A Double Blind Placebo Controlled Study - Homoeopathy in HIV Infection
NATIONAL JOURNAL OF HOMOEOPATHY 2001 Sep / Oct VOL III NO 5.
Dr D P Rastogi, Dr Vikram Singh, Dr V P Singh
Dr S.K.Dey, Dr K Rao
Abstract Objective: This study was aimed to evaluate the immuno-modulator role of homoeopathic remedies in HIV infection.
Methodology: A randomized double blind clinical trial was conducted to compare the effect of homoeopathic remedies with placebo, on CD4 +ve T-lymphocytes in HIV infected individuals, conforming to CDC stage II and III. 100 HIV +ve individuals between 18 and 50 years (71% males) were included in the study. 50 cases conformed to CDC stage II - Asymptomatic HIV infection, and other 50 cases to CDC stage III - PGL. Cases were stratified according to their clinical status and CD4 +ve Lymphocyte counts. The randomization charts were prepared much before the start of the trial by randomly assigning placebo and verum codes to different registration numbers from 1 to 50. A single individualized homoeopathic remedy was prescribed in each case and was followed up at a periodic interval of 15 days to one month. A six months study was performed for each registered case. Assessment of progress was made by evaluation of CD4 +ve Lymphocyte counts, which was decided as the main out come measure of the study; the results were compared with the base line immune status.
Results: In the strata of PGL, a statistically significant difference was observed in CD4 +ve T-Lymphocyte counts between pre and post trial levels in verum group (p < 0.01). In the placebo group a similar comparison yielded non-significant results. (p= 0.91). Analysis of change in the pre and post trial counts of CD4 +ve cells was also significant for the verum group (p=0.04).
In Asymptomatic HIV infection, differences in absolute CD4 +ve Lymphocyte counts between pre and post trial levels were not significant. Analysis of changes in pre and post trial CD4 levels of placebo and verum groups for combined strata of Asymptomatic and PGL groups was also not significant.
Conclusion: The study suggests a promising role of homoeopathic treatment in HIV infection in symptomatic phase, as evidenced by a statistically significant elevation of base line immune status in persistent generalized lymphadenopathy.
Key Words: Immuno-modulator, CD4 Lymphocytes
Abbreviations: HIV - Human Immuno-deficiency Virus; PGL - Persistent Generalized Lymphadenopathy; CDC - Centres for Disease Control, Atlanta, USA
Double blind placebo controlled trials are uncommon in Homoeopathy due to inherent problems in the methodology of treatment, i e, individualization procedure, treatment by multiple remedial agents for a single clinical diagnosis, etc. However, small group studies have been conducted on clinical problems like Acute childhood diarrhoeai, Influenzaii, Allergic Rhinitisiii, Fibrositisiv, Osteo Arthritisv. These trials with the exception of the last named, have suggested a significant positive role of homoeopathic treatment when compared to the placebo. A meta-analysis of placebo-controlled trials in Homoeopathy was conductedvi. The results of this analysis are not compatible with the hypothesis that clinical effects of homoeopathy are completely due to placebo. However, the investigators could not find enough evidence of efficacy of homoeopathy for any clinical condition.
Placebo controlled trials of therapy to inhibit progress of HIV associated disease have met considerable resistance, as the patients have been reluctant to accept the risk of receiving a placebo. In this context, it is worthwhile to consider that in the face of HIV disease the smallest chance of benefit is perceived as better than no benefit. Additionally, enough measures have been included in our trial protocol, so that patients not benefited by the therapy can be subjected to active therapeutic intervention in such an eventuality and not allowed to deteriorate further. Placebo controlled trial with homoeopathic medicines was not conducted in Human Immuno-deficiency Virus (HIV) infection, prior to our study. A preliminary report of our study is already publishedvii. The present article deals with interpretation of the results of the study with the help of a statistical analysis.
The primary target of HIV is the lymphocytes, which express CD4 protein on their surface, and the virus attaches to the lymphocyte, using this protein. These CD4 +ve T-Lymphocytes are preferentially infected and killed by the HIV as the infection progresses, depleting their numbers and enhancing the risk of opportunistic infections. Furthermore, it is known that extent of CD4 depletion is strongly associated with the risk of clinical progression and survival. Although any one individual may be an exception, for populations of HIV infected persons, studies have shown an unequivocal association between low levels of CD4+ cells and measurable deleterious events that are AIDS defining phenomena and by extrapolation, predict survival.
The absolute CD4 +ve T-Lymphocytes at any given point of time, is the best available cellular predictor of HIV progression, and is the most important factor of survival, regardless of how the individual achieved that level. Relatively small shifts in the numbers of CD4 +ve cells can be very important if they bring an individual's cell count into a better prognostic category. A stable CD4 level indicates HIV non-progression and therefore a halt in the decline in the number of CD4+ve cells is viewed as meaningfulviii. Therefore CD4+ve T-Lymphocytes are often used as surrogate markers in clinical trials. Initial trials using CD4 cells as surrogate immunological markers would establish that a therapy is potentially effectiveix. This should then pave way for larger multi-parametric studies involving immunological and virological markers.
Few studies in the past have indicated beneficial effect of homoeopathic treatment in HIV infectionx,xi. The Central Council for Research in Homoeopathy took up open pilot studies and followed a number of HIV +ve cases in different CDC stages and observed improvement both in terms of clinical manifestations and immunological statusxii, xiii, xiv, xv However, if a placebo controlled trial by homoeopathic medicines was shown to be influencing the CD4 +ve T-Lymphocytes in a beneficial manner, it would confirm the observations made in earlier studies.
