Complementary and alternative medicine use in British Columbia—A survey of HIV positive people on antiretroviral therapy

Complementary and alternative medicine in HIV care: frequency of consumption, risks and interactions with antiretroviral therapy

OBJECTIVES

People living with HIV (PLWH) are common users of complementary and alternative medicine (CAM). The main objective of this study was to study the frequency and patterns of CAM natural products use in a large cohort of PLWH and to identify potential drug-drug interactions (DDIs) and the impact on their antiretroviral treatment (ART) adherence and efficacy.

METHODS

This was a cross-sectional multicenter survey including 420 PLWH from different Spanish hospitals. Participants completed a face-to-face questionnaire on CAM consumption and different sociodemographic and clinical data were collected. DDIs between CAM and ART were identified and classified according to the Liverpool University Database and patient factors related to CAM consumption were assessed.

RESULTS

420 participants were included (82.6% male, mean age 47 years); 209 patients (49.8%) were taking at least one CAM. The most consumed CAM were green, black and red tea (n=146, 25.4%), ginger (n=26, 4.5%), fish oil (n=25, 4.4%) and cannabis (n=24, 4.2%). An ART based on integrase inhibitors was the only factor independently associated with CAM consumption (OR 1.54, 95% CI 1.04 to 2.26). 50 potential CAM-ART interactions in 43 (20.6%) patients taking CAM were identified, being clinically significant in 80% of the cases. CAM products most frequently involved with a potential significant DDI were supplements containing divalent cations (n=11) and garlic (n=7). No differences in ART efficacy and adherence were observed between patients with and without CAM consumption.

CONCLUSIONS

Almost 50% of patients were taking at least one CAM product and its use was associated with an integrase inhibitor based ART. One out of every six patients was at risk of presenting with an interaction between a CAM and their ART, confirming the need to review continuously the use of CAM as part of the medication review process.

Complementary and alternative medicine use among people living with HIV in Shiraz, Southern Iran

Background

Living with HIV requires lifelong care to support engagement with and adherence to antiretroviral therapy. The Middle East and North Africa region provides access to ART, but research is lacking on the lived-experiences of people living with HIV. Globally, complementary and alternative medicine (CAM) is increasingly used by patients who need support alongside receiving medical treatment for chronic conditions. This study aims to examine the frequency and reasons behind the use of CAM, as well as identify its associated factors among people living with HIV in Shiraz, Iran.

Methods

In this cross-sectional study, a total of 320 patients (aged 18-70 years) with a confirmed diagnosis of HIV residing in Fars province and diagnosed between 1999 and 2019 were recruited randomly through their clinical record numbers from five HIV treatment centers. They were surveyed on their quality of life and CAM use via the Short-Form Health Survey questionnaire (SF-36) and a semi-structured survey of "CAM use." The data analysis for this study involved the use of Chi-squared test, independent t-test, and multiple logistic regression model.

Results

Of 287 patients, 89.22% reported using CAM in the previous year. CAM use was more prevalent among those with a family history of CAM use (94.3% vs. 81.8%, p = 0.023). Frequent reasons for using CAM were reported to be sexual dysfunction (32.4%), depression (28.3%), thirstiness (23.3%), and nausea (17.5%). Quality of life, as measured via the SF-36 questionnaire in all its 8 sub-domains, did not differ among those who used CAM versus those who did not (61.5 ± 27.6 vs. 58.1 ± 30.9, p = 0.626).

Conclusion

CAM was used among a majority of people living with HIV in Shiraz, Iran. People who used CAM appeared to experience a similar quality of life relative to those who did not use CAM. Future studies on the modalities of engagement with CAM can improve patient-physician shared decision-making and increase lifelong care options for people living with HIV.

Adverse events in meditation practices and meditation-based therapies: a systematic review

OBJECTIVE

Meditation techniques are widely used as therapy and wellbeing practices, but there are growing concerns about its potential for harm. The aim of the present study is to systematically review meditation adverse events (MAEs), investigating its major clinical categories and its prevalence.

METHOD

We searched PubMed, PsycINFO, Scopus, Embase and AMED up to October 2019. Eligible studies included original reports of meditation practices (excluding related physical practices such as Yoga postures) with adult samples across experimental, observational and case studies. We identified a total of 6742 citations, 83 of which met the inclusion criteria for MAEs with a total of 6703 participants who undertook meditation practice.

RESULTS

Of the 83 studies analysed, 55 (65%) included reports of at least one type of MAE. The total prevalence of adverse events was 8.3% (95% CI 0.05-0.12), though this varied considerably across types of studies - 3.7% (95% CI 0.02-0.05) for experimental and 33.2% (95% CI 0.25-0.41) for observational studies. The most common AEs were anxiety (33%, 18), depression (27%, 15) and cognitive anomalies (25%, 14); gastrointestinal problems and suicidal behaviours (both 11%, 6) were the least frequent.

CONCLUSION

We found that the occurrence of AEs during or after meditation practices is not uncommon, and may occur in individuals with no previous history of mental health problems. These results are relevant both for practitioners and clinicians, and contribute to a balanced perspective of meditation as a practice that may lead to both positive and negative outcomes.

Interactions between antiretroviral therapy and complementary and alternative medicine: a narrative review

BACKGROUND

The use of complementary and alternative medicine including herbal medicine (phytotherapy), vitamins, minerals and food supplements is frequent among people living with HIV/AIDS (PLWHAs) who take antiretroviral (ARV) drugs, but is often not known by their prescribing physicians. Some drug-supplement combinations may result in clinically meaningful interactions.

AIMS

In this literature review, we aimed to investigate the evidence for complementary and alternative medicine interactions with ARVs.

SOURCES

A bibliographic search of all in vitro, human studies and case reports of the PubMed database was performed to assess the risk of interactions between complementary and alternative self-medication products and ARVs. The 'HIV drug interaction' (https://www.hiv-druginteractions.org) and 'Natural medicines comprehensive database' (https://naturalmedicines.therapeuticresearch.com) interaction checkers were also analysed.

