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Complementary Therapies in Clinical Practice 20 (2014) 118e124

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Complementary Therapies in Clinical Practice

journal homepage: www.elsevier .com/locate/ctcp

Use of complementary medicines among HIV-infected children inLagos, Nigeria

K.A. Oshikoya a,*, I.A. Oreagba b, O.O. Ogunleye a, M. Hassan b, I.O. Senbanjo c

aDepartment of Pharmacology, Lagos State University College of Medicine, Ikeja, Lagos, NigeriabDepartment of Pharmacology, College of Medicine, University of Lagos, Idiaraba, Lagos, NigeriacDepartment of Paediatric and Child Health, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria

Keywords:Complementary medicineHIV-infectionChildrenPrevalenceAdverse effect

* Corresponding author. Tel.: þ234 809 068 8437.E-mail address: med_modhospital@yahoo.com (K.

1744-3881/$ e see front matter � 2013 Elsevier Ltd.http://dx.doi.org/10.1016/j.ctcp.2013.12.001

a b s t r a c t

Background: Complementary medicine (CM) use is common among children with chronic illnesses suchas epilepsy and asthma. Lack of data on the profile of CM use among children with human immuno-deficiency virus (HIV) infection necessitated this study.Methods: Parents or caregivers of HIV-infected children attending the paediatric HIV-clinic in a teachinghospital in Lagos, Nigeria, were randomly selected and interviewed with a semi-structured (open- andclose-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 chil-dren. 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.

� 2013 Elsevier Ltd. All rights reserved.

1. Introduction

Human immunodeficiency virus (HIV) infection is a globalpublic health problem [1]. The virus gradually attacks, and damagesor destroys the cells of the immune system, leaving them unable tofight infections and predispose them to certain malignanciessuch as lymphomas and Kaposi sarcoma [2]. Acquired ImmuneDeficiency Syndrome (AIDS) is the final stage of HIV infection. Atthis stage, the immune systems of an individual living with HIVinfection are badly damaged. Such an individual is at risk foropportunistic infections (OIs), malignancies, or a very low CD4þcell count [2,3].

TheWorld Health Organization (WHO) and Joint United NationsProgramme on HIV/AIDS (UNAIDS) have reported a global increasein the number of children (below 15 years old) living with HIV from1.6million in 2001 to 2.1million in 2008 [4,5]. Themajority (90%) ofthese children live in sub-Saharan Africa. Globally, in 2008, anestimated 430,000 new infections occurred in children [6], ofwhich 90% were acquired during pregnancy through mother-to-child transmission (MTCT) of HIV. It is estimated that, of the430,000 new infections, between 50% and 75% were acquired

A. Oshikoya).

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during labour and in the peri-partum period. Of the remaining newinfections, the majority were acquired through breastfeeding [6]. In2008, about 280,000 children were reported to have died of AIDS[5,6]. However, the use of preventive treatment regimens hassignificantly decreased the incidence of mother-to-child HIVtransmission. Globally, in 2009, an estimated 370,000 childrencontracted HIV during the perinatal and breastfeeding period,compared to the 500,000 infected in 2001 [7].

Many HIV-infected children are diagnosed through high indexof suspicion on account of the disease being present in theirmothers. However, the infection may not be suspected until achild develops some symptoms which may vary by age and in-dividual child. Among the common symptoms in children arefailure to gain weight or grow according to the World HealthOrganization standardized growth charts; failure to reachdevelopmental milestones during the expected time frame; brainor nervous system problems which may be characterized byseizures, difficulty with walking, or poor performance in school[8]. In addition, children may present with recurrent bacterialinfections, unremitting fever, protracted diarrhoea, recalcitrantthrush, recurrent pneumonia, chronic parotitis, generalizedlymphadenopathy, and significant pruritic dermatoses [8].Mucocutaneous eruptions may be the first sign of HIV infectionin children and may vary in presentation, depending on theimmune status of the child [9].

