap and certain types of Mate teas.
One of the most important therapies in Chinese medicine relates to food, which is regarded as the "first fuel." When people become ill in China, food therapy is often the first line of treatment considered. Chinese food therapy includes all food used to strengthen digestion and to increase and balance the body's energy. Food therapy is often used prior to or in conjunction with other modalities, in order to increase the efficacy of all treatments. Food therapy is based on the concepts of Yin and Yang, or balance of energies. Similarly, Yin and Yang are fundamental concepts in Japanese macrobiotics and in nutritional supplementation.
For centuries, massage therapy and exercise have been important aspects of Chinese medicine and health, although not unique to Chinese medicine. Various techniques are involved in massage therapy. Exercise ranges from aerobic martial arts to Qi Gong, also known as Tai Chi. Many practitioners recommend that HIV positive people find some type of exercise such as Qi Gong that builds energy or helps consolidate Qi in the body. The idea is that oxygen helps the body move the energy or Qi, thereby creating more energy and rejuvenating the cells of the body. A practitioner might recommend that women with HIV join a health club or a clinical study which provides exercise equipment and instruction.
Meditation is an important aspect of Chinese medicine. Many forms exist, ranging from the very active to the contemplative. For example, there are walking meditations and sitting meditations. Watercolor painting is another meditative technique often used in China. Today, newer forms of meditation include relaxation exercises, cassette tapes, hypnotherapy and biofeedback.
In the Chinese medical view, HIV infection is a Toxic Heat condition. Symptoms of fever, sore throat, night sweats, rash and itching are all related to Toxic Heat problems. Cohen notes that, in her experience, many people with HIV "have red dots on the tongue, an additional indicator of Toxic Heat in the body." While many HIV-related conditions are found in both men and women, conditions involving the reproductive tract are different. Chinese medicine offers its own explanations for gynecologic disease in women with HIV. For instance, genital warts and cervical dysplasia are signs of Toxic Heat in women. Genital (and oral ulcers) are also Toxic Heat manifestations that can be treated by Chinese medicine.
HIV disease begins to manifest Toxic Heat in the central portion of the body, in the Spleen and Stomach. These organ systems, charged with fluid metabolism, digestion and provision of energy to the entire body, are highly affected by HIV. HIV affects digestion and results in symptoms like nausea, loss of appetite and diarrhea. Menstrual irregularities are believed to be related to the Spleen's loss of normal function, which is viewed as regulating the blood and transforming food into blood and energy. Women with menstrual irregularities may have a Spleen pulse that is "soft" or "slippery," and the tongue may be "puffy or scalloped with an absence of coating in the center and cracks down the middle, showing that the central Qi (or Spleen Qi) is deficient." The particular type of menstrual irregularity is diagnosed and the appropriate herbal remedy is recommended depending on the appearance of the tongue, the type of pulse and the type of bleeding.
Generally, menstrual problems in HIV positive women are attributed to Spleen Deficiency. The particular problem of amenorrhea, or scanty or absent menstruation, results from combination Spleen and Blood Deficiencies, and possibly Blood Stagnation. All of these distinctions determine which herbs to use to treat the condition.
Recurrent vaginal candidiasis or yeast infections are a complaint of many women with HIV. From the Chinese medical perspective, women with HIV and Spleen Deficiency often have Spleen Dampness, which can lead to the development of candidiasis at any site. Spleen Deficiency Dampness in women with HIV is also associated with difficulty digesting sugars and fermented food and beverages. Dampness leading to vaginal infections is further characterized as Cold Dampness or Damp Heat, which is revealed by the color and odor of the vaginal discharge and requires different herbal treatment. Herbal formulas are tried first. Supplemental acidophilus bacteria and garlic also may be used, in both intravaginal and dietary supplemental forms. Nutritional counseling instructs women with candidiasis to avoid foods such as sugars, yeasts and fermented products, and to increase intake of greens, vegetables and protein. Chinese dietary recommendations to combat Dampness include reducing the consumption of dairy products and increasing barley consumption. For women with esophageal candidiasis, an AIDS-defining condition, Cohen recommends treatment with pharmaceutical antifungals as well as Chinese herbal therapy.