CONTENT

St John's wort, some forms of garlic, grapefruit and red rice yeast are known to have significant interaction and thus should not be co-administered, or should be used with caution with certain ARV classes. Data on other plant-based supplements come from in vitro studies or very small size in vivo studies and are thus insufficient to conclude the real in vivo impact in case of concomitant administration with ARVs. Some polyvalent minerals such as calcium, magnesium, and iron salts can reduce the absorption of integrase inhibitors by chelation. Potential interactions with vitamin C and quercetin with some ARVs should be noted and efficacy and tolerance of the treatment should be monitored.

IMPLICATIONS

This review shows the importance of screening all PLWHAs for complementary and alternative medicine use to prevent treatment failure or adverse effects related to an interaction with ARVs. Further human studies are warranted to describe the clinical significance of in vitro interactions between numerous complementary and alternative medicine and ARVs.

Role of medicinal plants in HIV/AIDS therapy

Human immunodeficiency virus (HIV) causes the potentially life-threatening and chronic disease called acquired immune deficiency syndrome (AIDS). The main target of this viral disease is to suppress the immune system and make the body unresponsive to external stimuli. According to global health observatory data since epidemic, more than 78 million people were affected by HIV and 39 million people died globally. Until 2017, 36.5 million people were living with HIV. An estimated 0.8% (0.6%-0.9%) of adults aged 15-49 years worldwide is living with HIV. The World Health Organization (WHO) reported that the African region remains most severely affected, with nearly one in every 25 adults (4.1%) living with HIV and accounting for nearly two-thirds of the people living with HIV worldwide. WHO reported that globally only 21.7 million (19.1 million-22.6 million) people have had access to antiretroviral therapy up to 2017. Currently, antiretroviral therapy (ART) is available for the control of HIV but has serious associated side effects such as lipodystrophy. Because of the limitations, associated with ART, researchers throughout the world are trying to explore and develop more reliable and safe drugs from natural resources to manage HIV infection. A wide range of medicinal plants have been studied and have reported significant potential against HIV. Plants like Rheum palmatum L., Rheum officinale, Trigonostem axyphophylloides, Vatica astrotricha, Vernonia amygdalina, Hypoxias pelargonium, Sidoides hemerocallidea and Sutherlandia frutescens etc. have high efficacy to cure HIV. The exact mechanism of action is still not known but various phytoconstituents isolated from medicinal plants such as alkaloids, flavonoids, polyphenols, terpenoids, tannins, proteins and coumarins have the potential to interrupt the life cycle of HIV as well as act as immunomodulators to enhance the immune system of infected patients with no well reported side effects. It could be concluded that medicinal plants have potential for the management of HIV/AIDS but more studies are needed to reveal rigorous efficacy and safety concerns by conducting clinical trials at vast level to explore therapeutic impact of medicinal plants.

Prevalence and factors associated with the use of traditional medicines among human immunodeficiency virus and acquired immunodeficiency syndrome patients in Sokoto, Nigeria

Background

In resource-scarce settings like Nigeria, access to conventional drugs and antiretroviral therapy (ART) is highly limited, hence the resort to use of traditional herbal medicine by a significant number of people living with human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) (PLWHAs). Traditional medicine (TM) continues to provide health coverage for most of the people in developing countries, and it is equally becoming increasingly popular in western countries.

Aim

This study aims to present the status and use of TM and determine the factors associated with its use among patients with HIV/AIDS on highly active ART in a tertiary health institution in Sokoto, Northwest Nigeria.

Methodology

This was a descriptive, cross-sectional study involving HIV/AIDS patients attending antiretroviral treatment center of the Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Nigeria. The study population comprised PLWHAs attending the ART clinic of the hospital (UDUTH). A total of 271 respondents were recruited into the study and administered a set of pretested structured questionnaire. Ethical approval for this study was obtained from the ethical committee of the teaching hospital.

Results

Only 11 (4.2%) of the respondents had used TM before, of whom 9 (5%) were females and 2 (2.7%) were males with P = 0.399. Only one of the respondents had side effects following the use of TM, and the most common reason for the use of TM was as a result of too much weight loss.

Conclusion

Although the use of TM among the study participants in Sokoto was low, there is need to educate PLWHAs about the possible risks of interactions following the concurrent use of TM and ART.

Benefits and extent of CAM use among persons living with HIV attending an antiretroviral therapy clinic in Warri, Nigeria

PURPOSE

The objective of this study was to assess the use of complementary and alternative medicine (CAM) therapies among patients on anti-retroviral therapies as well as the possible reasons for their use.

METHOD

This cross-sectional survey was conducted with the aid of an interviewer-administered questionnaire on HIV-positive patients attending the antiretroviral therapy clinic (Heart-to-Heart centre) of the Central Hospital, Warri, Nigeria. Patients who were 18 years and over were included after a brief introductory talk on the nature of the study. Participation was voluntary and anonymous.

KEY FINDINGS

One hundred and thirty-five patients participated in the study, 50 (37%) patients used one form of CAM. Of the patients who used CAM, 17 (34.0%) patients used herbal medicines; eight (16.0%) patients used spirituality, and 25 (50.0%) nutritional supplements. The CAM methods used by the patients were for the treatment of discomforts related to antiretroviral therapy (ART), eight (16.0%); the treatment of medical conditions not related to ART, 13 (26.0%), boosting the immune system, 25 (50%) among other reasons. The study revealed that a higher percentage of HIV-infected patients (76.0%) did not disclose their use of CAM to their healthcare providers.

CONCLUSION

Although highly active antiretroviral therapy has proved to be very effective in the management of patients with HIV, CAMs are still much in use.