K.A. Oshikoya et al. / Complementary Therapies in Clinical Practice 20 (2014) 118e124 119

As HIV infection becomes more advanced, children start todevelop opportunistic infections such as pneumocystis pneumonia,lymphocytic interstitial pneumonitis, and candida or yeast in-fections. These are infections that rarely affect healthy people butcan be deadly for people whose immune systems have beencompromised [8].

Antiretroviral therapy (ART) is the current mainstay of treat-ment of HIV/AIDS. Before the advent of ART, people living with HIVeasily progressed to AIDSwith an associated highmortality [9]. ARTinvolves the use of a combination of antiretroviral (ARV) drugs tofight the HIV virus from a variety of positions within the cell [10].HIV-infected infants and children now survive to adolescence andadulthood following early initiation of ART [11]. In addition to ART,therapy for specific infections and malignancies are essential intreating HIV-infected persons. Nucleoside or nucleotide reversetranscriptase inhibitors (NRTIs), protease inhibitors (PIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), fusion in-hibitors, CCR5 co-receptor antagonists (entry inhibitors), and HIVintegrase strand transfer inhibitors are the classes of ARV drugspresently in use [9]. At least three drugs from at least two classes ofthe ARV drugs is recommended for initial treatment of infectedinfants, children, and adolescents because it provides the best op-portunity to preserve immune function and delay disease pro-gression [12]. Drug combinations for initial therapy in ART-naivechildren include two NRTIs plus one NNRTI or one PI [9].

Worldwide, over 4 million adults and children are now on an-tiretroviral therapy (ART), but the scaling up of ART has met withless success in infants and very young children as compared withthat in older children [13]. Currently, in the majority of children,ART is initiated in those who have developed serious illness as aresult of advanced HIV infection (AIDS), and at an average age ofapproximately five years. Those who are unable to access ART maybe compelled to use alternative therapies. Even among those usingART, antiretroviral drugs may be responsible for a wide range oftoxicities, ranging from low-grade intolerance to life-threateningside-effects [9]. In addition, lack of cure and preventive vaccinefor HIV/AIDS have prompted some patients to use complementarymedicines or seek alternative therapies, particularly the herbalremedies [14,15]. The safety of herbal remedies has been a majorpublic health concern especially when the active constituents ofthe products have not been characterised.

Complementary and alternative medicine, according to theNational Centre for Complementary and Alternative Medicine(NCCAM), are the treatments and healthcare practices that are notintegral part of conventional western medicine, not taught inmedical schools, and not generally used in hospitals [16]. Com-plementary medicine is used together with conventional medicine,while alternative medicine is used in place of conventional medi-cine. However, these terminologies were not clearly defined inmost studies that have evaluated CAM use among HIV-infectedpatients [17e23]. This probably accounted for a variation in theprevalence of use of complementary or alternativemedicine amongHIV infected people reported in the literature [15,17e23].

Data are lacking on the use of CM in HIV-infected children.However, one study has documented a prevalence of 22% amongHIV-infected children in the United States [17]. In HIV-infectedpatients, CM are used to improve the general health [18], to pre-vent opportunistic infections [10,19], to treat symptoms such aspain and stress, depressed immunity, diarrhoea, cough, nausea andvomiting [19,20], or to reduce the side-effects of ART [10]. However,the safety, efficacy, quality and standardization of the CMs have notbeen evaluated [24]. Adverse effects of CM have been reportedamong a general paediatric population [21] and include multiplepharmacologic interactions with prescription medicines [25],anaphylaxis, renal failure, malignancies and death [25,26].

Complementary medicines are quite expensive and the costs arenot covered by the national health insurance in most countries.More than 80% of the parents of HIV-infected children surveyed inthe USA were responsible for the cost of CM use for their children[17]. In Canada, out-of-pocket costs of CM ranged from no cost tomore than CAD$250 permonth [22], while in South Africa, between£4 and £27 was expended per month on traditional medicines byHIV/AIDS patients [27].

