Traditional, complementary and alternative medicine use by HIV patients a decade after public sector antiretroviral therapy roll out in South Africa: a cross sectional study

Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndromes (AIDS) are amongst the biggest health challenges faced by African nations. The last decade (2001–2010) saw many developing countries, including South Africa, roll out successful antiretroviral (ARV) programmes through a global advocacy initiative to reduce the associated morbidity and mortality as well as the cost of ARV medicines to overcome the health care human resource crisis, to simplify the drug regimens, monitor and improve the quality of care [1]. Globally people tend to use traditional medicine under the terms complementary and alternative medicines (CAM), including for HIV and other chronic conditions [2]. HIV-infected patients may turn for their health management to public, private, household/self-care and other community based non-formal health sectors such as traditional and faith healers, herbalists and other vendors [3]. In South Africa, public sector healthcare is offered to patients with HIV-infection at different levels of the health care system: Primary Health Care (PHC) clinics, Community Health Centres (CHC), District Hospitals (DH), Regional Hospitals (RH), Academic Hospitals (AH) and Central Hospitals (CH).

South Africa launched its first Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment with its national antiretroviral guidelines in 2004. During that time, HIV was highly politicised in the country, with very senior officials denying the link between HIV and AIDS; the latter was seen as a condition associated with poverty in the socio-economic contexts of South Africa [4]. The politicisation of HIV and AIDS was also used before 2004 to promote traditional, complementary and alternative medicines (TCAM) by senior government officials who advocated the use of treatment modalities outside the orthodox system of HIV treatment, such as lemon juice, beetroot and garlic [5]. The period after the introduction of highly active antiretroviral therapy (HAART) has been marked by the political will towards promoting universal access to antiretroviral therapy (ART) as well as integrating traditional medicine into the public health care sector [6]. The political support has resulted in South Africa having one of the most successful public health sector ARV programmes on the African continent, with at least two million people receiving ART [7]. One critical question remains however on the prevalence of TCAM use a decade after easy access to ARV medicines was made possible by the government.

The World Health Organisation (WHO) defines African traditional medicine (ATM) as “The sum total of all knowledge and practices, whether explicable or not, used in the diagnosis, prevention and elimination of physical, mental, or societal imbalance, and relying exclusively on practical experience and observation handed down from generation to generation, whether verbally or in writing” [8]. Other forms of health care, such as Ayurveda and Traditional Chinese medicine, which are not part of Africa’s own traditional medicine category, are not integrated into the dominant health care systems, but fall under CAM [9]. The practice of African traditional healing in South Africa is regulated by the Traditional Health Practitioners Act (Act 35 of 2004, further replaced by Act 27 of 2007) while the practice of CAM is legally allowed under the Allied Health Practitioners Act (Act 63 of 1982) and includes Ayurveda, Traditional Chinese Medicine, Osteopathy, Chiropractic, Homeopathy, Naturopathy, Phytotherapy, Therapeutic Aromatherapy, Massage therapy, and Reflexology [10]. Some HIV infected patients who receive care at public health sector ARV facilities may also use other methods of healing/treatment, either indigenous to African communities or not; the prevalence and reasons for their use are not well known.

South Africa has a diverse population made up of four main ethnic groups, namely Black African (79 %), White (9.6 %), Coloured (8.9 %) and Indian (2.5 %) [11]. However, the use of TCAM in combination with prescribed ARVs by HIV patients from different racial groups is not well known in the era of a successful ARV programme. The use of TCAM by HIV –infected patients in KwaZulu-Natal has been reported in the literature [12‐14]. Data from one such study conducted in KwaZulu-Natal showed that TCAM was commonly used for HIV- infection during the 6 months study period (317/638, 51.3 %) in combination with prescribed ART [15]. Concerns relating to the safety of uncontrolled medicinal products have been raised with reference to intrinsic toxicity and quality issues associated with TCAM; other risks include adverse drug reactions such as liver toxicity reportedly associated with the use of kava-kava [16] and drug interaction with ARVs and medicinal plants [17]. Another concern is a delay reported in starting with ART amongst HIV patients who use the services of traditional healers in pre-ART phase in Mozambique [18] whilst issues with HIV patients on ART abandoning treatment for exclusively being managed by prayers and faith healing were noted in Zambia [19]. Poor adherence to ART was also noted with the concurrent use of TCAM and ARVs [20]. Although studies reported poor adherence in HIV patients on concurrent use of TCAM and ART [21, 22], another study documented that patients adhering to ART for HIV/AIDS also used CAM measures such as homeopathy and herbal medicines for ARVs side-effects, immune system enhancement, and overall well-being [23]. This study therefore aimed at determining whether HIV patients attending public health sector ARV clinics still used TCAM for HIV-infection while on a successful ARV programme. The specific objectives were to determine the prevalence of the use of TCAM for HIV –infection pre –ART and its ongoing use after starting with ARVs. In addition the study was conducted to ascertain whether socio-economic status and/or the apartheid structure of the past had an influence on the use of TCAM by HIV infected patients.