Pattern of Traditional Medicine Utilization among HIV/AIDS Patients on Antiretroviral Therapy at a University Hospital in Northwestern Ethiopia: A Cross-Sectional Study

The objective of this study was to assess traditional, complementary, and alternative medicine (TCAM) utilization pattern among HIV/AIDS patients on antiretroviral therapy at University of Gondar Comprehensive Specialized Hospital. Materials and Methods. Data on sociodemographic profile and clinical and TCAM utilization were collected using a structured, pretested questionnaire from April 01 to May 28, 2014, through interviews with patients. Data on CD4 count, HIV stage, and ART regimen were collected from patient records. Analysis was conducted descriptively using SPSS version 20. Results. Of the 300 participants, 43.7% reported using TCAM, with the largest proportion of them from religious institutions (churches/mosques) (41.22%), followed by home prepared (32.82%) and traditional healers (16.03%). The leading forms of TCAM used were spiritual and herbal therapies constituting 56.49% and 36.64% of the patients, respectively. The most frequently used herbal products included Nigella sativa (22.92%) and Moringa oleifera (20.83%). Most of the patients (73.30%) using TCAM reported improvement in their conditions. Conclusions. TCAM utilization among HIV/AIDS patients on ART was common and different sources and types were used alongside ART, with improvement reported by most. Further research is needed to identify CAM therapies which may be used as adjunct treatments among these patients.

Prevalence and Characteristics of CAM Use among People Living with HIV and AIDS in Lebanon: Implications for Patient Care

This study aimed to assess the prevalence and determinants of Complementary and Alternative Medicine (CAM) use among People Living with HIV and AIDS (PLWHA) in Lebanon and to identify related issues that may affect patient care. A cross-sectional survey design was used to interview 116 PLWHA in Beirut. The questionnaire addressed sociodemographic and disease characteristics as well as CAM use. The main outcome of the study was CAM use since diagnosis. Data analysis included descriptive statistics and logistic regression analyses. Overall, 46.6% of participants reported using one or more CAM therapies, with herbs and herbal products being the most commonly used (63%). A higher education level was associated with a 3-fold increase in the odds of CAM use. Among users, 20% used CAM as alternative to conventional treatment, 48% were not aware of CAM-drug interactions, 89% relied on nonhealth care sources for their choice of CAM, and 44% did not disclose CAM use to their physician. CAM use is prevalent among Lebanese PLWHA. Findings of this study highlighted the need to educate health care practitioners to have an open communication and a patient-centered approach discussing CAM use during routine care and to enhance awareness of PLWHA on safe use of CAM.

Possible Drug-Herb Interaction between Herbal Supplement Containing Horsetail ( Equisetum arvense) and Antiretroviral Drugs

The use of alternative medicines, including herbs, is common among HIV-positive patients, even in those on antiretroviral treatment. Equisetum arvense, known as "horsetail," is mainly used for its diuretic properties. There are limited data about the pharmacological properties of this compound and the potential drug-herb interactions. The authors report 2 cases in which a possible drug-herb interaction may have led to virological breakthrough in patients who were maintained on the same regimen for many years, including lamivudine (3TC)/zidovudine (ZDV)/efavirenz (EFV) and emtricitabine (FTC)/tenofovir (TDF)/EFV, respectively. Therefore, a drug-herb interaction may be expected when these agents are taken concurrently. Until additional data are available, the authors advise clinicians to avoid this combination when possible.

Gene Expression Profiles of HIV/AIDS Patients with Qi-Yin Deficiency and Dampness-Heat Retention

Objectives: Traditional Chinese Medicine (TCM) applied in the clinic as a complementary and alternative therapy has helped improve immunity and reduce side effects and symptomatic treatment in patients with HIV/AIDS. However, the mechanisms of TCM syndromes are not clear. Transcriptomics enables the study of such TCM syndromes.

Design: This study compared the messenger RNA (mRNA) expressions of healthy persons and patients with HIV/AIDS who had two common TCM syndromes, qi-yin deficiency and dampness-heat retention, to find the difference in HIV/AIDS with TCM syndromes.

Results: Comparison with healthy persons identified 113 mRNAs—41 enhanced and 72 decreased—in the qi-yin deficiency group. Additionally, 76 mRNAs were found in the dampness-heat retention group: 14 increased and 62 decreased. Functional genetic analysis of the mRNAs indicated that two TCM syndromes were correlated with cell apoptosis, immunoinflammatory responses, and lymphocyte activation. Differentially expressed mRNAs in the qi-yin deficiency group were obviously associated with cellular activity, communication, protein localization, cellular ion homeostasis, and regulation of cell motion, whereas mRNAs in the dampness-heat retention group were associated with sequence-specific DNA binding, cellular response to stress, and hemopoietic or lymphoid organ development.

Conclusions: These results suggest that the formation of different TCM syndromes in patients with HIV/AIDS were founded on biological transcriptomics, which reveal mechanisms of the formation of these syndromes in HIV/AIDS. Differentially expressed mRNAs in two TCM syndrome groups tended to normalize after TCM intervention, which indicates that TCM might remit symptoms by changing genetic expression.

A pilot feasibility and acceptability study of yoga/meditation on the quality of life and markers of stress in persons living with HIV who also use crack cocaine

BACKGROUND

Persons living with HIV (PLWH) who also use crack cocaine may have stressful, chaotic lives and typically do not engage in standard medical care that addresses a multitude of extenuating life circumstances. Yoga/meditation (YM) improves quality of life (QOL) and biomarkers of stress, but the effect of this intervention is almost unknown in PLWH, particularly those who use crack cocaine.

OBJECTIVES

This pilot study sought to compare the feasibility and acceptability of 60-minute, twice-per-week sessions of YM for 2 months with those of no-contact control and to evaluate the effects of the intervention on QOL (according to the Short Form-36, Perceived Stress Scale [PSS], and Impact of Events Scale [IES]) and salivary cortisol and dehydroepiandrosterone sulfate (DHEA-S) among PLWH who use crack cocaine.

DESIGN

Participants were randomly assigned to YM or no-contact control and were assessed at baseline, 2 months after the intervention, and 4 months' follow-up.

RESULTS

The YM program was acceptable and feasible, with high overall attendance (89%) and individual participation in yoga sessions (83%). YM participants showed modest improvements on QOL. The PSS total score and the IES intrusion score improved significantly 2 months after the intervention, but cortisol and DHEA-S did not change.