The specific pharmacokinetic and pharmacodynamic in-teractions between CM and ARV drugs rarely have been evaluated,leaving the overall consequences of their co-administration largelyunknown. Herbal medicines are the most frequently used CMamong HIV-infected patients in Africa [19,26] and the USA [23].African potato (Hypoxis hemerocallidea) and Sutherlandia, currentlybeing evaluated for HIV treatment in South Africa, are potentialinhibitors of ARV drug metabolism and transportation [28]. StJohn’s wort (Hypericum perforatum) has been used as an herbalantidepressant [29] and is known to adversely interact with in-dinavir by reducing its plasma level [30]. Similarly, large doses ofgarlic (Allium sativum) are known to reduce the plasma level ofsaquinavir [31]. Consequently, concomitant use of herbal CM andARV drugs may result in a significantly reduced plasma level andreduced efficacy of ARV drugs.

Given the dearth of information on the profile of CM use amongHIV-infected children, this study aimed to determine the preva-lence, pattern of use, parental sources of information, perceivedbenefits, cost, and adverse effects of CM among HIV-infected chil-dren in Lagos, Nigeria as well as the types of ARV and co-prescribeddrugs used with CMs in the HIV-infected children.

2. Material and method

2.1. Setting

HIV-infected children with documented confirmatory results inthe case files constituted the study population. We recruited onlythe subjects who were enrolled on ART at the paediatric HIV/AIDSclinic of the Lagos State University Teaching Hospital (LASUTH),Ikeja, Nigeria. The clinic is held twice weekly (Monday andThursday) and an average of 25 patients were attended to per clinicvisit.

2.2. Study design

This is a cross-sectional study conducted between 1st July and31st December 2012. The study involved the parents or care-givers of 187 HIV-infected children selected randomly duringtheir consecutive visit to the clinic. A semi-structured question-naire with open- and close-ended questions, modified from theone previously used to assess the use of CMs among childrenwith chronic illnesses in Lagos; Nigeria [32] was the instrumentfor this study. The semi-structured questionnaire was developedto obtain the following information: demography of both theparents/caregivers and their HIV-infected children, and the typeof CM, if any, used by the patient. Information was also obtainedon the sources, cost, perceived benefits and adverse effects of theCM used.

The part of the questionnaire seeking information about use ofCM requires the respondents to respond to questions such aswhether or not the child had ever used CM for HIV/AIDS, andwhether or not the child was currently using CM. Where CM iscurrently used, we sought if it was regularly used with ARV drugs.Among thosewho had ever used CM, we sought if they had stoppedin the last sixmonths. Theywere also required to choose the type(s)of CM used from a pre-determined list which included biological

K.A. Oshikoya et al. / Complementary Therapies in Clinical Practice 20 (2014) 118e124120

products, other unorthodox practices, physical and mind bodysystem therapy, and energy therapy.

Responses were also sought about how often the child usesCM and if this was ever disclosed to the doctors taking care of thechild. Among those using CM, we sought to know if CM had beendiscontinued, especially in the last six months, and if CM wasperceived to be beneficial to the child. Their sources of CM werealso sought using a pre-determined list that included relatives,friends, neighbours, print and electronic media, churches, openmarket advertisement, medical staff, and CM practitioner. Pro-visions were made for the participants to suggest any responsethey considered useful but not included in the pre-determinedlists.

The open-ended section of the questionnaire was on the reasonsfor not disclosing CM use to doctors, an approximate estimate ofthe cost of CM per month, reasons for using CM, perceived benefitsof CM, reasons for discontinuing CM, and adverse effects experi-enced by the child while on CM.

CM was defined according to the classification of the NationalCentre for Complementary and AlternativeMedicine (NCCAM) [16].Complementary or alternative medicines were classified into fivecategories: “Alternative or Unorthodox Medical Systems” (builtupon complete systems of theory and practice. They include ho-meopathic medicine, naturopathic medicine, traditional Chinesemedicine, and Ayurveda), “Mind-Body Interventions” (uses a vari-ety of techniques designed to enhance the mind’s capacity to affectbodily function and symptoms. They include cognitive-behaviouraltherapy, meditation, prayer, mental healing, and therapies that usecreative outlets such as art, music, or dance), “Biologically BasedTherapies” (involve the use of substances found in nature, such asherbs, mega-dose vitamins, and foods), “Manipulative and Body-Based Methods” (these are based on manipulation and/or move-ment of one or more parts of the body. They include chiropractic orosteopathic manipulation and massage), “Energy Therapies” (theyinvolve the use of energy fields and include bio-field therapieswhich affect energy fields that purportedly surround and penetratethe human body- e.g. Reiki and therapeutic touch, and bio-electromagnetic-based therapies that involve the unconventionaluse of electromagnetic fields, such as pulsed fields, magnetic fields,or alternating-current or direct-current fields).

