HIV AND LONGEVITY: CANNABIS AND LIFESTYLE
Carol de Launey (1997)

INTRODUCTION

HIV-positive gays may be more likely to use cannabis than HIV-negative gays (Wodak 1996). Jadresic et al (1993) reported a cohort study of HIV-positive and negative gays before, and 6 months after, diagnosis. The groups didn't differ in anxiety or depression levels before and after diagnosis, and they also didn't differ in use of drugs, with around one third of each group using cannabis regularly. However, in the Jadresic et al study, follow-up was six months after diagnosis, which may not be sufficient time for lifestyle changes to occur. Kaslow et al (1989) report results from a two year cohort study of gay American males; HIV-positive gays were more likely to use cannabis, and more likely to use it weekly or more often.

There are more HIV-positive gay males living on the north coast of NSW, then in any other rural area in Australia. The north coast is one the fastest growing regions in Australia. Older citizens, professional couples, artists, and young people are attracted by the climate and lifestyle of the region. There are alternative communities throughout the north coast, notably at Bellingen, Byron Bay, Main Arm, Mullumbimby, and in the Lismore area. The north coast is very popular with international and Australian tourists, offering rivers and beaches, fishing, rainforests, volcanic mountains, and a mild sub-tropical climate.

It is not surprising, then, that many Positive gays are attracted to the north coast. As Di Furniss, Manager of Northern Rivers AIDS Council said: "The Northern Rivers region has the largest positive population outside metropolitan areas in NSW; and this is a reflection of the massive drift from the city to the northern rivers. For Positives the region offers: a) access to complementary therapists, and b) a less stressful lifestyle." (pers comm, Lismore 10/3/97) NSW has the highest proportion of people living with AIDS in Australia, with around two thirds of all AIDS cases (Commonwealth of Australia, 1993). Therefore it is probable that northern NSW does have a large Positive population.

The north coast is well-known for cannabis as well. For example, it has double the arrest rate of the whole state for cannabis use, and more than three times the state rate of arrests for cannabis cultivation (NSW Bureau of Crime Statistics 1996). So the north coast seemed like a good place to look at why Positive gays use cannabis. The current study was designed to shed some light on the question: do Positive gays use cannabis because they are `party people', or are they using it medicinally? This is only a small pilot study, but the results have implications for people living with HIV/AIDS, and for others with serious illnesses.

I interviewed four long-term survivors of HIV/AIDS. They'd seroconverted 11 to 17 years ago. Their ages ranged from 26 to 45. Two of them have survived cancers twice. The other two participants have had no illnesses. Three of the respondents live alone; partners have died and friends have died. They are all long-term cannabis users, using for an average of around twenty years.

Before discussing the interviews, what basis is there for positive gays to use cannabis therapeutically? And what are the risks? Very briefly, Grinspoon and Bakalar (1993) in Marihuana, the Forbidden Medicine, suggest a range of medical uses, listed in descending order of empirical support: To alleviate the severe nausea and life-threatening loss of appetite associated with cancer chemotherapy; For glaucoma; Epilepsy; Multiple sclerosis; Paraplegia and quadriplegia, (paralysed patients preferred cannabis to prescription spasm medication, and male patients said it helped achieve and maintain an erection) (p 83); For AIDS; Chronic pain; Migraine; Pruritus; Menstrual cramps; Labour pain; Depression and other mood disorders; Insomnia; For antibacterial and anti-tumour properties.

AIDS patients used cannabis as an alternative and/or complement to conventional therapies, to improve their appetite, and for pleasure. Ron Mason, an AIDS survivor, couldn't tolerate AZT because he was anaemic, and other anti-viral drugs damaged his hepatitis-infected liver. Ron attributed his good health to smoking cannabis. "It makes me feel as if I am living with AIDS rather than just existing." (p 87) Stephen Jay Gould, a Professor at Harvard University, uses cannabis to alleviate the effects of cancer chemotherapy. He said: "... mental states can feed back upon the body through the immune system. In any case, I think everyone would grant an important role in the maintenance of spirit through adversity; when the mind gives up, the body too often follows. (And if cure is not the ultimate outcome, quality of remaining life becomes, if anything, even more important." (p 31)

Grinspoon and Bakalar noted that cannabis not only improved appetite but also enhanced the flavour of food and the pleasure of eating. (p92) The authors said that patients generally prefer to smoke street cannabis rather than use synthetic THC (pp 19, 39).