CONCLUSIONS

This pilot study showed a high level of feasibility and acceptability and modest effects on measures of QOL among PLWH who use crack cocaine. The results suggest utility of YM as a simple, safe, and inexpensive format to improve QOL in a population that has many medical difficulties and extenuating stressors.

Polypharmacy, drug-drug interactions, and potentially inappropriate medications in older adults with human immunodeficiency virus infection

OBJECTIVES

To describe the frequency of medication-related problems in older adults with human immunodeficiency virus (HIV) infection.

DESIGN

Retrospective chart review.

SETTING

Community.

PARTICIPANTS

HIV-positive individuals aged 60 and older and age- and sex-matched HIV-negative individuals.

MEASUREMENTS

Total number of medications, potentially inappropriate medications (PIMs) according to the modified Beers Criteria, anticholinergic drug burden according to the Anticholinergic Risk Scale (ARS), and drug-drug interactions using the Lexi-Interact online drug interactions database.

RESULTS

Of 89 HIV-positive participants, most were Caucasian (91%) and male (94%), with a median age of 64 (range 60-82). Common comorbidities included hyperlipidemia, hypertension, and depression. Participants were taking a median of 13 medications (range 2-38), of which only a median of four were antiretrovirals. At least one PIM was prescribed in 46 participants (52%). Sixty-two (70%) participants had at least one Category D (consider therapy modification) drug-drug interaction, and 10 (11%) had a Category X (avoid combination) interaction. One-third of these interactions were between two nonantiretroviral medications. Fifteen participants (17%) had an ARS score of 3 or greater. In contrast, HIV-negative participants were taking a median of six medications, 29% had at least one PIM, and 4% had an ARS score of 3 or greater (P < .05 for each comparison, except P = .07 for anticholinergic burden).

CONCLUSION

HIV-positive older adults have a high frequency of medication-related problems, of which a large portion is due to medications used to treat comorbid diseases. These medication issues were substantially higher than HIV-negative participants. Attention to the principles of geriatric prescribing is needed as this population ages in order to minimize complications from multiple medication use.

Use of complementary medicines among HIV-infected children in Lagos, Nigeria

BACKGROUND

Complementary medicine (CM) use is common among children with chronic illnesses such as epilepsy and asthma. Lack of data on the profile of CM use among children with human immunodeficiency virus (HIV) infection necessitated this study.

METHODS

Parents or caregivers of HIV-infected children attending the paediatric HIV-clinic in a teaching hospital in Lagos, Nigeria, were randomly selected and interviewed with a semi-structured (open- and close-ended) questionnaire. Clinical details of the patients were extracted from their case files.

RESULTS

A total of 187 parents/caregivers were interviewed. Most of the parents/caregivers (181; 96.8%) have used CMs for their children. Mind-body interventions (181; 36.6%) and biological products (179; 36.2%) were frequently used. Relatives, friends and neighbours influenced CM use in 37.1% of the children. CMs were used mostly to treat weight loss (79; 43.7%), cold (40; 22.1%), and fever (39; 21.6%).

CONCLUSION

CM use is common among HIV-infected children in Lagos.

Complementary therapy provision in a London community clinic for people living with HIV/AIDS: a case study

AIM

To present a case study of complementary therapy (CT) provision within a community HIV multi-agency service in a Northwest London deprived area.

METHODS

Anonymised routine service data were provided for all clients (n = 1030) August 2010 to October 2012. Face-to-face meetings provided feedback from volunteers (9 CT-using clients and 9 staff).

RESULTS

CT-users were demographically similar to other clients. Support for coping with HIV was commonly cited as a service benefit. Over 26 months 1416 CT sessions were provided; 875 aromatherapy and 471 shiatsu. CT-users' most common concerns were pain (48%), stress (15%) and insomnia (13%), few had heard of or used CT before. Perceived mental and emotional benefits included relaxation,stress relief, relieving musculoskeletal aches and pains. Service challenges included time and funding, though staff felt CT may be cost-effective.

CONCLUSIONS

CT may provide important support and treatment options for HIV disease, but cost effectiveness requires further evaluation.

A review of the use of complementary and alternative medicine and HIV: issues for patient care

HIV/AIDS is a chronic illness, with a range of physical symptoms and psychosocial issues. The complex health and social issues associated with living with HIV mean that people living with HIV/AIDS (PLWHA) have historically often turned to complementary and alternative medicine (CAM). This article provides an overview of the literature on HIV and CAM. Databases were searched using keywords for CAM and HIV from inception to December 2012. Articles in English and in Western countries were included; letters, commentaries, news articles, articles on specific therapies and basic science studies were excluded. Of the 282 articles identified, 94 were included. Over half reported prevalence and determinants of CAM use. Lifetime use of CAM by PLWHA ranged from 30% to 90%, with national studies suggesting CAM is used by around 55% of PLWHA, practitioner-based CAM by 15%. Vitamins, herbs, and supplements were most common, followed by prayer, meditation, and spiritual approaches. CAM use was predicted by length of time since HIV diagnosis, and a greater number of medications/symptoms, with CAM often used to address limitations or problems with antiretroviral therapy. CAM users rarely rejected conventional medicine, but a number of CAM can have potentially serious side effects or interactions with ART. CAM was used as a self-management approach, providing PLWHA with an active role in their healthcare and sense of control. Clinicians, particularly nurses, should consider discussing CAM with patients as part of patient-centered care, to encourage valuable self-management and ensure patient safety.