We also extracted from the case files of the children informationabout their HIV confirmation and duration of illness since confir-matory diagnosis, clinical stage of the disease, presence and typesof opportunistic infection, baseline and current viral load and CD4þcount, and current medications, including ART and co-prescribedmedicines for opportunistic or concurrent infection.

Patients who had used CM, at least once, for HIV treatment wereregarded as CM-users, while those who had not used CM at all fortheir present illness were considered non-users.

Table 1 shows how the parents were classified according to theirmonthly income. Low income earners received� ₦ 40,000 (US$250at ₦160 ¼ US$ 1) per month.

The major outcomes measured were the current ART andconcomitant medications of the patients, and the profile of CMutilisation.

Table 1Income classification of parents of HIV-infected children using complementarymedicine.

Income class Income per month (Naira) Income per month(US Dollars; $1 ¼ 160 naira)

Low �40,000 �250Medium 40,000e250,000 �250e1600High 250,000 1600

2.3. Sample size determination

Raosoft� sample size calculator was used to determine thesample size. [33] A sample size of 187 was calculated from the 360population of registered HIV-infected children during the studyperiod using 5% error margin at 95% confidence interval, assuming50% of the patients were using CM and had the heamatological andvirological laboratory results documented in their case files.

2.4. Data collection

The parents or caregivers of HIV-infected children who werewilling to participate in the study were interviewed face-to-face bytrained personnel in a private room.

The interview lasted an average of one hour and was in theappropriate language (English, Yoruba or Pidgin English) that wasunderstood by the participants. The content of the questionnairewas validated by two paediatric resident doctors in two differentHIV/AIDS clinic at the General Hospitals in Lagos (General HospitalIkorodu and Massey Street Children’s Hospital). It was pre-testedon 10 parents and caregivers who were randomly selected fromanother teaching hospital (Lagos University Teaching Hospital,Idiaraba). Thereafter, the necessary amendments were made. Thefew amendments made included the sources of information aboutCM and the estimated cost per month. Some names were added tothe list of CM. The data obtained from the pre-test exercise wereexcluded from the results presented in this study.

2.5. Ethical considerations

The study was approved by the ethics committee of the LagosState University Teaching Hospital (LASUTH), Ikeja. Participantsgave informed consent to participate in the study. Agreement wasreached between the researchers and participants on the use of thedata obtained for scientific purposes. Confidentiality of the infor-mation collected was assured to the participants.

2.6. Statistical analysis

Data were analysed using SPSS version 13. Results are presentedin frequency tables, mean � standard deviation (s.d), and medianwith interquartile range (IQR). Student’s t-test was used to comparecontinuous variables at a 5% level of significance. The open-endedquestions were analysed using simple descriptive statistics.

3. Results

The study involved a total of 187 parents/caregivers and theirHIV-infected children. The parents/caregivers were predominantlyfemale (156; 83.4%) with 103 (54.5%) having at least a secondaryschool education. They were either mostly unemployed or intopetty trading (trade that is conducted on a small scale or sale ofsmall inexpensive items) (128; 68.4%). They also were mostly oflow- and medium- income (146; 77.7%). Forty parents/guardians(31; 16.6%) were not educated at all. The overall mean age of theparents/guardians was 38.2 � 6.2 years.

Majority of the children were female (156; 83.4%), had HIVclinical stage 1 infection (127; 67.9%), and their median agewith therange was 4.6 [IQR (2e9)] years. The mean duration of illness of thechildren was 3.2 � 2.0 years and the mean duration of their clinicattendance was 20.4 � 5.2 months. Opportunistic infections (60;32.1%), tuberculosis (25; 13.4%), and skin infections (27; 14.4%)were the most common problems associated with HIV infection inthe children. All the patients had been treated, at least once, formalaria with artemisinin-based combination therapy.