In terms of risk, these authors point out that the safety factor (the lethal dose divided by the effective dose) for alcohol is 4 - 10, Seconal 3 - 50, and for THC 40,000 (extrapolated from mice data); many chemotherapy drugs have a safety factor of 1.5 or less. (p 138) Risks include attention impairment, and doctors should warn patients not to drive for several hours after use. (p 139) Grinspoon and Bakalar also note a risk of anxiety, particularly with novice users, (p142) and that cannabis may exacerbate psychotic tendencies in some schizophrenic patients. (p 144)

Dependence "seems to afflict proportionately fewer marijuana smokers than users of alcohol, tobacco, heroin, cocaine, or even benzodiazepines". (p 147)

The Sydney Star Observer (24/10/96) a gay newspaper with a wide circulation, mentioned aspergillus, a common mould that grows in decaying vegetation including damp cannabis, as a risk for Positive smokers. It was suggested that cannabis be dried to 10% water content. The article also discussed Marinol (or Dronabinol), a synthetic cannabinoid approved in Australia for appetite stimulation in wasting diseases, warning that Marinol may affect driving and operation of machinery. However one person who took part in Marinol trials was quoted as saying: "I did not have any increase in appetite, and I slept so much that there was no nausea'." This person went back to having a daily (illegal) joint. Thus in the USA and in Australia, some patients prefer smoking `street' cannabis to synthetic cannabiniods.

In humans there are receptors for naturally-occurring THC-like chemicals in a number of sites, including brain, testes, spleen, tonsils, and cells involved in immune functions (such as peripheral blood leucocytes). (Bayewitch et al, 1996) However the actions of cannabinoids are complex, with THC for example, sometimes exerting stimulatory effects and sometimes inhibitive (Bouaboula M et al, 1993). The main problems with most studies at the cellular level are: a) that synthetic THC may be used, or only one cannabinoid; b) that cells (eg hamster ovary cells) may be clones, and are generally in vivo (a cluster of cells in a medium, rather than tissue in a living body); and c) that results tend to indicate effects rather than any substantive information; For example, Bayewitch et al (1996) found that THC produced different effects (stimulating and suppressing adenylyl cyclase activity in hamster cells) depending on whether the cell type was found in the brain or the immune system.

Some laboratory studies with animals have suggested that cannabis may damage the immune system, but human studies don't appear to support this. For example Kaslow et al, in the journal of the American Medical Association (1989) reported results from a large, multi-centre cohort study of close to 5,000 homosexual men in the USA. They reported that use of psychoactive substances (including cannabis) was not related to the development of AIDS, was not associated with manifestations of immunodeficiency, and did not increase the risk of seroconversion in positive participants.

There is surprisingly little in the literature about HIV-positive gays, their uses of cannabis, and its effects on their health and well-being.

RESULTS

Respondents were aged from 26 to 45 (mean age 37 years). The length of time they had known they were HIV-positive ranged from 11 to 12 years, but two respondents had good reason to believe they seroconverted 16 and 17 years ago.

Table 1 Profiles of respondents

All were also long term cannabis users (using for a average of 19 years), although some used cannabis only moderately. Engagement with conventional and alternative therapies also varied depending on the individual:

Table 2 Use of therapies

Some use conventional therapies, but all expressed a preference for alternative therapies (which can be expensive), or for none. All four stated quite firmly that they preferred to avoid conventional medicines if possible, but alternative therapies apparently did not replace or complement medical treatments for three of the four long term survivors.

All four respondents were also long term cannabis users, although patterns of use varied: three were using cannabis moderately, while Steve has been a heavy user of cannabis for the last twenty years.

Table 3 Use of cannabis

Two used cannabis to help them sleep, two had no problems sleeping. All spoke of the benefits to appetite and attitude towards food. Respondents had used cannabis to treat physical problems such as nausea, loss of appetite, depression, loss of libido, insomnia, and stress. Generally speaking, they did not think of cannabis as medicinal, but as a part of their lifestyle, enhancing their social and personal experiences.

All four respondents mentioned using cannabis for relaxation. Relaxation was the most popular reason for cannabis use in a recent study involving 268 long term cannabis users, also in northern NSW (Didcock et al 1997). In the Didcock et al study, 61% said they used cannabis for relaxation or relief of tension, while the second most popular use, enjoyment, was only mentioned by 27% of the long-term users. (p34)

Following are brief cameos of the respondents:

Bob is 45 years old. He was diagnosed HIV-positive 12 years ago, but believes he seroconverted 17 years ago. He drove cabs in Sydney for 16 years. He said: "Then my partner of eight years died, and I wasn't particularly well, that's when I moved up here." He did not believe that cannabis had adversely affected his immune system: "Not at all. No, I think I'm one of the longest surviving full-blown AIDS cases in [Australia] now, and I've been diagnosed with Karposi's sarcoma 2 years ago, and I haven't had another lesion since." Bob is using AZT and 3TC.

