Popular Use of Traditional Chinese Medicine in HIV Patients in the HAART era

Kurtland Ma; Shui-Shan Lee; Elsie K. Y. Chu; Dennise K. P. Tam; Victoria S. C. Kwong; Choi-Fung Ho; Kathy Cheng; Ka-Hing Wong

AIDS and Behavior. 2008;12(4):637-642. 

Abstract and Introduction

Abstract

Seventy-six Chinese male HIV patients were interviewed on their use of traditional Chinese medicine (TCM). All except one had undetectable viral load, 28 had already progressed to AIDS. Forty-five (59.2%) had used TCM - 11 infrequently and 33 commonly. No specific TCM recipe was preferentially used, while a variety of herbal tea and other over-the-counter health products of TCM in origin were reported. A minority (28.9%) have consulted a TCM practitioner in the preceding 6 months. Most patients admitted using TCM for the treatment of minor ailments (60.0%) and general health maintenance (57.8%), while western medicine was chosen for the therapy of major medical illnesses. TCM did not seem to have significant influence on the conventional HAART in this cohort. Many used TCM at a time interval from HAART in order not to affect the latter's effectiveness.

Introduction

Complementary and alternative therapy (CAM) refers to the use of treatment not provided by clinicians in conventional health services, though both serve the same goal of pursuing good health (Ni, Simile, & Hardy, 2002). Traditional Chinese Medicine (TCM) constitutes one form of CAM which is widely used in Chinese communities around the world. In Hong Kong where over 95% of the population is ethnic Chinese, many believe Western medication and TCM care are complementary (Lee, 1983). From 10 to 15% of people reported the use of TCM or consulted herbalist for specific health problem (Lau, Leung, & Tsui, 2001; Wong, Wong, & Donnan, 1995). The proportion of those who had used TCM at least once was much higher (Hon et al., 2004; Tang & Wong, 1998; Wong et al., 1995). The integration of Western medication and TCM may carry significant implications in healthcare outcomes, especially in places where the use of TCM is widespread. This applies to conditions like HIV/AIDS which is becoming a chronic disease the best care model of which is yet to be established.

In the West, the prevalence of CAM use ranged between 27 and 100% of HIV patients from 1980 to 1996 (Ernst, 1997). In some studies up to 70% of HIV/AIDS patients have used CAM in the course of their illness (Fairfield, Eisenberg, Davis, Libman, & Phillips, 1998; Furler, Einarson, Walmsley, Millson, & Bendayan, 2003), the variation of which depends on the definition and study designs. Data from Asia is only available in a Thailand study in 2003, with 95% of the HIV patients reporting the use of some forms of CAM, and 78% having visited a CAM provider (Wiwanitkit, 2003). A significant proportion of these studies were conducted before the introduction of highly active antiretroviral therapy (HAART), the latter becoming a gold standard in clinical HIV management. With the widespread use of HAART in not just developed but developing countries, there is the new concern about interaction between CAM and HAART, which may potentially affect the outcome of treatment (Mills, Montori, Perri, Phillips, & Koren, 2005).

We set out to explore the pattern of TCM use by ethnic Chinese HIV patients. Hong Kong is uniquely positioned for such a study in light of the high proportion of Chinese patients, access to TCM and TCM practitioners, superimposed on the pre-existing western health care system. HAART has become a standard of HIV treatment in the territory since the mid-nineties, enabling the impacts of TCM use to be studied.

Methods

Participants

This study forms part of a questionnaire survey administered to male patients attending the Integrated Treatment Centre (ITC),a purpose-built HIV specialist service operated by the Department of Health in Hong Kong. The clinic has an active caseload of about 800. The number of female patients is very small in the cohort and we have therefore decided to focus on male patients in this study. HAART is prescribed in accordance with guidelines following the principles established by the Panel on Clinical Practices for Treatment of HIV Infection convened by the United States Department of Health and Human Services (CDC, 1998). The inclusion criteria were: (a) on HAART for one year or more; (b) Chinese; and (c) consent to join the study.

Measures

A self-administered anonymised questionnaire survey was administered to eligible patients. The respondents were asked to complete it while waiting for/after consultation at the Centre in confidence. Questions in the survey covered the following areas:(a) report of TCM use, (b) general beliefs and perception about TCM; (c) association of TCM use with HAART, and (d) sources of advice on TCM. TCM use was defined as the consumption of recipes as prescribed by TCM practitioners, products perceived to be TCM in nature and purchased over the counter (OTC) or provided by other people, like friends or relatives. This relatively loose definition was used in order to capture all potentially relevant information as well as the perception of individuals.The questionnaires were coded and additional information was retrieved from the clinical information system, with the consent of the patients: latest clinical staging (CDC, 1992); CD4 and viral load readings.