Prevalence and predictors of traditional medicine utilization among persons living with AIDS (PLWA) on antiretroviral (ARV) and prophylaxis treatment in both rural and urban areas in South Africa

Previous studies have reported that majority of antiretroviral (ARV) treatment-naïve patients use traditional medicine (TM). Given that TM use is ubiquitous in South Africa especially for chronic conditions, there is a potential for ARV non-adherence and serious drug interactions among patients with HIV/AIDs who use TM. The motivating factors for TM use in HIV/AIDS patients on ARV and prophylaxis treatment have not been well defined in South Africa. This study aimed to investigate the prevalence, facilitators, predictors, and types of TM used among persons living with HIV/AIDS on antiretroviral treatment. The study was a cross-sectional survey which involved 100 participants enrolled at ARV clinics in two South African provinces. Univariate and bivariate analyses were performed to assess the relationships between variables and potential predictors of TM. Sixteen percent of participants on ARV reported TM use. Seventy-nine percent used TM prior to a diagnosis of HIV. Participants were more likely to use TM if they were from a rural province, female, older, unmarried, employed, had limited education, or were HIV-positive for less than five years. TM users reported utilizing herbal or medicinal mixtures that were claimed to heal all conditions. This study provides insights into the treatment modalities selected by patients with HIV/AIDS in South Africa who are receiving ARV. This study revealed that less than 20% of participants co-used TM and ARV. However, close to 80% of participants utilize TM before contracting HIV, which is in keeping with approximate estimates by the WHO.

Why HIV positive patients on antiretroviral treatment and/or cotrimoxazole prophylaxis use traditional medicine: perceptions of health workers, traditional healers and patients: a study in two provinces of South Africa

The study explored the perceptions, knowledge and attitudes of patients, health workers and traditional healers about the use of traditional medicine and Anti Retroviral Therapy (ART). The study explored the perceptions, knowledge and attitudes of patients, health workers and traditional healers about the use of traditional medicine and Anti Retroviral Therapy (ART), using an exploratory qualitative design in two provinces of South Africa: an urban township health facility in the Western Cape, and a rural district hospital in KwaZulu-Natal (KZN) with antennal HIV rate of 32% and 28%'respectively. In-depth interviews were conducted with 14 participants: six HIV patients on ART and using Traditional Medicine(TM), two doctors, two nurses and four traditional healers. Two focus group discussions -one at each site - were held with community health workers who work with HIV-positive patients (Western Cape [5] and in KZN [4]). Patient said to have used Traditional Healing Practices (THP) before they were diagnosed with HIV, and some who have been diagnosed with HIV continue using TM in conjunction with ART and/or Cotrimoxazole prophylaxis. Patients preferred not to disclose THP to health professionals because of lack of support and understanding. Patients utilize THP because of family expectations, privacy and confidentiality, especially when they have not disclosed their HIV status. Healthcare professionals had strong negative opinions about THP, especially for HIV-positive patients. Traditional healers supported the patient's rationale for THP use. This study revealed a need to better understand factors involved in patients' choosing to use THP concurrently with ART.

An investigation of the possible interaction between the use of Vitamin C and highly active antiretroviral therapy (HAART) adherence and effectiveness in treated HIV+ women

OBJECTIVES

Our goal in this study was to examine how Vitamin C interacts with antiretroviral therapy in individuals with HIV. We specifically evaluated how Vitamin C impacts highly active antiretroviral therapy (HAART) adherence and HAART effectiveness as adjudicated by HIV viral loads and CD4 cell counts. Women served as their own controls, comparing periods of Vitamin C usage with periods of non-usage.

DESIGN

An intra-individual, cross-sectional comparative study 'nested' in the WIHS observational cohort study.

SUBJECTS

Women in the Women's Interagency HIV Study (WIHS).

OUTCOME MEASURES

Adherence, CD4 count and viral load.

RESULTS

Our study population was drawn from 2813 HIV+ participants who contributed 44,588 visits in WIHS from October, 1994 to April, 2009. Among them, there were 1122 Vitamin C users with 4954 total visits where use was reported. In the multivariate model adjusting for age, education, race, income, drug use, Vitamin C use order and depression score, there was a 44% increase in the odds of ≥ 95% HAART adherence among participants during their period of Vitamin C use compared to when they were not using Vitamin C (OR=1.44; 95% CI=1.1-1.9; P-value=0.0179). There was an association with Vitamin C usage and CD4 counts on viral loads.

CONCLUSION

Vitamin C usage appears to be associated with improved adherence. Future Vitamin C studies should target specific HAART drugs, and prospective clinical outcomes.

Concurrent use of complementary and alternative medicine with antiretroviral therapy reduces adherence to HIV medications

Objective

Antiretroviral therapy requires strict adherence to ensure therapeutic success. Concurrent use of complementary and alternative medicine (CAM) could alter the adherence to and thereby effectiveness of antiretroviral drugs. This study examined the association of CAM use with adherence to antiretroviral therapy (ART) and CD4 count.

Methods

The study was conducted in two HIV clinics: one in a semi-urban, the other in a rural area. Adherence to ART was assessed using the Morisky Medication Adherence Scale (MMAS). Data on type of CAM used and MMAS adherence were collected by patient interview and demographic; clinical data were collected from hospital records.

Results

Altogether 212 HIV patients participated in the exit study conducted over 3 months. Almost half (47.9%) used CAM concurrently with antiretroviral drugs. Dietary supplements (40.3%), healing systems (36.5%) and exercise (23.2%) were mainly used. The use of CAM significantly lowered adherence to ART (89.4% in non-CAM users versus 82.5% in CAM users, P = 0.01). Improvement in CD4 count was less in patients using CAM compared to non-CAM users although the difference was not statistically significant (310.5 ± 294.0 cells/L in CAM users versus 224.5 ± 220.0 cells/L in non-CAM users, P = 0.13). Patients attending the rural HIV clinic were more likely to use CAM compared to patients attending semi-urban hospital (χ2 test = 7.0; P &lt; 0.01).

Conclusion

Use of CAM could lower adherence to antiretroviral therapy. There is need to develop protocol which could help in monitoring CAM use in HIV patients especially those from rural settings.