Table 3Types of CM used by HIV-infected children.

Types of CM Frequency ofCM-users

Percentage ofCM-users (%)

Biological productsHerbs 70 37.4Garlic 34 18.2Lemongrass 26 13.9Ginger 24 12.8Special diet/nutritional therapy 8 4.3Aloe vera� 5 2.7Irish/sweet potato 5 2.7GNLD� product 3 1.6Mega-dose multivitamin 2 1.1Jobelyn� product 1 0.5Forever living� products 1 0.5Total 179 95.8Other unorthodox medical systemsBlessed/anointed oil 39 20.9Concoction soup 30 16.0Blessed/anointed water 21 11.2Black soap bath 18 9.6Honey mixture 13 7.0Olive oil 11 5.9Ayurveda (Habbatus sauda) 7 3.7Quail egg 5 2.7Total 134 71.7Mind-body interventionsSpiritual healing/prayer 181 96.8Total 181 96.8

Forever Living� and GNLD� (Golden Neo Lite Diamite) products are nutritionalhealth supplement and mega-dose multivitamins; Jobelyn� product is an immunebooster nutritional supplement containing Sorghum leaf extract.

K.A. Oshikoya et al. / Complementary Therapies in Clinical Practice 20 (2014) 118e124 121

3.1. Current antiretroviral therapy

Zidovudine e nevirapine- lamivudine (135; 72.2%) was themost prescribed ARV combination. Other combinations prescribedwere zidovudine-abacavir-lamivudine (14; 0.5%), zidovudine-lamivudine-efavirenz (11; 5.8%), nevirapine-abacavir-lamivudine(7; 3.3%), efavirenz-abacavir-lamivudine (6; 3.8%), efavirenz-abacavir- lopinavir/ritonavir (5; 2.7%), abacavir-lamivudine- lopi-navir/ritonavir (4; 2.1%), abacavir-efavirenz-stavudine (3; 1.6%), andefavirenz-lamivudine-stavudine (2; 1.1%).

3.2. Current concomitant medications of the patients

The 25 patients with tuberculosis were treated with a combi-nation of isoniazid-rifampicin-pyrazinamide-ethambutol. Table 2shows the list of frequently co-prescribed drugs used by the pa-tients. Co-trimoxazole and artemisinin-based combination therapywere the most frequently used medicines by all the patients inaddition to their ARV drugs.

3.3. Profile of CM utilisation

CM was reportedly used by 181 (96.8%) patients. Among thesepatients, 77 (41.2%) were currently using CM (users). Of the 77 CM-users, 47 (60.0%) were using CM concurrently with ARV drugs. Theuse of CM was stopped six months prior to the study by 30 (16.0%)patients.

The specific CMs used are listed in Table 3. A total of 494 CMs(either alone or in combination with other CM) were used by thepatients. Spiritual healing and prayer were the most frequentlyused CM (36.6%), followed by biological products (36.2%), and otherunorthodox medical systems (27.2%). Sixty-two patients (33.2%)were usingmore than one biological product at a time. Based on theclassification of CM, none of the patients used energy therapy. Fig. 1indicates that 110 (60.8%) children were using the three forms ofCMs, 33 (18.2%) children were using both biological products andmind-body systems, 10 (5.5%) children were using biologicalproducts and other unorthodox medical systems, and 10 (5.5%)

Table 2List of co-prescribed drugs taken by the HIV-infected patients from the timecommenced on ART to the time of the survey.