A research nurse presented all interested patients during the study period with an explanation of the study, a consent form,and the self-administered questionnaire for completion.

Data Analysis

Chi-square test and odds ratio were used to calculate the association between categorical data, and these were applied to the comparison between TCM users and non-TCM users, as well as Common and Infrequent TCM users. Comparison on continuous data was calculated by non-parametric tests (Mann-Whitney U Test) since data was not normally distributed, and it was only applied to the comparison between TCM users and non-TCM users.

Results

The survey was conducted over a four-week period in July and August 2005. Eighty-two patients were recruited, accounting for 36.4% of all patients attending the clinic in the same period of time. The results of 76 successfully completed questionnaires were finally available for analysis. There was no significant difference between the age, viral load and CD4 counts between recruited patients and those who had not been recruited (results not shown).

The mean age of the enrolled patients was 45.36 (range: 25-72 years). They have been receiving medical care at the ITC for a mean of 80.7 months (range: 17-215 months). The main route of HIV transmission was heterosexual contact, 50 (66.7%), followed by sex between men, i.e. in men having sex with men (MSM) 23(30.3%). A fraction (36.8%) of the subjects had developed AIDS before the survey. The median duration of treatment with HAART was 58.6 months (range: 13-101 months). All had undetectable viral load (less than 400 copies/ul) during the recent blood taking at within 4 months prior to the survey. The one with high viral load (54,000 copies/ul) had in fact stopped HAART recently following treatment failure. Full adherence to all doses of HAART within the past month was reported by 54 (66.7%) of all study participants while 27 (33.3%) reported having missed one dose or more within the past month.

Prevalence and Patterns of TCM Use

Forty-five of the patients (59.2%) had used TCM before—26 (57.8%) of them purchased proprietary items over the counter (OTC), 28 (62.2%) consulted TCM practitioner, and 5 (11.1%) obtained from other sources. Thirteen of them (28.9%) have consulted a TCM practitioner in the preceding 6 months at the following frequencies: a total of ≤2 times (7, 53.8%), 3-4 times (3, 23.1%) and 5 or more (3, 23.1%). shows the characteristics of the TCM users and non-users. The median age of TCM users was 47 (25-72 years old), and 42 (28-71 years old) for non-TCM users. TCM users tended to be older in age, but it did not reach statistical significance (Mann-Whitney U = 515.50, P > 0.05). No difference was found in duration of illness, duration on HAART and CD4 count between the two groups. However, use of TCM was associated with clinical stages. Patients in stage B were less likely to use TCM (OR = 0.23; 95% CI 0.09-0.63) while patients in stage C were more likely to use TCM (OR = 3.00; 95% CI 1.08-8.37).

Table 1.  Characteristics of Respondents (n = 76)

  Units of measurement Range (mean)
TCM users (n =45) Non-TCM users (n = 31)
Age Years 28-71 (47.2) 25-72 (42.7)
Duration since diagnosis Months 18-217 (86.0) 22-218 (84.2)
Duration on HAART Months 13-101 (61.2) 13-95 (54.8)
Latest CD count No. of cells/ul 27-1358 (427.1) 31-893 (483.7)
Latest viral load Copies/ml (PCR) All < 400 (except 1 case) All < 400
  Categories No. (%)  
Clinical Stagea A 13 (28.9%) 6 (19.4%)
  B 11 (24.4%) 18 (58.1%)
  C 21 (46.7%) 7 (22.6%)
Transmission route Heterosexual 30 (66.7%) 20 (66.7%)
  Men having sex with men (MSM) 14 (31.1%) 9 (30.0%)
  Haemophilia 1 (2.2%) 1 (3.3%)
Education level No schooling 1 (2.3%) 1 (3.2%)
(n = 43) Primary 10 (23.3%) 3 (9.7%)
  Secondary 25 (58.1%) 25 (80.6%)
  Tertiary 7 (15.6%) 2 (6.5%)
Employment status Full/Part-time employment 28 (62.2%) 19 (61.3%)
(n = 44) Self-employed 1 (2.2%) 2 (6.5%)
  Students 1 (2.2%) 1 (3.2%)
  Unemployed 10 (22.7%) 6 (19.4%)
  Retired 4 (9.1%) 3 (9.7%)