Prevalence and patterns of Moringa oleifera use among HIV positive patients in Zimbabwe: a cross-sectional survey

Supplementation of conventional medicines with herbs is increasing globally, including among people infected with HIV. Yet there is little data systematically describing the prevalence and patterns of this supplementation and on which counseling scripts can be based. Moringa oleifera is an herb found in the tropics and sub-tropics commonly used for medicinal and nutritional purposes. This survey determined the prevalence and patterns of use of M. oleifera among HIV positive patients. The study was a cross-sectional survey. HIV-infected adults were enrolled from an opportunistic infections clinic of a referral hospital. Using a previously piloted researcher administered questionnaire; patients who reported to the clinic over three months were interviewed about their use of herbal medicines. The focus was on M. oleifera use, and included plant part, dosage, prescribers and the associated medical conditions. Sixty-eight percent (68%) of the study participants consumed M. oleifera. Of these, 81% had commenced antiretroviral drugs. Friends or relatives were the most common source of a recommendation for use of the herb (69%). Most (80%) consumed M. oleifera to boost the immune system. The leaf powder was mainly used, either alone or in combination with the root and/or bark. M. oleifera supplementation is common among HIV positive people. Because it is frequently prescribed by non-professionals and taken concomitantly with conventional medicine, it poses a potential risk for herb-drug interactions. Further experimental investigations into its effect on drug metabolism and transport would be useful in improving clinical outcome of HIV positive patients.

Concomitant herbal medicine and Antiretroviral Therapy (ART) use among HIV patients in Western Uganda: a cross-sectional analysis of magnitude and patterns of use, associated factors and impact on ART adherence

Use of herbal medicines among patients receiving Anti-retroviral Therapy (ART) remains by far an uncharacterised phenomenon in Africa and Uganda specifically. We evaluated the use of herbal medicines among patients on ART at the HIV clinic of Mbarara Regional Referral Hospital (MRRH), examined factors associated with their concomitant use and their impact on ART adherence. This was a cross-sectional study among 334 systematically sampled patients receiving ART at the HIV clinic of MRRH from February to April 2010. We collected data on patient demographics, clinical characteristics, perceptions of quality of care received, self-perceived health status, information on ART received, herbal medicines use and ART adherence. Study outcomes were concomitant herbal medicine and ART use, and ART adherence. Descriptive analysis and logistic regression were conducted using Stata10.0. Close to half, 155 (46.4%) reported concomitant herbal medicines and ART use, with 133 (39.8%) using herbal medicines at least once daily. Most (71.6%) used herbal medicines to treat HIV-related symptoms. A majority (92.3%) reported that the doctors were unaware of their use of herbal medicines, 68.5% citing its minimal importance to the attending physician. Most frequently used herbs were Aloe vera (25%) and Vernonia amygdalina (21%). Time since start of ART (OR 1.14 95% CI: 1.01-1.28, for each one year increase), number of ART side effects reported (≥3 vs.≤1, OR 2.20 95% CI 1.13-4.26) and self-perceived health status (Good vs. Poor, OR 0.31 95% CI 0.12-0.79) were independently associated with concomitant herbal medicine and ART use. Concomitant herbal medicine and ART use was not associated with poor ART adherence (OR 0.85 95% CI 0.47-1.53). There is widespread concomitant herbal medicines and ART use among our patients, with no association to poor ART adherence. Patients appear to use these therapies to complement as opposed to substituting ART.

Prevalence and factors associated with traditional herbal medicine use among patients on highly active antiretroviral therapy in Uganda

Background

In Africa, herbal medicines are often used as primary treatment for Human immunodeficiency virus (HIV) related problems. Concurrent use of traditional herbal medicines (THM) with antiretroviral drugs (ARVs) is widespread among HIV infected patients. However, the extent of THM use is not known in most settings in Sub-Saharan Africa. This study aimed at determining the prevalence and factors associated with THM use among HIV infected patients on highly active antiretroviral therapy (HAART) attending The AIDS Support Organization (TASO) in Uganda. TASO is a non-governmental organization devoted to offering HIV/AIDS care and treatment services in the population.

Methods

This was a cross-sectional study carried out in two TASO treatment centres in Uganda among 401 randomly selected eligible participants. We included participants who were 18 years and above, were enrolled on HAART, and consented to participate in the study. Data was collected using an interviewer-administered semi-structured questionnaire. THM use referred to someone who had ever used or was currently using herbal medicine while on highly active antiretroviral therapy (HAART) by the time of the study. Data was captured in Epi-data version 3.1 and exported to STATA version 9.0 for analysis.

Results

The prevalence of THM use was 33.7%. Patients on HAART for < 4 years were more likely to use THM (OR = 5.98, 95% CI 1.13 - 31.73) as well as those who experienced HAART side effects (OR = 3.66, 95% CI: 1.15 - 11.68). Older patients (≥39 years) were less likely to use THM (OR = 0.26 95% CI: 0.08 - 0.83). Participants with HAART adherence levels > 95% were less likely to use THM (OR = 0.09, 95% CI 0.01 - 0.65).

Conclusion

The prevalence of THM use among participants on HAART was high. This raises clinical and pharmacological concerns that need attention by the health care service providers.

A mixed-methods evaluation of complementary therapy services in palliative care: yoga and dance therapy

To inform service provision and future research, we evaluated two complementary therapy services: yoga classes and dance therapy [The Lebed Method (TLM)]. Both were run as 6-week group courses. Patients completed the Measure Yourself Concerns and Wellbeing questionnaire pre- and post-course. Mean change over time was calculated for patient-nominated concern and well-being scores. Qualitative data regarding factors affecting health other than the therapy and benefits of the service were analysed using content analysis. Eighteen patients participated (mean age 63.8 years; 16 female; 14 cancer diagnoses); 10 were doing yoga, five TLM, and three both yoga and TLM; 14 completed more than one assessed course. Patients' most prevalent concerns were: mobility/fitness (n= 20), breathing problems (n= 20), arm, shoulder and neck problems (n= 18), difficulty relaxing (n= 8), back/postural problems (n= 8), fear/anxiety (n= 5). Factors affecting patients' health other than the therapy were prevalent and predominantly negative (e.g. treatment side effects). Patients reported psycho-spiritual, physical and social benefits. Concern scores improved significantly (P < 0.001) for both therapies; improved well-being was clinically significant for yoga. Evaluations of group complementary therapy services are feasible, can be conducted effectively and have implications for future research. Yoga and TLM may be of benefit in this population.