Type of medication prescribed Number of patient Percentage ofpatient (%)a

Artemisinin-basedcombination therapy

187 100.0

Co-trimoxazole 187 100.0Multivitamin 70 37.4Cefuroxime 35 18.7Amoxicillin þ clavulanic acid 30 16.0Paracetamol 26 13.9Isoniazid 25 13.4Rifamipicin 25 13.4Pyrazinamide 25 13.4Ethambutol 25 13.4Ascorbic acid 24 12.8Chlorpheniramine 20 10.7Amoxicillin 19 10.2Erythromycin 18 9.6Ampicillin þ cloxacillin 15 8.0Fluconazole 13 7.0Loratadine 9 4.8Metronidazole 7 3.7Prednisolone 7 3.7Griseofulvin 2 1.1

a Each patient was prescribed more than one medication and the list excludedcream, lotion or shampoo prescribed for skin rashes or lesions.

children were using other unorthodox medical systems and mind-body systems.

Relatives, friends and neighbours influenced 67 (37.1%) of theparents and caregivers to use CM for their children. Churches (12;6.6%); traditional herbal medicine practitioners (9; 5.0%); openmarket advertisements (6; 3.3%); and electronic media (4; 2.2%)were the other sources of information about CM to the parents andcaregivers. Eighty-three parents and caregivers (45.9%) did notdisclose their sources of information about CM.

Most of the patients (157; 86.7%) used CM daily; a few usedthem weekly (14, 7.7%) or monthly (10; 5.5%). Only 55 (30.4%)parents and caregivers disclosed the use of CM for their children tothe doctors. Most of the parents/caregivers (99; 54.7%) had nospecific reasons for not disclosing CM use for their children to thedoctors, while 27 (14.9%) parents withheld this informationbecause they were not asked by the doctors. The average cost permonth amongst the majority who used CM every day was ₦ 15,500(US$ 96.88).

The parents/caregivers used CM for their children because oftheir religion/belief (163; 90.1%) or because they perceived herbalmedicines to be of natural sources (65; 35.9%). Other reasons forusing CM included: to promote healthy living of the children (56,30.9%); perceived effectiveness of CM (48; 26.5%); belief that CMboosts body immunity (36; 19.9%); belief that CMs are cheap (33;18.2%); and perception by the parents that CMs are free of anyadverse effects (20; 11.1%).

None of the patients used CM specifically to treat or cure the HIVinfection. CMs were used specifically to treat symptoms such asweight loss (79; 43.7%), cold (40; 22.1%), fever (39; 21.6%), cough(23; 12.7%), and skin rashes (21; 11.6%). Thirty-five (19.3%) of theparents/caregivers observed some benefits of CM in their child thatwere inexplicable, while the majority (72; 39.8%) observed nobenefit. CM was discontinued six months prior to the study by 30patients due to counselling by friends and relatives (21) and advicefrom their doctors (9). None of the patients stopped CM because of

Fig. 1. Multiple response analysis indicating the specific complementary medicinesused by HIV-infected children either singly or in combinations. “A” represents bio-logical products, “B” represents other unorthodox medical systems, and “C” representsmind-body interventions.

K.A. Oshikoya et al. / Complementary Therapies in Clinical Practice 20 (2014) 118e124122

their adverse effects. Specific adverse effects of CMs observed in thepatients by their parents/caregivers were vomiting (14), diarrhoea(14), nausea (13), abdominal pains (12), and headache (5).

The overall mean viral load of the patients decreased from1255.3 � 588.0 copies (baseline) to 1125.8 � 592.0 copies (as attime of the study). There was no significant difference between thechange in the mean viral load for HIV-infected children using bio-logical products and those using non-biological CM (1100.7� 588.6copies and 1311.7�658.8 copies, respectively; p¼ 0.885). Similarly,the overall mean CD4þ count increased from 698.6 � 352.0 cellsmm�1 (baseline) to 812.5 � 477.4 cells mm�1 (as at time of thestudy) (p ¼ 0.048). There was no significant difference between thechange in the mean CD4þ counts of HIV-infected children usingbiological products and those using non-biological CM(828.5 � 482.0 cells mm�1 and 800.4 � 422.0 cells mm�1, respec-tively; p ¼ 0.492).