 

aClinical stage A, asymptomatic; B, symptomatic but not amounting to AIDS; C, development of AIDS defining illness. The classification is in accordance with the CDC recommendations of 1993 (CDC, 1992)

Patients who had used TCM were classified as Infrequent or Common Users. Infrequent Users were those that reported using any 1 or more types of TCM only 1-2 times in the preceding 6 months, such as patients who had sampled one form of TCM but had not used it habitually. The more frequent users and those taking TCM regularly were classified as Common Users. Using this criteria, 11 (14.5%) were Infrequent TCM Users and 33 (43.4%) were Common Users (the two did not add up to 45 because of one missing entry). There's no difference in age, duration of illness and HAART between the two groups.

A total of 30 different types of TCM had been reportedly used by the patients. Some TCM-using patients reported usage of multiple types of TCM while others did not specify any. All reported recipes were oral preparation and were classified into three categories(prescription from TCM practitioner, over-the-counter preparations, and herbal tea). Two thirds (31) used only one type/recipe of TCM, while 32.7% (13) used more than one. Of the 24 OTC TCM preparations reported, only two forms had been used by more than one patient, namely, lingzhi (a mushroom, Ganoderma lucidum), in 10 (41.7%), and cordyceps (a genus of Ascomycete fungi) by 3 (12.5%) of the patients. Herbal tea was reported as TCM, and have been used quite commonly, in 9 (20.5%) of the patients.

Beliefs About TCM

For those who used TCM, the treatment of minor ailments (27/45, 60.0%) and general health maintenance (26/45, 57.8%) were the main indications. Common Users were more inclined to consume TCM for general health maintenance (OR = 5.33; 95% CI 1.18, 24.18), while Infrequent Users were more likely to consume TCM to treat minor ailments (OR = 9.41; 95% CI 1.08, 82.10). About half trusted that TCM was useful because of prior experience of effectiveness (23/44, 52.3%), or following recommendations of family members or friends(19/41, 43.2%). There was no difference between Common and Infrequent Users in this regard.

Comparing between TCM and western medicine, a majority (58/75, 77.3%) believed that the latter was more effective in treating major illnesses; whereas opinion on minor illness was split. Overall, many believed TCM to be useful for supporting the maintenance of health (56/75, 74.7%). In the event of a minor medical problem, many (33/76, 43.4%) preferred to see only western doctor,or not seeking any advice (27/76, 35.5%) instead of consulting a TCM practitioner in the first place (4/76, 5.3%).

HIV, HAART and TCM Use

All except one patients trusted that HAART was more potent than TCM for the treatment of HIV infection, though a majority (86.3%) acknowledged that side effect was plentiful with HAART. Western medicine was believed to be more effective in managing HAART associated side effects (51.3% vs. 27%). Many (58/41, 78.4%) believed that there could be interactions between TCM and HAART, which could be negative (43.1%), positive (6.9%), or both (50.0%) ( ). For those who had taken TCM (n = 45, missing = 3), all except 2 (4.7%) took it one hour or more before or after antiretroviral medications. Seventeen (40.5%) actually took TCM at an interval of 4 h from HAART. Almost every respondent (19/21, 90.5%) did not inform the TCM practitioner about his HIV status.

Table 2.  Reasons for and Beliefs About TCM Use (n = 44)

  Common users 33 (%) Infrequent users 11 (%)
(a) Main indications
General health maintenance 22 (66.7%) 3 (27.3%)
Treatment of minor illness 17 (51.5%) 10 (90.9%)
Prior evidence of effectiveness 17 (53.1%)a 6 (54.5%)
Recommendations of family/friends 13 (40.6%)a 5 (45.5%)
Recommendation ITC physicians/nurses 2 (6.3%)a 0 (0%)
Customary use 3 (9.4%)a 0 (0%)
(b) Comparing with western medicine
More effective than Western medicine 7 (21.9%)a 2 (18.2%)
Less side effects than Western medicine 3 (9.4%)a 2 (18.2)
More affordable than Western medicine 2 (6.3%)a 1 (9.1%)
Faster effect than Western medicine 2 (6.1%)a 0 (0%)
(c) TCM in HIV treatment
Faster effects on HIV than HAART 1 (3.0%) 0 (0%)
Longer-lasting effects on HIV than HAART 10 (30.3%) 0 (0%)
Higher effectiveness than HAART 1 (3.0%) 0 (0%)
Less side-effects than HAART 31 (96.9%)a 10 (100%)a
Effectiveness in treating side effects from HAART 9 (27.3%) 2 (18.2%)a
Interaction between TCM and HAART 25(75.8%) 10 (90.9%)