Complementary and alternative therapy (CAT) use and highly active antiretroviral therapy (HAART): current evidence in the literature, 2000-2009

AIM AND OBJECTIVE

To determine current evidence about the use of complementary and alternative medicine in the context of highly active antiretroviral therapy. The following objectives included identifying the risks and benefits of using complementary and alternative medicine when living with the human immunodeficiency virus (HIV) and taking such medications.

BACKGROUND

In Canada and the USA, HIV/AIDS service organisations recognise that people affected or infected by HIV are increasingly choosing to use complementary and alternative medicine to cope with this disease. These same organisations advocate for increased access to complementary and alternative medicine and more information about the safe use of complementary and alternative medicine to make informed decisions. Based on the increased integral use of complementary and alternative medicine and conventional medicine in Canada and the USA, the literature review was limited to these two countries.

DESIGN

Systematic review.

METHOD

Available full-text abstracts published in English from 2000-2009 were retrieved by electronic searches of selected databases, including the websites of Health Canada and American National Center for Complementary and Alternate Medicine (NCCAM). Forty studies were examined and were categorised by referring to the NCCAM (2007) four types of complementary and alternative medicine.

RESULTS

Insufficient evidence exists to support the use of a particular complementary and alternate therapy to enhance the management of HIV disease.

CONCLUSION

Decisions about using complementary and alternative medicine in conjunction with highly active antiretroviral therapy are often poorly informed. Safety risks and potential drug interactions are frequently ignored as people who use highly active antiretroviral therapy prefer to focus on the physical and mental benefits of using selected complementary and alternate therapies to promote their quality of life.

RELEVANCE TO CLINICAL PRACTICE

As life expectancy increases, from the use of highly active antiretroviral therapy, it is important for health professionals like nurses to be knowledgeable about the prevention, assessment and treatment of HIV symptoms and treatment side effects. Given the increased trend of using complementary and alternative medicine by the general population, it is also important to understand the appropriate use of complementary and alternative medicine for symptom management in HIV/AIDS care.

Nonsurgical Management of Severe Osteonecrosis of the Knee in an HIV-Positive Patient: A Case Report

Due to the life-prolonging effects of combination antiretroviral therapy, many people with HIV are living longer. However, this enhanced longevity is often mirrored by increased disability resulting from HIV and/or the adverse effects of medication. Management of HIV-positive patients is further complicated by comorbidities related to aging, including bone and joint disorders. In this paper, we describe the nonsurgical management of an HIV-positive patient with premature onset of severe osteonecrosis of the knee. A 50-year-old man who had been HIV-positive for 16 years and on combination antiretroviral therapy for 11 years presented to his family physician with extreme discomfort in his right knee. He was diagnosed with osteonecrosis of the right knee, but resisted total knee arthroplasty because of potential complications under anesthesia related to comorbid advanced liver disease. Instead, a successful combination of non-surgical management strategies was employed by the patient and his health care team.

Reasons, perceived efficacy, and factors associated with complementary and alternative medicine use among Malaysian patients with HIV/AIDS

OBJECTIVES

The primary objective of this study was to evaluate the pattern of use, reasons for use, and perceived effect of complementary and alternative medicine (CAM), accompanied by identification and comparison of the factors that are potentially associated with CAM use.

DESIGN

This cross-sectional study was carried out in 325 randomly sampled patients with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), at HIV/AIDS referral clinics in the Hospital Sungai Buloh, Malaysia. Simple random sampling was used, where randomization was done using patients' medical record numbers.

SUBJECTS AND METHODS

Semistructured face-to-face interviews were conducted using 38 questions pertaining to type, pattern, perceived efficacy, adverse effects, and influential factors associated with CAM use. In addition, CD4 count and viral load readings were recorded.

RESULTS

Of 325 randomly sampled patients with HIV/AIDS, 254 of them were using some forms of CAM, resulting in a utilization rate of 78.2%. Vitamins and supplements (52.6%), herbal products (33.8%), and massage (16.6%) were the top three most frequently used CAM modalities. Sociodemographic factors including education level (p = 0.021, r(s) = 0.148), monthly income (p = 0.001, r(s) = 0.260), and family history of CAM use (p = 0.001, r(s) = 0.231) were significantly associated and positively correlated with CAM use. However, the majority of these patients (68%) did not disclose CAM use to health care professionals. About half of those who rated their health as good or very good perceived it as a result of CAM use.

CONCLUSIONS

This study confirmed the range of 30%-100% CAM use among individuals infected with HIV/AIDS. Although, on the one hand some types of CAM reduced viral load and enhanced the immune system, on the other hand some forms of CAM produced a detrimental effect on the virological suppression, opening this platform to more research and investigation in order to optimize the use of CAM among patients with HIV/AIDS.

Virologic and immunologic outcome of treatment of HIV infection with a herbal concoction, α-Zam, among clients seeking herbal remedy in Nigeria

This study was to determine the effectiveness (CD4 count and viral load) of a safe herbal concoction, α-Zam used by clients seeking herbal remedy for treatment of HIV infection in Nigeria. 51 patients taking α-Zam as complementary and alternative therapy through the herbal therapist were studied for a period of 16 months. Preliminary medical and laboratory examinations using WHO and CDC criteria were done after confirmation of HIV infection by Western blotting in the nearest teaching hospitals to the residence of the patients. Regular visits were paid to the patients after commencement of the α-Zam to assess the side-effects, drug interactions, toxicity and effectiveness of the herbal remedy. There was a statistical significance (P<0.05) between pre-treatment and post-treatment CD4 count. 4 (7.8%) of the patients had average increase in CD4 count of 262±16 cell/µL, 23 (45.1%) patients with average increase 310±16 cell/µL, 16 (31.4%) patients with average increase 456±25 cell/µL and 8 (15.7%) patients with average increase 510±36 cell/µL( %) were at WHO staging I , II, III and IV respectively within 4 months on herbal therapy. There was very marked reduction in viral (HIV-RNA) load with 41 (80.4%) and10 (19.6%) HIV infected patients had undetectable viral load and <1000 copies/ml respectively after the therapy. All symptoms and signs associated with HIV infection in all patients fully subsided within 4 weeks of commencement of α-Zam therapy and there was no evidence of negative drug interaction in those HIV patients using both the herbal and highly active anti-retroviral therapy (HAART). The study is in progress to determine periodic immunological outcomes of post therapy in all patients.