4. Discussion

Mind-body interventions, specifically spiritual healing andprayers, were the CMs used by most of the patients. In Africa, it iswell documented in history that diseases whose aetiologies wereinexplicable have been given supernatural explanations amongvarious ethnic groups [34,35]. Because HIV infection has no knowncure and definite origin, it has been given a supernatural explana-tion among various ethnic groups in Ghana [34]. Such explanationsof disease causation and treatment outcome may have influencedthe attitude of parents and caregivers of our patients to seek divineinterventions, in the form of spiritual healing and prayers, outsidethe hospital. Despite the continuing educational campaigninforming the general populace that HIV infection is currentlyincurable, many HIV-infected patients in Ghana still attribute theinfection to witchcraft. Therefore, they resorted to using multiplehealth care centres, either serially or simultaneously, hoping thatone of the health facilities would provide a cure or relief, and anexplanation about the source of the infection [34].

The overall prevalence of CM use was 96.8% and it decreased to41.2% six months preceding this survey. The overall CM prevalencewas much lower than the 22% reported among HIV-infected chil-dren in the USA [17] probably because of the differences in thedefinition of CM employed in the two studies. We defined CM ac-cording to the NCCAM which included biological products, otherunorthodox health systems, and body-mind interventions [16],while the American study restricted CM to use of traditional herbalmedicines only [17]. The sample size (187 children) evaluated inour study was much larger than the size (46) evaluated by Ang et al.

in the American study [17]. This also may have accounted for thedifferences in the prevalence rates.

To the best of our knowledge, this study is the first that specif-ically looked into the use of CM among HIV-infected children. Theonly available study compared CM use among HIV-infected chil-dren with those who were having asthma or in healthy states.Paediatric data are, therefore, lacking for comparison with our re-sults. However, when the present CM prevalence was comparedwith the 31e54% reported among children with asthma, sickle cellanaemia and epilepsy, the differences were very considerable[32,36e38]. Differences in parental perception of the illnessaffecting their child may have contributed to the result variations.Parents of children with asthma, sickle cell anaemia, and epilepsyhave been reported to be more knowledgeable about the disease,medications used, as well as their effects and adverse effects [39e41]. In contrast; patients with HIV infection have demonstratedpoor knowledge of the disease and themedications. A survey of 157HIV-infected adults receiving care at a community-based clinic inthe USA showed that a considerable number of the patients couldnot name their ARV drugs, take their medications correctly or knowthe meaning of a CD4þ count or viral load [42]. The majority of thepatients in the survey read up to secondary school educationsimilar to the level of education of themajority of parents evaluatedin our study.

Biological products were the other CMs frequently used forchildren in this study. Excluding special diet and nutritional ther-apy, and mega-dose multivitamins, biological products constituted34.2% of the total CMs used for all the patients. The biologicalproducts were, however, predominantly herbs and herbal products.The use of herbal remedies among HIV-infected adults[15,19,43,44] and children with chronic illnesses [32,37,37,44] iswidespread globally. Duggan et al. [23] has documented that ex-ercise, lifestyle changes, and dietary supplements were more uti-lised than herbal remedies among HIV-infected adults. Thisvariation showed that environment probably influences the typesof CM used for adults and children.

Among the CM-users, 60% were using CM concurrently withARV drugs. Herbal medicines and their products were among themedicines frequently used concurrently with ARV drugs. Similarpractice has been reported in Nigeria [15], America [23], SouthAfrica [19], Brazil [44], and Uganda [45]. In the present study, thepatients were also on regular co-prescribed medicines, such as co-trimoxazole and ACT antimalarial; the patients were, therefore, atrisk for ARV- herb and drugeherb interactions. The risk for adverseherbedrug or herbeARV interactions is likely to be higher amongthe patients who used more than one biological product. Drugeherb interactions have been reported in patients using both herbalCMs and prescribed medications [46,47]. The few patients on Irishand sweet potatoes were at risk for over exposure to ARV drugsbecause of their inhibitory effects on the metabolism and trans-portation of ARV drugs [28], while the considerable numbers ofpatients on garlic were at risk for under-exposure to saquinavir ifincluded in their ART regimen [31]. We did not know if the in-teractions between the herbal remedies and co-prescribed or ARVdrugs were responsible for the adverse effects reported by someparents in this study. Diarrhoea, vomiting, and abdominal painsexperienced by some of the patients have been documented in astudy that evaluated herbal medicine use among HIV-infectedadults in Nigeria [15], South Africa [19], and the United States[20]. These adverse effects may be life-threatening and needs to befurther investigated.