 

aAnalysis with missing data

Respondents were asked how their TCM usage had changed since their HIV diagnosis. No patient began using TCM after their HIV diagnosis. A majority of the Infrequent (69.2%) and Common (76.0%) TCM Users reported no change in the habit after HIV diagnosis. Increase in TCM usage since diagnosis was reported by none of the Infrequent Users and 7 (21.2%) of the Common Users. On the other hand, 1 (9.1%) Infrequent User and 2 (6.1%) Common Users decreased their TCM usage since diagnosis. Only 15.4% of Infrequent Users (n = 2) reported having stopped taking TCM altogether since HIV diagnosis while no Common TCM User reported doing so.

Discussion

This is the first study addressing the use of TCM in a Chinese population on HAART, showing that the practice was common. The main indication was general health maintenance, and/or treatment for minor illness, rather than specifically for HIV/AIDS. A good variety of TCM products were used, many of which might not actually be considered medicinal in nature in Chinese communities. The difference in the definition of TCM and the perception of patients about what constituted TCM could have affected the reported frequency in this and other study. Lingzhi, for example, is commonly used to improve health status, prolong life or sometimes as a tonic (Jong & Birmingham, 1992). Herbal tea was widely used for treating common cold or other minor ailments, and was the most common TCM product consumed in our study. The ready access to these products and the customary use in families probably explain their popularity. More than half of our TCM users did not consult any TCM practitioners upon their consumption. Over-the-counter TCM was actually preferred by patients. Although the use of TCM was common among those who have developed AIDS, further study is needed to explore the relationship between TCM use and severity of the illness.

HAART was the standard treatment received by patients in the study. While TCM was used, adherence to HAART was not adversely affected, as has been reported in earlier studies (Fong et al., 2003). This confirms the findings of other studies, that the choice of treatment was largely based on the type of illness which they are suffering from (Hon et al., 2004; Lau & Yu, 2000; Lewith & Chan, 2002). We postulate that our patients, while using another form of medication (TCM), exhibited an augmented initiative to care for themselves or a greater desire to be in control of their own healthcare decision-making (Hsiao et al., 2003). It's noted however that missing a few doses was quite common, and was associated with the use of TCM, though this did not reach statistical significance. The clinical relevance is not known as all patients had undetectable viral load, an indication of effective viral suppression.

Apparently, TCM and western medicines belong to two distinctly different framework of approaches to health and diseases. Effective integration is potentially beneficial but remains a distant goal to be achieved. An open, effective patient-health service provider communication is important, which could avoid serious adverse effects and negative interactions between the use of HARRT and TCM (Hsiao et al., 2003). More than 75% of our TCM users did not consult any clinic staff on their use of TCM, though they did not anticipate disapproval. Despite the low rate of disclosure, our patients did view positively their physicians' or nurses' responses to TCM (results not shown). There are two possible explanations for the low disclosure rate. First, the tremendous effort has been put forward by the clinic staff on adherence to antiretroviral drug, leaving little room for other issues like TCM (Wynia, Eisenberg, & Wilson, 1999). Second, as TCM consumption is generally thought to be unrelated to HIV treatment, patients may think that it is unnecessary to raise for discussion This may also reflect the lack of knowledge over the risk and benefits on TCM use, and the possible interaction, either positive or negative, with HAART. Future studies on barriers to effective discussion on TCM use between the physicians and the patients, and their clinical impacts, would be useful.

Understandably, our study was limited by its design in focusing on a selected group of HIV patients in a specialist clinic. The responses could be setting specific, and may not be extrapolated to patients with the same ethnicity in the same or other countries. Since HAART was the standard treatment in the clinic, it could be argued that only those accepting this form of treatment would be recruited. All our subjects have started their HAART treatment and may not encompass the views and opinions of patients who have chosen to utilize TCM as the core HIV treatment. Our results may therefore underestimate TCM usage in HIV patients in general. On the other hand, the term TCM was loosely defined in this study. We included a wide variety of OTC preparations or herbs/herbal preparations prescribed by TCM practitioners. We could not distinguish the perceived benefits between OTC preparations and TCM prescribed by TCM practitioners. Despite these drawbacks, our study did highlight the popularity of TCM use in the HAART era, a phenomenon which should be taken into consideration when studying the impacts of HIV treatment in the society.

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