"I've smoked cannabis since I was about 19 on a very casual basis; there's been years when I've gone without, totally. In '811 had testicular cancer; I'd have a smoke of cannabis immediately after the therapy.. Over the period of 6 weeks the doctors commented, they were astounded that I'd only lost a stone".

He mentioned a number of medical uses for cannabis: "Nausea most definitely. I was on anti-nausea pills, but the cannabis just wiped out the nausea and also gave me an appetite. Also for mild pain." Bob mentioned that cannabis helped his sexuality: "when I lost my libido pretty much altogether, for different reasons: chemical use, depression, being put down by a schizophrenic partner, and cannabis is the one thing that does help trigger off a sex drive".

Cannabis helps Bob's moods, and insomnia: "I find I can channel my head better if I'm feeling a bit depressed. Sometimes I might wake up (I live alone), I have my moments of depression and it certainly can help get my head out of that." "I try to avoid sleeping tablets because they can jolt my mood the next day, particularly Rhohypnol,"... but cannabis "enables me to relax, shift the head space to a more sleep-conducive mood, and I don't have the side-effects the next day." "A lot of HIV drugs are very toxic, so I do avoid them as much as possible for that reason. .. I just wish they'd alter the laws, at least allow us to grow 3 plants, or 5 plants, for our own personal use, like Adelaide and Canberra, because there is stresses attached to growing illegally"

Troy is 26 years old. He was diagnosed HIV-positive 11 years ago. "I thought I wasn't going to see my 21st birthday out"' "But I did, and it was just like `why hadn't I died?' So I had to look at other ways -- I've only probably got 7 years, I don't really want to live much older -- I don't even really want a cure sometimes. I'm used to my life now. I was never on a path before."

Troy was a prostitute and involved in pornographic films during his teens: "The first real drug I was addicted to was heroin. That was when I was 13. I was a runaway with an 18 year old boyfriend; he took me to Sydney and we got caught up in a pornographic racket, and I was put in a room with these guys for 3 days, and then the police busted us... I got addicted to heroin then':

Troy did not use conventional therapies: "I don't really like taking medication from doctors, you see I don't know what goes in them, and I find that they heal you for a short period but the end result is it comes back. So I'd rather weather it, and try to build my immune system up". "[I use] positive thinking. I try to stay away from fats, I eat a lot more vegetables than I did." He has cut back on alcohol; he uses heroin when he's particularly under stress: "It used to be three, four times a year, but in the last year only once... The last time was when I actually moved up here, and that was family; they put me under stress". He would like to use alternative therapies and vitamins, but can't afford to. He moved to the north coast for the alternative lifestyle, fresh air, climate, and because "You can grow more pot".

"Cannabis was my last drug, and it's my saviour. I can get all the effects of any other drug, as long as its good quality. The laws are so wrong." "If I could I'd smoke 6 cones a day, but at the moment I'm probably having about 3 cones of leaf a day, only because leaf dregs me out, I'd rather smoke heads because I've still got the energy, it gives me more energy". "I'11 eat better, I'll actually cook things, and take time to look at what I'm eating, better than when I'm straight, I'll just slap it together." As well "it can slow me down. I go too fast, I think too fast, so it slows me down.".

Peter is 42 years old. He was diagnosed as HIV-positive 11 years ago, but believes he seroconverted 16 years ago. He was involved in restaurants in Sydney, as well as social work, and research. Peter had cancer in 1992, with chemotherapy and radiation therapy: "I never had any side effects, not headaches, nausea, vomiting .. every night someone would come into hospital and take me downstairs and give me a joint.."

"I'd had no cancer for four and a half years completely, and then in the beginning of [1996] I had dementia, HIV-related." "I couldn't walk for three months because I had no sense of balance. I couldn't talk (legibly).. I couldn't read. I went onto a combination of drugs, including AZT.... I'd been stalling and stalling, but I had no choice. So for about 6 months I was completely stuffed, physically and mentally." During this period Peter found that he was very sensitive to cannabis, and generally avoided it unless he was "safe in bed".