The influence of relatives, friends and neighbours on a patient’sdecision to use CM has been reported in HIV-infected adults [44]and children with chronic illnesses [32,38]. Only 37% of the par-ents sourced CM information for their children from relatives,

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friends and neighbours compared to 80% of the patients in Brazil[44] and 60%e86% of the parents of children with chronic illnesses[32,38] who relied on a similar source of information for CM. Thehigh percentage of parents in this study who did not disclose theirsources of information about CM may have contributed to thediscrepancies in our result and those of the previous studies. This is,however, a major limitation of the study.

Only about one-third of the parents disclosed the use of CM fortheir children to the doctors. Unfortunately most of the parentsgave no specific reasons for not disclosing CM use for their children.This was similar to the low proportion of HIV-infected adults whodisclosed the use of herbal medicine CM to their doctors [19,44],but in contrast to the non-disclosure of CM use for children withchronic illnesses reported in a previous study [32].

Considering the inhibiting and inducing effects of most ARVdrugs on hepatic metabolising enzymes [48], which may ultimatelyaffect the plasma levels of herbal remedies, co-prescribed or ARVdrugs and the fact that 27 (14.9%) parents in this study did notdisclose use of CM in their children because they were not asked,physician should consider CM use as an important part of themedication history when evaluating HIV-infected patients.

There are few previous data on the out-of-pocket cost of CM inthe treatment of HIV infection [19,20,22,27]. Herbal remedies werethe most expensive of the CMs utilised by the patients in SouthAfrica (US$ 16.84 per month) and the United States of America (US$51.67 per month) [19,20]. These were cheaper than the US$ 96.88expended per month on CM in the present study. Since most of theparents surveyed in this study were low- and middle-incomeearners, the present cost of the CM is substantial and may add tothe financial burden on the parents.

CM therapy has been used for HIV-infected patients to treatweight loss [20], to improve immunity [15,19]; to relief pain andstress or improve their overall well-being [19]; to reduce fever andtreat cough [45]; and to treat other symptoms of the infection [44].It is therefore not surprising to see the parents used CM symp-tomatically to treat their children for weight loss, cold, fever, cough,and skin rashes.

It is important to note that there was a marginal but not sig-nificant decrease in the viral loads of children who used biologicalCMs compared to those who used alternative medical systems. Incontrast, the CD4þ count marginally but not significantly increasedin children who used biological CMs compared to those who usedother unorthodox medical systems. These may suggest a benefit ofbiological CMs over other unorthodoxmedical systems and calls fora critical evaluation of the role of herbal remedies in the manage-ment of HIV-infected children as well as the clinical trials of bio-logical CMs.

This study has focused on evaluating CM use in HIV-infectedchildren. A comparative study with a control cohort of non-HIVinfected Nigerian children would perhaps provide more informa-tion about CM use. The findings of this study may not be general-ised to HIV-children in other states in Nigeria or those patients whodid not seek hospital treatment.

The cross-sectional study design did not permit an investigationof the interactions between ARV or co-prescribed drugs and CM.We could not exclude recall bias of the parents in a self-reportedstudy like this.

5. Conclusions

CM is commonly used by HIV-infected children in Lagos, Nigeriafor symptomatic treatment of the associated problems. There wereinconsequential adverse effects associated with CM in HIV-infectedchildren. Most of the parents did not disclose CM use for theirchildren to the doctors. Paediatric doctors should find out about use

of CM when taking medication history from the parents of HIV-infected children so as to avert potential adverse herbedrug orherbeARV drug interactions. Clinical trials of the biological CMsshould be performed to ensure these products are safe for HIV-infected children.

Conflict of interest

All the authors have no conflict of interest to declare.

Acknowledgements

We are indebted to the paediatric nurses at the outpatient clinicin the centre for this study.

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