Semecarpus anacardium Linn.: A review

Semecarpus anacardium Linn. (Family: Anacardiaceae), commonly known 'Ballataka' or 'Bhilwa', has been used in various traditional system of medicines for various ailments since ancient times. Its nuts contain a variety of biologically active compounds such as biflavonoids, phenolic compounds, bhilawanols, minerals, vitamins and amino acids, which show various medicinal properties. The fruit and nut extract shows various activities like antiatherogenic, antiinflammatory, antioxidant, antimicrobial, anti-reproductive, CNS stimulant, hypoglycemic, anticarcinogenic and hair growth promoter. The article reviews the various activities of the plant.

Knowledge, beliefs, and health care practices relating to treatment of HIV in Vellore, India

In India, little is known about health care-seeking behavior among HIV-infected individuals. Similarly, little is known about how HIV is being treated in the community, in particular by Indian Systems of Medicine (ISM) providers. Therefore, while ART implementation programs continue to expand, it is important to determine whether the knowledge, attitudes, and treatment practices of HIV-infected individuals and their health care providers are aligned with current treatment recommendations. We conducted in-depth qualitative interviews with persons with HIV (n = 9 men and 17 women), family members of persons with HIV (n = 14 men and 3 women), and ISM providers (n = 7). Many of the patients we studied turned at some point to ISM providers because they believed that such practitioners offer a cure for HIV. ISM treatments sometimes had negative impacts including side effects, unchecked progression of an underlying illness, and financial depletion. Indian women tended to be less knowledgeable about HIV and HIV treatments, and had less access to financial and other resources, than men. Finally, most of the ISM providers reported dangerous misconceptions about HIV transmission, diagnosis, and treatment. While the existence of ART in India is potentially of great benefit to those with HIV infection, this study shows that a variety of social, cultural and governmental barriers may interfere with the effective use of these therapies. Partnerships between the allopathic and traditional/complementary health sectors in research, policy, and practice are essential in building comprehensive HIV/AIDS treatment strategies.

Use of traditional complementary and alternative medicine for HIV patients in KwaZulu-Natal, South Africa

Background

Traditional medicine use has been reported is common among individuals with moderate and advanced HIV disease. The aim of this cross-sectional study was to assess the use of Traditional Complementary and Alternative Medicine (TCAM) for HIV patients prior to initiating antiretroviral therapy in three public hospitals in KwaZulu-Natal, South Africa.

Methods

Using systematic sampling, 618 HIV-positive patients were selected from outpatient departments from three hospitals and interviewed with a questionnaire.

Results

TCAM was commonly used for HIV in the past six months by study participants (317, 51.3%) and herbal therapies alone (183, 29.6%). The use of micronutrients (42.9%) was excluded from TCAM since mostly vitamins were provided by the health facility. Herbal therapies were the most expensive, costing on average 128 Rand (US$16) per patient per month. Most participants (90%) indicated that their health care provider was not aware that they were taking herbal therapies for HIV (90%). Herbal therapies were mainly used for pain relief (87.1%) and spiritual practices or prayer for stress relief (77.6%). Multivariate logistic regression with use of herbs for HIV as the dependent variable identified being on a disability grant and fewer clinic visits to be associated with use of herbs, and TCAM use for HIV identified being on a disability grant, number of HIV symptoms and family members not contributing to main source of household income to be associated with TCAM use.

Conclusion

Traditional herbal therapies and TCAM are commonly used by HIV treatment naïve outpatients of public health facilities in South Africa. Health care providers should routinely screen patients on TCAM use when initiating ART and also during follow-up and monitoring keeping in mind that these patients may not fully disclose other therapies.

Discontinuation and Modification of Highly Active Antiretroviral Therapy in HIV-Infected Ugandans

BACKGROUND

Data on discontinuation and modification of highly active antiretroviral therapy (HAART) are scarce among sub-Saharan African populations. We sought to estimate the prevalence and to identify factors associated with these phenomena in our resource-limited setting.

METHODS

Patients were recruited into this cross-sectional study from 2 treatment centers in Kampala, Uganda. Discontinuation and modification were assessed by self-report using semistructured quantitative and unstructured qualitative interviews. Discontinuation was defined as the simultaneous stopping of all antiretrovirals for at least 1 month, and modification as the changing of at least 1 antiretroviral used in an initial HAART regimen. Factors independently associated with each outcome were assessed using multivariate logistic regression.

RESULTS

Of 686 subjects evaluated, 94 (13.7%) had ever discontinued therapy, whereas 175 (25.5%) had ever modified their regimen. The median CD4 count was 175 (interquartile range: 66-297) cells/microL. Factors associated with discontinuation were HAART experience before starting the current regimen (odds ratio [OR] = 3.70, 95% confidence interval [CI]: 2.13 to 6.25), use of alternative medicines (OR = 2.18, 95% CI: 1.06 to 4.47), hospitalization (OR = 2.36, 95% CI: 1.32 to 4.20), and 1 year or less on HAART (OR = 11.11, 95% CI: 5.00 to 25.00). Modification was associated with more than 3 months' duration on HAART (OR = 3.13, 95% CI: 1.16 to 8.33) and being unmarried (OR = 1.64, 95% CI: 1.02 to 2.70).

CONCLUSIONS

The proportions of discontinuation and modification of antiretroviral therapy (ART) observed in our resource-poor setting pose a challenge to the limited treatment options presently available. Drug cost as a major reason for discontinuation of HAART has major implications for ART programs that charge fees in resource-limited settings.