Cannabis and HIV - Current Research and Clinical Trials
Last, but certainly not least, in our Pride blog series we take a look at cannabis and HIV through this pharmacist's favorite lens - prescription products, current research, and the clinical trial pipeline.
As we discussed in our first post of the series, the activists behind many early medical marijuana movements specifically supported the plant's use for patients living with HIV and AIDS. Cannabis has been reported to help HIV patients cope with neuropathy (nerve pain), anxiety, depression, nausea, vomiting, loss of appetite, and cachexia (tissue injury and destruction). Some studies have even shown that easing these symptoms with cannabis help patients be more adherent to their anti-retroviral medications. Let's start with the prescription drugs first and then dive into that statement further.
Prescription Cannabinoid Products
While the first state medical cannabis programs wouldn't start until the mid 1990s, Marinol, a prescription-only synthetic THC, was approved by the FDA in 1985. The original approval for Marinol was limited to nausea and vomiting in cancer patients, but by 1992 the FDA approved the additional indication of 'anorexia associated with weight loss in patients with AIDS'(1).
To put that indication in perspective, for people with HIV loss of as little as 5% of their body weight can be life threatening (2). The initial studies of Marinol in HIV patients were small (139 patients) and short (6 weeks), but did show improvements in appetite, body weight, mood, and nausea compared to placebo.
Despite positive results, Marinol did not gain significant use for HIV patients, likely for a combination of reasons. The product is an oral capsule, making it difficult to fine-tune dosing and take 'on-demand'. While it's available in generic forms today, the original brand name prescription was expensive and may not have been covered by insurance. Even today the brand name product costs between $700 - $2500 per month depending on dose.
Medical Cannabis Programs and HIV Research
While the pharmaceutical approach to cannabis for HIV patients had a bit of a false start, the popularity of 'traditional' cannabis products among HIV patients is much more prevalent. Estimates vary, but some larger surveys estimate use of cannabis in as many as 1 in 3 HIV patients (3).
In Oregon, the Oregon Medical Marijuana Program (OMMP) includes HIV as a qualifying condition for the cardholder program, and reports 1.1% of current enrollees are HIV patients (4). That number, of course, only represents enrolled cardholders, and any adult over 21 can access cannabis in the state.
In addition to helping combat the anxiety and depression that accompany an HIV diagnosis, cannabis has been shown to alleviate symptoms of nausea, vomiting, weight loss, and nerve pain. It is particularly important to understand symptom management for these patients, as these symptoms can be caused both by the disease and by long-term treatment with anti-retroviral therapy.
Patient surveys have found cannabis very effective for nerve pain in HIV, with one survey reporting that 94% of users found improvement with cannabis use (5). The same survey also found that over half of users suffering from loss of appetite and weight loss reported improvement with cannabis.
Adherence to anti-retroviral therapy is critical to suppressing the virus and preventing its transmission, but a multitude of social, economic, and health factors can prevent consistent adherence to medication for many people. Side effects like nausea and vomiting can be contributing factors to non-adherence for any medication, including anti-retrovirals. Interestingly, a survey from the Journal of Acquired Immune Deficiency Syndrome found that patients using cannabis to alleviate nausea and vomiting were able to be more adherent to their medications than nonusers (6).
Like any drug, cannabis does not come without side effects and must still be used with caution. Cognitive impairment and memory deficits occur in people living with HIV, and can also occur with cannabis use. A recent article reviewed over 40 studies on this effect, and the results were inconclusive as to whether or not cannabis exacerbated cognitive impairment in HIV patients (7). This continues to be a hot topic of study in clinical trials as well.
A resounding theme from the authors of every study we just mentioned is that more research is needed to draw conclusions about how cannabis interacts with HIV, and the long term risks and benefits of its use now that people with HIV are living longer than ever before.
The good news is our favorite site, clinicaltrials.gov, shows activity in this area is far from slowing down. For example:
Cannabis is also being compared head-to-head with its prescription counterpart Marinol in a study by Wayne State University.
The Albert Einstein College of Medicine is running a trial examining the relationship between cannabis use, cognition, and mobility in HIV and non-HIV women.
This activity is encouraging, but when it comes to research we can't get enough! I am hopeful that continued study in this area will lead to more insights on how persons with HIV can live their best, healthiest lives.
(1) Package insert. Marinol (dronabinol capsule). Abbvie, Inc. Updated October 18, 2019.
(6) Marijuana Use and Its Association with Adherence to Anti-Retroviral Therapy Among HIV-Infected Persons with Moderate to Severe Nausea. de Jong et al. Journal of Acquired Immune Deficiency Syndrome. Vol 38(1). January 2005.