This study found that a few HIV patients still used ART concurrently with TCAM for their HIV-infection a decade after the implementation of a successful ARV programme in South Africa. However there was a decrease on the use of TCAM evidenced by a drop in the percentage of participants that took TCAM prior to (21.85 %) and post ART (8.12 %). This finding is consistent with data obtained from other studies. In one such study conducted between October 2007 and February 2008 in KwaZulu-Natal the authors reported a decline in prevalence of complementary or traditional treatments in HIV-infected patients from 36.6 % prior to ART to 7.9 % after 6 months on ART [12]. In another longitudinal follow-up study the authors reported a further decrease in TCAM at 12 and 20 months post ART [27].

The utilization of public sector ARV clinics in this study was predominantly by Black African females with the majority reporting being single and never married. Many more females used ATM healers and visited CAM practitioners in the post ART era than males as evidenced in this study. The lower percentage of males visiting ARVclinics could be supported by another study that found that men reported several barriers to the use of public and private clinics for sexual health services in Gauteng province (South Africa), and many preferred the services of traditional healers for sexually –transmitted –infections [28]. Another study found an increased use of CAM amongst women in rural areas in Australia [29].

Almost none of the participants in the relatively high income bracket/category had used ATM healers or CAM practitioners post ART, this is in contrast with findings of another study done amongst African-Americans where the high income category afforded participants to use CAM for treatment [30]. However, the finding of this study was consistent with the findings from a national household survey on the utilization of traditional healers in South Africa which showed that the wealthiest had a tendency neither to consult traditional healers nor to use public sector healthcare facilities for health issues [31]. This may justify the high number of Black African HIV patients attending public sector ARV clinics, with a few Coloured, Indian and White participants also not reporting a substantial use of TCAM.

The role played by the type of dwelling and the the participants’ place of residence place and locality of clinics has been demonstrated by patients in seeking care after traditional healers [32]. We found that there was no significant difference between the types of locality and place of clinics and the use of ATM prior to ART, but there was a significant decline in the prevalence of the use of ATM healers and CAM practitioners after joining the ARV programme. The use of TCAM in the pre-ART phase may have been due to the unaffordability and inaccessibility of HAART. People had to find alternate means to manage their HIV condition. A few participants in this study visited CAM practitioners for HIV infection (37/1748, 2.12 %) when compared to ATM healers (142/1748, 8.12 %). Patterns of CAM use and ethnic-specific CAM use vary across racial/ethnic groups demonstrating the role of culture in choices of the use of CAM practitioners [33].

From this study and other previous studies we can hypothesize that the introduction and progressive free access to ART in public sector healthcare facilities have contributed to the decline in the use of TCAM amongst South African HIV infected patients a decade after the roll-out of ARV programme. Challenges of pharmacological interactions caused by concomitant use of traditional herbal therapies and conventional antiretroviral medicines should be a cause of concern for quality of care offered to patients and should be investigated further for risk of clinically significant pharmacokinetic (PK) interactions [17].

Since a low percentage of HIV patients in this study still used TCAM for HIV-infection, further studies are needed to determine reasons and factors associated with the use of TCAM, and or benefits/risks of concurrent use of TCAM with ART while on a successful programme.

A decade after the introduction of ART and despite the success of the public health sector ARV programme in South Africa, the use of TCAM is still prevalent amongst a small percentage of HIV infected patients attending public sector healthcare ARV clinics. In the pre-ART phase, many patients tend to use TCAM. However, there is a decrease in the use of TCAM in the post ART phase. An hypothesis can be assumed that free access to ART may account in the decrease of the use of TCAM by HIV patients. Public sector healthcare ARV clinics are mainly used by Black African patients, with a few patients from the other racial groups. Although the majority of patients did not report using TCAM while on ART, further research is needed to explore reasons for use and health benefits or risks experienced by the minority that uses both conventional antiretroviral therapy and traditional medicine.