When the condition of Spleen Dampness progresses (or, in Chinese medical parlance, when Dampness sinks to the Lower Burner), genital herpes outbreaks and pelvic inflammatory disease (PID) may occur. This sinking or progressive descent of the condition occurs when Damp Heat or Liver Heat pass through the Liver channel, which passes through the pelvic and groin areas, the chest, and encircles the mouth. Thus, herpes sores and canker sores also may develop around the mouth or elsewhere on the body.
HIV positive women with Toxic Heat and Liver Qi congestion may experience vaginal or cervical human papillomavirus (HPV) infection. From the Chinese perspective as well as the Western perspective, HPV infection may lead to cervical neoplasia, a precursor of cervical cancer. Cigarette smoking is believed to enhance HPV infection by both Chinese and Western medical practitioners. The uniquely Chinese medical explanation is that chronic HPV infection and cervical neoplasia are due to Spleen and Kidney Qi Deficiencies, and the recommendation may be to use herbal formulas specially designed for women to regulate the Liver, Spleen and Kidney Qi. Herbal formulas are also available for intravaginal use.
Lifestyle factors such as stress, drug and alcohol abuse, low self-esteem, history of physical or sexual abuse and abdominal surgery are believed to have profound effects on an HIV positive woman's health, and can result in Liver Qi Stagnation-related PMS, for example. Herbal formulas designed for balancing women's health are often recommended.
Women with HIV may experience depression. In Chinese medicine, the liver is known as the Temperamental Organ or the Sea of Emotions. In Chinese medicine, the strength of the Spirit is considered crucial to health. Thus treatment for Liver Stagnation, such as acupuncture, may alleviate depression or anxiety as well as aggravated PMS.
In Chinese medicine, women with HIV, like men with HIV, must address the overarching and ongoing HIV-related problems of Toxic Heat and Central Qi Deficiency. At Quan Yin, a popular Chinese herbal formula called Enhance is used to "regulate the immune system, tonify the Spleen Qi, clear the Heat and toxins, and stimulate bone marrow." Many other herbs believed to have microbicidal (antiviral/antifungal/antibacterial) properties are used. For example, Cordyceps or Dong Chong Xia Cao, an herb used to treat HIV, is currently being studied in China for the treatment of cancer. Many other herbs and herbal formulas are available to treat common HIV-related problems such as diarrhea and anemia.
Wilson and Cohen advocate comprehensive and individualized treatment plans for women with HIV. They favor a complementary East/West approach and recommend that women with HIV receive their primary care from medical doctors. This way, serious symptoms can be diagnosed early and conventional treatment can begin when necessary (e.g., in the event of esophageal candidiasis). Chinese medicine may make it possible to reduce the duration of pharmaceutical treatment, for example, for candidiasis. Chinese medicine--herbs, Qi Gong exercise, dietary changes, massage and meditation--can be used in complementary fashion to strengthen the body before, during or after conventional medical treatment.
Discussing CAM use with your doctor increases your treatment options as well as your chances for receiving the best healthcare possible. Since your doctor may not mention CAM, you can initiate the conversation. David Eisenberg, MD, in an article in the Annals of Internal Medicine, suggests some helpful steps:
These suggestions should help improve communication between you and your primary care provider, give you vital information about your health and treatment plan, and maximize your opportunities for optimal health care.
The following studies of CAM are currently enrolling women with HIV around the country. Since herbal therapies are generally not considered harmful to pregnant women, childbearing potential and/or pregnancy are not usually exclusion criteria for women seeking to enroll.
At the Immune Enhancement Project in San Francisco, an FDA-approved trial funded by the National Institutes of Health (NIH) is evaluating acupuncture and herbal treatment vs standard Western medicine (the antibiotic Augmentin) for chronic HIV-related sinusitis. The trial is still enrolling. For more information, call 415-252-8711.
