San Francisco General Hospital

To Beat Pain and Numbness in Arms and Legs -- a Side Effect of Certain AIDS Drugs, Which Can Cause Nerve Damage -- Some People With HIV Turn to Acupuncture

Acupuncture is commonly thought of as an "alternative" form of therapy, although its history as a treatment for physical ailments predates the era of laboratory-produced drugs by several thousand years. While the pharmaceutical industry has made impressive strides in the past decade in curtailing the rate at which HIV replicates, drugs have not eradicated the virus from a single individual to date. So it is not surprising that many people with HIV turn to medical therapies that are considered non-traditional in this country.

Some healthcare providers are uncomfortable when they learn that their patients are exploring treatment modalities such as acupuncture. However, a growing number of these professionals recognize the value in helping patients explore and evaluate alternative therapies. And a significant number of primary care providers have come to recognize that such therapies should not be thought of as alternatives to traditional medical care but rather as concurrent or complementary therapies -- therapies used in conjunction with, not instead of, conventional drug treatments.

Even if a physician does not wish to encourage such therapies, it is important that he or she maintain an open mind on the topic -- so that patients will not be tempted to conceal this part of their treatment regimen from their primary care provider. A comfortable rapport between patient and doctor is fundamental to a healthy therapeutic relationship, and a patient's desire to explore alternative survival strategies should not be allowed to compromise that relationship.

What is acupuncture?

The basic premise of acupuncture is that pain and illness are caused by imbalances in energy flow within the body. The term for this energy is "qi" (pronounced "chi"). Qi circulates along 12 pathways in the body. Specific points along these pathways have been identified as acupuncture sites and given names such as "Spleen 21." Practitioners believe that by inserting thin needles (usually made of stainless steel) at these points, they can restore the natural flow of qi along a pathway that has become disturbed or obstructed. Restoration of the natural flow of qi is thought to help relieve pain and treat underlying illnesses.

"A significant number of primary care providers have come to recognize that such therapies should not be thought of as alternatives to traditional medical care but rather as concurrent or complementary therapies -- therapies used in conjunction with, not instead of, conventional drug treatments."

Acupuncture is frequently administered within the broader context of traditional Chinese medicine. Practitioners of this ancient tradition choose from a variety of treatment modalities when developing an individual treatment regimen for a patient. In addition to acupuncture, these modalities include therapeutic massage, stress reduction techniques, and the application of heat and herbs that is known as "moxabustion."

Early in the AIDS epidemic, the only references to acupuncture in the medical literature focused on its potential role in viral transmission. (The concern at that time was that the reuse of needles, without proper sterilization, might transmit HIV. This minuscule and largely theoretical risk has been effectively eliminated by the use of proper sterilization techniques and disposable needles.) Today, despite the widespread use of acupuncture among people with HIV, there is still a paucity of information in the medical literature on the effect of this therapy on manifestations of HIV infection. Most of what we know comes from conference abstracts and anecdotal reports.

The World Health Organization has identified several groups of diseases that respond well to acupuncture treatment. These include infections of the upper and lower respiratory tract, certain diseases of the eye (such as conjunctivitis and glaucoma), gastrointestinal complaints (such as chronic gastritis, constipation, and diarrhea), and neurologic symptoms like peripheral neuropathy.

"Pain, a frequent symptom in people with HIV disease, appears to be particularly responsive to the effects of acupuncture. While the exact mechanisms by which acupuncture relieves pain remain obscure, there is clinical evidence that more than the placebo effect is at work."

This list correlates well with a chart review study conducted by the American College of Traditional Chinese Medicine, which has been providing acupuncture treatment to HIV-infected individuals for a number of years. The authors of that study identified the following health problems as the ones that most frequently respond well to acupuncture: weight loss, diarrhea, abdominal pain, nausea, headache, and peripheral neuropathy.

Pain, a frequent symptom in people with HIV disease, appears to be particularly responsive to the effects of acupuncture. While the exact mechanisms by which acupuncture relieves pain remain obscure, there is clinical evidence that more than the placebo effect is at work. In one study of individuals being treated for substance abuse, 40 individuals received treatment at specific acupuncture points while 40 others had needles inserted randomly. Half of those who received authentic treatment successfully completed the program, compared with only one of those who got nonspecific treatment. In addition, treated individuals had fewer relapses.

In other studies of the physiological effects of acupuncture, investigators have shown that the insertion of needles at certain points consistently produces a localized reduction in pain, whereas needles inserted at other points induce generalized anesthesia.

Acupuncture as a treatment for peripheral neuropathy

Whatever the mechanism at work, acupuncture has become a popular treatment for people with peripheral neuropathy, which is a common complaint of people with HIV. Neuropathy, or nerve damage, manifests as pain, tingling, or numbness in the extremities, usually the feet. Its severity can range from mild discomfort to a debilitating condition, robbing a person of the ability to walk or even stand. Neuropathy is a recognized side effect of certain antiretroviral drugs, but it can also be caused by HIV itself.

At the World Federal Acupuncture Society Conference that was held in Paris in 1990, licensed acupuncturist Magnolia Goh reported encouraging results from a small study of 31 HIV-positive patients with peripheral neuropathy. The participants in this study received one to three acupuncture treatments a week. Twelve patients had their pain completely alleviated by acupuncture, and another eleven experienced relief of most of their symptoms. Only three patients had no response. In most patients, results were felt after three to five treatments.

"Among the many attractive features of acupuncture therapy are its safety and its relatively affordable cost. Convenience is also a consideration: it is not necessary to plan one's life around acupuncture treatments, which is a particular boon to individuals who must plan their lives around their antiretroviral therapy schedules."

Researchers at Boston University School of Medicine used objective quantitative measurements as well as subjective questionnaires to judge the effects of acupuncture in 39 individuals with HIV-related peripheral neuropathy. Patients received two treatments a week for six months. For a variety of reasons, 13 patients did not return after their initial treatment. In the remaining 26 participants, quantitative sensory testing of the big toe demonstrated significantly improved sensation at follow-up visits. Neurologic exams showed improved sensory capabilities in seven participants, no change in 13, and deterioration in three. However, a majority of these study subjects noticed an improvement in their quality of life after several months of acupuncture treatments.

Despite the limited clinical data on the use of acupuncture to treat peripheral neuropathy and other HIV-related symptoms, acupuncture clinics are flourishing in many cities. Drs. Naomi Rabinowitz and Michael Smith, who have operated a highly popular clinic for HIV patients at Lincoln Hospital in the Bronx since the early 1980's, pioneered the use of acupuncture in people with HIV. Many other clinics dedicated to providing acupuncture to HIV patients have since opened, and they draw large numbers of patients.

Among the many attractive features of acupuncture therapy are its safety and its relatively affordable cost. Convenience is also a consideration: it is not necessary to plan one's life around acupuncture treatments, which is a particular boon to individuals who must plan their lives around their antiretroviral therapy schedules. But proponents of acupuncture will need to make their case with hard data at conventional medical conferences before many practitioners feel secure in suggesting this treatment to their patients -- and before insurance companies begin to cover the cost of this often helpful alternative therapy.