Throughout his illness he was taking herbal remedies: "Echinacea, St Mary's thistle, St John's Wort, and Golden Seal, .. and the dope then became far more a therapeutic thing.." "And then I left the wheelchair and walked unaided. I made it to the Tropical Fruits' (a north coast gay group's) New Year's Eve party, with just joints and rain water, and I was fine." "In both cases I was given a few months to live. But as you can see, here I am, enjoying life." Peter moved to the north coast for its spiritual energy, alternative therapies, and to live the way he wanted to live. As well "I left the city because the chemical levels there were just ridiculous. Things I'd like to blame my cancer for in the first place."

He didn't start smoking tobacco or cannabis until he was 28, and still doesn't like smoking. He would prefer an unlimited amount of cannabis leaf, to make cookies. He said he used to be a heavy user of alcohol, "You could almost have called me an alcoholic." He has given up alcohol and tobacco recently. When asked if cannabis harmed his immune system he said: "No. I think I'm perfect proof of that. I think it's exactly the opposite, I think it's increased it."

Steve is 34 years old. He was diagnosed HIV-positive 11 years ago. He did various things in Sydney, including work for a government department. He has used cannabis since first form in High School (age 12). Cannabis plays: "A pretty big role in my life, I smoke it every day, and I believe that it reduces stress in my life." "I've been lucky in the sense that I've never been busted by the cops, but it is a concern, yes, definitely." The only damaging effect from 22 years of heavy use is "It gives me a hacking cough.. bongitis". His use of cannabis didn't increase or decrease following his diagnosis. He smokes constantly, an estimated 30-plus cones per day. He said: "Why should people's in tolerances affect my life. All it's doing is making my life a little bit more enjoyable, I'm not hurting anyone else. I'm certainly not going to stop."

Steve has not been ill at all, and does not use conventional medicine: ".. most people I've known that had HIV and who've passed away have actually been on some treatment, so that to me is a pretty clear indication to be wary." "I don't consider I live with AIDS. It's just like another little label people put on me.... I don't believe everything I hear for a start.. not with HIV"." "There's a lot of misinformation that's given to people, and there's not a lot of hope given to people. To take away people's hope, you're already starting the fight with a handicap."

Steve has cut back on alcohol, and only uses tobacco with cannabis now. He doesn't use alternative therapies because he hasn't been sick. He says he gets a cold once a year. He mostly eats fruit and bread, and lives in a tranquil environment in a rural area.

The results of this pilot study present a number of important research questions, as the following Discussion suggests.

DISCUSSION

Why do positive gays use cannabis? The results from this research suggest that cannabis is an integral part of the respondents' lifestyles. Given that cannabis is reasonably accessible in the NSW north coast, the amount used reflects individual preferences. The participants were all long term cannabis users, and further research might investigate whether long term cannabis smokers who are HIV-positive differ from other long term cannabis smokers. I suspect that they don't. For example, all four participants said that they used cannabis to relax. Relaxation was the most popular reason for cannabis use in the study of long-term cannabis smokers in northern NSW (Didcock et al 1997). Relaxation and stress reduction are particularly important for Positive gays to maintain an acceptable quality of life.

From the medical perspective, many seriously ill patients experience conventional treatments as powerful and dangerous. Cannabis offers many a "benign alternative". (Grinspoon and Bakalar, 1993) For at least some people living with HIV/AIDS cannabis doesn't appear to impair immune function or longevity... indeed cannabis may be beneficial. An obvious area for research would be to compare longevity between HIV-positive long-term cannabis users and non-users.

Certainly the medical uses of cannabis should be further researched: a) There needs to be clarification of the interactions between active cannabinoids; b) Further investigation of why people apparently prefer to smoke an illegal joint than to use legal synthetic cannabinoids; and c) An investigation of the beneficial effects of cannabis for the illnesses listed by Grinspoon and Bakalar (1993). If the claims made in their work are valid, cannabis has a legitimate role in the treatment of a remarkable range of serious illnesses.

But perhaps the most important of all, this research raises the question: How does cannabis influence survival and quality of life for people living with HIV/AIDS? All four respondents wanted to avoid conventional treatments; all four used meditation/ positive thinking/ relaxation; all four had reduced their use of alcohol, and improved their diet (two are now vegetarians); all four are aware of the need to find ways to minimise stress; and all four use cannabis to support those changes.

Cannabis may be an important part of a lifestyle `package' supporting the health of some people with serious illnesses in the following ways: