Using Cannabis to Manage HIV and AIDS
By Diana Hahn and Stacey Marie Kerr MD
There have been significant advances in treating HIV/AIDS since the emergence of the disease a few decades ago, however patients still face significant challenges in managing a variety of symptoms that commonly include pain (neuropathic and otherwise), nausea, loss of appetite, anxiety, and depression.
Some HIV/AIDS patients use medical cannabis to treat many of these symptoms. The evidence we have points to the efficacy of medical cannabis, however information about cannabinoids and the specific treatment of HIV/AIDS patients is very limited.
Still, many of the purposes for cannabis in HIV/AIDS patients are common to other serious diseases for which cannabis has also been shown to be effective. Clinical trials have also shown that at least for the short term, cannabis use is safe for HIV/AIDS patients, and does not interfere with the safety or efficacy of other common antiretroviral therapies.
In a 2003 survey of 252 HIV/AIDS patients, 24% reported cannabis use. The most common reasons for use were:
|Reason||Percentage of Respondents Reporting|
|Relief from Anxiety and/or Depression||57%|
|Relief from Pain||28%|
The survey data points to some of the areas in which cannabis may be effective, as well as how common cannabis use is among this patient population. Clinical evidence supports many of the findings of this survey, particularly in regards to pain management and appetite.
Neuropathic pain is a serious issue that affects 30% of HIV/AIDS patients. It has been described as sharp, severe, like a 3rd degree burn deep within the tissues. It prevents sleep, causing stress and anxiety. Antiretroviral treatments often do nothing to improve this pain, with some medications making it worse.  Many patients are prescribed opioids for HIV/AIDS-related neuropathic pain, however these drugs aren’t without their own adverse effects and potential for abuse. Cannabis presents a potential alternative that may address pain as well as other symptoms concurrently. For more information about treating pain with cannabis, click here.
In a 2007 randomized placebo-controlled clinical trial, smoked cannabis reduced pain significantly more than the placebo with no adverse effects. 50 patients participated, with those receiving cannabis smoking a cannabis cigarette 3 times a day for 5 days. The conclusion of the trial reported that cannabis is effective at treating chronic HIV-associated sensory neuropathy, and is comparable to other oral drugs that treat the same condition. 
Results of Pain Clinical Trial:
|Overall Pain Reduction||34%||17%|
|>30% Pain Reduction||52%||24%|
|Pain Reduction from 1st “Cigarette”||72%||15%|
Another trial performed with a majority of patients with advanced HIV who were exposed to potentially neurotoxic dideoxynucleoside reverse transcriptase inhibitors (example – AZT) showed that 46% of patients with clinically meaningful pain experienced >30% reduction in pain, compared to 18% of patients on placebo.  These parallel findings reinforce the efficacy of cannabis in managing HIV/AIDS-related pain.
appetite and nausea
Although weight loss, wasting syndrome, and nausea were not named in the survey mentioned at the beginning of this article, the “improved appetite” response points to the challenge many HIV/AIDS patients face in regards to gastrointestinal and nutritional issues. Almost half of AIDS patients experience nausea by the time they are at an advanced stage of disease.  Nausea makes eating difficult, contributing to weight loss and wasting syndrome. It can also make it very difficult to take medications crucial for effective treatment of the disease.
There is documentation of cannabis’ efficacy in addressing appetite and nausea, though much of it is more specific to cancer than to HIV/AIDS. Nonetheless, based on both anecdotal and survey data it appears that strain specific cannabis works for HIV/AIDS patients. Patients report that they prefer smoking whole plant cannabis over synthetic THC drugs (i.e. dronabinol/Marinol).  Reasons reported for this preference included more rapid acting effects as well as better control over titration. 
Cannabis and Treatment Adherence
Adherence to treatment, or taking prescribed medications consistently, is crucial to effective HIV/AIDS management. It is not uncommon for patients to struggle with adherence due to not only the symptoms of the disease, but to the adverse effects of treatment as well. Antiretroviral therapy (ART) adverse effects most commonly include nausea and/or vomiting, but may also include anxiety, depression, pain, and difficulty sleeping.
While ARTs may have these undesirable effects, there are undeniable benefits to taking medications exactly as prescribed. Excellent adherence, generally defined as taking 95% of medication, is associated with suppressed viral load, increased CD4 response, slower disease progression, lower rates of hospital admission, and prolonged survival. 
It is worthwhile to consider what effect if any cannabis has on adherence to ARTs. Interestingly, whether a patient suffers from nausea/vomiting may be an indicator as to whether cannabis will support or deter from the ability to be consistent with meds. 
In a study where adherence was defined as not missing any ART doses in the past week:
|Adherence % without Cannabis Use||Adherence % with Cannabis Use|
|Patients with Nausea||48%||75%|
|Patients Without Nausea||57%||72%|
In light of these statistics, it makes sense for physicians to monitor patients to ensure that cannabis is being used effectively, is supporting the consistent use of ART medications, and is improving quality of life, rather than detracting from adherence and therefore overall outcomes.
Initial studies show that cannabis and cannabinoid medicines appear to be safe for HIV/AIDS patients, and do not have drug-drug interactions with ARTs. Most specifically, there has been concern regarding cannabinoids sharing the P450 metabolic pathway with protease inhibitors, a common class of antiretroviral drugs. Protease inhibitors include indinavir (Crixivan) and nelfinavir (Viracept). A randomized placebo-controlled 21-day clinical trial was done to investigate whether sharing this metabolic pathway might alter the efficacy of the protease inhibitor, therefore increasing viral load. The result of this trial showed that neither smoked cannabis nor oral THC adversely affected HIV RNA levels, CD4 cell counts, or CD8 cell counts. 
While symptom relief is clearly a benefit of cannabis use, it is important to learn whether cannabis use may limit the efficacy of other medications as well as possibly suppress the immune system.  Currently there is very limited research in regards to the effect of cannabinoids on the immune systems of HIV/AIDS patients, but reassuringly, no serious adverse events have been documented thus far.
Prentiss D, et al. Patterns of Marijuana Use Among Patients with HIV/AIDS Followed in a Public Health Care Setting. J Acquir Immune Defic Syndr. Volume 35, Number 1, January 1 2004.
Ellis RJ, et al. Smoked Medicinal Cannabis for Neuropathic Pain in HIV: A randomized, crossover clinical trial. Neuropsychopharmacology 2008.
Abrams DI, et al. Cannabis in Painful HIV-Associated Sensory Neuropathy. NEUROLOGY 2007; 68:515-521, 2007.
Solano JP, et al. A Comparison of Symptom Prevalence in Far Advanced Cancer, AIDS, Heart Disease, Chronic Obstructive Pulmonary Disease, and Renal Disease. Journal of Pain and Symptom Management. Vol 31, No. 1, January 2006.
Abrams DI, et al. Short-Term Effects of Cannabinoids in Patients with HIV-1 Infection. Ann Intern Med. 2003;139:258-266.
de Jong BC, et al. Marijuana Use and its Association with Adherence to Antiretroviral Therapy Among HIV-Infected Persons with Moderate to Severe Nausea. J Acquir Immune Defic Syndr Volume 38, Number 1, January 1 2005 .
AIDS Action. AIDS Action Supports Research and Use of Medical use of Cannabis for HIV/AIDS. www.aidsaction.org.