Methods
A randomized double blind placebo controlled clinical trial of homoeopathic treatment in HIV infection was conducted by C C R H at Regional Research Institute for Homoeopathy, Mumbai, between 22nd July 1995 and 8th February 1997.
The trial was conducted by studying the subjects under two different strata. The first strata comprising of Asymptomatic HIV +ve cases defined by absence of clinical signs and symptoms that correspond to symptomatic HIV disease, viz. chronic recurrent fever, chronic recurrent diarrhoea, progressive neurasthenia/weakness, weight loss, generalized lymphadenopathy, minor or major opportunistic infections, etc. and reasonably good number of CD4+ve Lymphocytes that otherwise classifies the case under symptomatic HIV disease/AIDS. The second strata comprised of HIV+ve cases that belonged to CDC stage III, Persistent Generalized Lymphadenopathy (defined as enlargement of lymph nodes having a size of > 1cm in diameter, in more than two extra inguinal sites and of > three months duration), with good number of CD4+ve Lymphocytes.
50 cases were registered in each strata. The strata were dealt separately by two co-investigators in patient interview, counseling, history taking, remedy selection, follow-up review and periodical analysis. The randomization, blinding of the subjects and medicine dispensing was handled by a co-coordinator separately in absolute confidentiality. The randomization charts were prepared much before the start of the trial by randomly assigning placebo and verum codes to different registration numbers from 1 to 50. The cases were registered at different points of time during the study in the order they have reported to the institute's OPD, and was assigned a registration code as per the pre-coded randomization chart, thus randomly received either placebo or medicine.
Subjects between 18 and 50 years of age (males=71%) who have shown a positive antibody reaction to HIV1 or HIV2 or both confirmed by repeat Elisa and/or Western blot were inducted into the trial (99% HIV-1 infection). Subjects having past history of convulsions or cardiac disease and currently requiring medication for control, those having taken AZT in the immediately preceding four weeks and pregnant and lactating women formed the exclusion criteria and were not considered for the trial. Any subject with poor compliance and follow up less than three months, having taken any other therapy, who have developed any life threatening condition or adverse effects of the therapy which required active therapeutic intervention, and women who have conceived subsequent to registration were considered as lost to follow-up and were not considered for final analysis.
Every case was subjected to pre-entry investigations as below.
ELISA for HIV antibodies was performed by:
- ImmunoComb®, HIV 1and 2 Bispot, PBS Orgenics, France- A qualitative and differential detection of HIV-1 and HIV-2 IgG antibodies by Solid phase Enzyme Immunoassay (EIA). (Sensitivity: 100%; Specificity: 98.4%); Batch #: 950027 (Exp.27/08/1996) ; 960205 (Exp.: 25/01/1997)
- HIV-SPOT, Diagnostic Biotechnology, Singapore - A rapid qualitative test for the detection of HIV1 and 2 Antibodies. (Sensitivity: 98.8%; Specificity: 100%); Batch #: 5LD105 (Exp. 2/11/1996), 6HG104 (Exp. 19/7/1997).
- The institute did not posses facilities for Western Blot testing, but the result of a subject who undertook this test in any private laboratory, was taken into cognizance.
- Vacutainer® brand (Becton-Dickinson) Blood collection tubes were used throughout the study for collection of blood samples, sera, and whole blood, etc. The sera were preserved for possible future analysis.
- Routine Haematological investigations performed using QBCII Centrifugal Haematology System (Becton-Dickinson) and QBC Venous and Capillary Blood Tubes (Becton-Dickinson).
- ESR tested using Monovette® (Starstedt, Germany) brand of Blood Collection system.
- VDRL was tested using TrepoStat® - Reagen Protein Reaction (RPR) method.
- A Delayed hypersensitivity reaction was obtained by Montoux skin test which was performed with Tuberculin PPD Solution (10 TU), Span Diagnostics, India.
- Immunocytometry tests (CD4/CD8/CD3) were conducted with FACSCountTM System (Becton-Dickinson) and FACSCountTM system reagents and controls. The instrument employs direct two-colour immunoflorescence for enumerating absolute lymphocytes(CD3+ cells), and its subsets T-helper Lymphocytes (CD3+CD4+) and T-Suppressor Lymphocytes (CD3+CD8+). The system has a built in quality control which prevents erroneous results. The system is fully automated, run by a FACSCount system software and requires no user intervention while running the samples. The enumeration of absolute lymphocytes is direct method and does not require an external haematology instrument.
Reagent Lot Batch # 50012121 (Exp. 13/10/1995); 50042121 (Exp. 5/2/1996); 60012121 (Exp. 15/4/1997); Control Lot Batch #: 49071721(Exp.13/11/1995); 59011721 (Exp.5/2/1996) ; 59051721 (Exp. 20/6/1997). - Fluctuations are known to occur in total lymphocyte counts with diurnal cycles . This has been avoided by consistently collecting the haematological samples during the forenoon of the sample collection day from 9am to 11 am, throughout the study period. All samples were processed on the same day of collection to avoid sample instability which may affect the results.
- A routine ECG and chest X-ray taken to rule out any underlying cardiac or chest disease.
After initiation of the treatment, the routine haematological investigations were carried out during follow up, at an interval of one month and immunological and serological investigations at three months.
During every follow-up a pre-defined check list was used to assess the clinical status and response to the treatment. The observations were entered in the standard data recording proforma. The checklist was prepared so as to ensure that the co-investigator inquires into the subject's normal biological functioning like appetite, stool, urine and sleep and appearance of any clinical event attributable to HIV infection. Body weight was recorded on every visit using a standard personal weighing scale. The indicated homoeopathic remedy was prescribed during each follow-up by the co-investigator, which is either continuation of previous remedy in the same potency or higher scale.