Also in San Francisco, the Community Consortium in conjunction with Quan Yin is conducting a pilot study of Chinese herbs for cryptosporidiosis-negative, HIV-related diarrhea. The small study will evaluate whether taking Chinese herbs is safe and effective in reducing diarrhea that is unrelated to cryptosporidiosis. Call the Community Consortium at 415-476-9554. An upcoming study, also conducted by the Community Consortium and funded through NIH and Bastyr University in Washington, is a pilot study of Chinese herbs for the treatment of mild to moderate anemia.
A Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA) study of acupuncture and amitriptyline (Elavil) for peripheral neuropathy is ongoing in several states, including California, Colorado, New Jersey, New York and Pennsylvania. Another CPCRA study is looking at nutritional supplementation, including Peptamen, Nubasics, multivitamin and multimineral supplementation. Call 1-800-TRIALS-A for information about these and other CPCRA trials.
A double-blind, placebo-controlled trial of oral L-carnitine for the treatment of AZT-induced myopathy is ongoing in Bethesda, MD. Muscle biopsies are involved. The study is sponsored by the NIH National Institute of Neurological Disorders. Call 301-402-4479.
At Mt. Sinai School of Medicine in New York City, an ongoing study is evaluating supplementation with methionine, an amino acid, for the treatment of myelopathy, a neurological disease associated with HIV. Call 212-241-8902.
A placebo-controlled study of the hormone DHEA for the treatment of depression in men and women with HIV, will enroll those with fewer than 400 CD4 cells/mm3 and "low mood/energy." Call the NY State Psychiatric Institute at 212-543-5762.
Finally, a study of acupuncture and moxibustion for diarrhea related to chronic malabsorption in HIV is ongoing. Sponsored by the Center for Holistic Medicine on Long Island, NY, the study is taking place at the Columbia University School of Nursing. For more information, call 212-305-3852.
If you are interested in Chinese medicine or another type of CAM, first talk to your primary care provider for a referral and about potential CAM therapies. Medical and public libraries as well as bookstores are good places to find information about CAM therapies.
For licensing requirements for any given state, contact:
National Certification Commission for Acupuncture and Oriental Medicine
PO Box 97075
Washington, DC 20090-7075
202-232-1404
The following agencies can provide referrals to local Chinese medicine practitioners:
American Association of Oriental Medicine
433 Front Street
Catasauqua, PA 18032
610-266-1433
California Association of Acupuncture and Oriental Medicine
1231 State Street, Suite 208-A
Santa Barbara, CA 93101
888-432-5669 (in CA only) or 805-957-4384
Institute for Traditional Medicine
2017 SE Hawthorne Street
Portland, OR 97214
503-233-4907
Finally, the following organization can provide referrals to medical doctors who also practice acupuncture:
American Academy of Medical Acupuncture
5820 Wilshire Boulevard, Suite 500
Los Angeles, CA 90036
213-937-5514
For other types of CAM, such as chiropractic, naturopathy and homeopathy, various medical regulatory and licensing agencies in your state may provide information about a specific practitioner's credentials and training. The Office of Alternative Medicine Clearinghouse has several fact sheets on CAM, including one entitled "Alternative Medicine Research Using MEDLINE."
Berrier J and others. Use of complementary/alternative therapies by HIV + women: the women's interagency HIV study (WIHS). The XI International Conference on AIDS. Vancouver, BC. July 1996. Abstract Th.D.5120.
Cohen M. The Chinese Way to Healing: Many Paths to Wholeness. Berkeley/Putnam Group. September 1996.
Cohen M and Surasky A. Chinese medicine for HIV+ women. Immune Enhancement Project News. Summer 1996.
Cohen M and Wilson C. Chinese medicine and alternative therapies. The National Conference on Women & HIV. Pasadena, CA. May 1997. Abstract 113.
Gorbach S. Dietary management of AIDS wasting. AIDS wasting diagnosis and treatment. XI International Conference on AIDS. Vancouver, BC. July 1996. Satellite symposium.
Jonas WB. Researching alternative medicine. Nature Medicine 3(8): 824-827. August 1997.
This information is designed to support, not replace, the relationship that exists between you and your doctor.