Reasons,Perceived Efficacy,and Factors Associated with Complementary and Alternative Medicine Use Among Malaysian Patients with HIV/AIDS

Abstract

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.

Introduction

I n Malaysia, use of complementary and alternative medicine (CAM) for disease prevention and treatment is prevalent in patients with chronic diseases.^1

–4 Interestingly, about 80% of the population in Africa and Asia rely on traditional medicine as the primary therapeutic modality.⁵ Similarly, 70%–80% of the population in developed countries has been using CAMs for decades.⁵ The cumulative incidence rate of CAM use among human immunodeficiency virus (HIV)-positive people has been varied in a wide range of 30%–100%.⁶ This variation is often dependent on the definition used. Sometimes, the existence of an arbitrary boundary between CAM and conventional therapies is the reason for such variation.⁷

CAM use has increased in popularity among HIV-positive individuals in recent years. Vitamins and dietary supplements, massage, and acupuncture are the most common CAM modalities used by these individuals.^7,8

–12 Despite undergoing highly active antiretroviral therapy (HAART), a significant number of patients with HIV/AIDS use CAM as additional armament in their combat against HIV/AIDS, regardless of the regions in which they live. A study by Fairfield et al. reported that 76% of HIV-infected patients use CAM.⁷ In Europe, approximately 60% of HIV/AIDS respondents were using CAM, while 42.9% reported using more than two types.⁸ In Uganda, about 64% of respondents were using CAM after they were diagnosed with HIV, and 32.8% of them were taking CAM together with antiretroviral drugs.¹³ In the Asia-Pacific region, it was found that 56% of Australians¹⁴ and 95% of Thais¹⁵ with HIV/AIDS were using CAM. Interestingly, it was found that only 4.0% of participants in South Africa¹⁶ and 1.4% of participants in Boston, US⁷ had refused to take HAART and utilized CAM exclusively to treat their infection.

Despite the widespread use of CAM, little is known about the characteristics of HIV-infected CAM users. Studies conducted on a general population in Australia and the United States showed that CAM use is more commonly reported among more educated, younger females with higher income.^17,18 However, HIV-positive individuals in South Africa, who were rural residents with no or little income and more HIV-related symptoms, were also found to use CAM.¹⁶ The findings of this study were similar to those of a Swedish study except for education level, which was not found to be associated with CAM use.¹⁹ Moreover, no correlation was found between income level and CAM use in United States.²⁰ Nonetheless, traditional medicine was the most common CAM among HIV-infected individuals in Uganda (90.4%),¹⁴ while religious healing such as ritual remedies were commonly used in Thailand (84%).¹⁵

On the other hand, in regard to the frequency of visiting CAM providers, participants with higher education levels as well as those who were perceived as having poor health consulted CAM providers more frequently than the rest.¹⁹ Similarly, a study by Agnoletto et al. reported that CAM use is less common in patients who adhere to HAART and more common in patients who experience side-effects of HAART.⁸ It was also found that people living with HIV/AIDS do not like to inform health care professionals about CAM use.¹⁶ In contrast, many studies reported that almost half of the participants would discuss with health care providers before they start taking CAM.^7,21,22 Consequently, people who are taking ART give priority to strengthening the immune system as well as relieving symptoms by taking CAM.^7,10,13 It has been observed that advice from family and friends on CAM may influence patients with HIV/AIDS to use CAM. Seventy percent (70%) of the participants felt that CAM had improved their quality of life.¹² However, the researchers were not able to find a correlation between CAM use and CD4 counts and viral load readings.^{8,9,11,12,16,20,22,23} A study in Uganda showed that 93.9% of participants on CAM had a CD4 count lower than 200 cells/μL.¹⁶

The use of alternative medicine may be triggered by various factors that eventually could direct the person toward CAM, such as discontent with conventional medicine, the need for ideological congruence, and the need for personal control. This cross-sectional study was intended to assess the use of CAM among individuals infected with HIV/AIDS, reasons for CAM use, perceived effect of CAM, and factors associated with CAM use.

Materials and Methods

This was a cross-sectional study carried out on randomly sampled individuals infected with HIV/AIDS, at Malaysian HIV/AIDS referral clinics in the Hospital Sungai Buloh, Malaysia. The sociodemographic characteristics and clinical variables such as diagnosis, CD4 count, viral load and conventional treatment were recorded from the computerized medical records. However, to minimize the ambiguity, sociodemographic characteristics were reconfirmed at the start of the interview. The sample consisted of individuals either infected with HIV/AIDS alone or in combination with other medical conditions, whether on conventional treatment for HIV/AIDS (antiretroviral drugs) with or without CAM.

The calculated sample size was 377 with an estimated dropout rate of 20%. Out of a total HIV/AIDS population of about 94,573, prevalence is highest among Malays (0.461%), followed by Chinese (0.221%).²⁴ The simple random sampling technique was used, where randomization was carried out using patients' medical record numbers. Based on the randomization procedure adopted for this study, every fifth patient attending the clinic was selected from a pool of an average 60 patients per day. A total of 400 patients with HIV/AIDS attending the clinics were randomly approached. However, at the end of the data collection phase, 330 patients agreed to be interviewed. Five (5) of them were excluded because they did not meet the inclusion criteria. Thus, the final sample size was 325. The data collection form that was used as a tool in this study consisted of four sections: section A for sociodemographic factors, section B for clinical variables, section C for details of CAM use, and section D for factors associated with CAM.

A 15–20-minute interview was carried out to gather the necessary information regarding perceived efficacy of CAM on disease status, influential factors to start CAM, reasons for taking CAM, types of CAM used, number of visits to the practitioner, and disclosure of CAM use to the health care professionals. The study information sheet was shown and consent (either verbal or written) was obtained from all the recruited patients prior to the interview. Then each subject was asked, ‘‘Have you ever used CAM for HIV/AIDS or HIV related problems?’’ This question was considered the screening question. A study participant was defined as “case” when answer was “yes,” while the control was the HIV-positive subject who answered ‘‘no’’ to the screening question. Information confidentiality was assured to all the study participants. Name and identity card number of study participants were not taken so as to assure the confidentiality and anonymity of the patients. Depending on their willingness, participants were given an option for an interview to be conducted in a waiting area or in a seminar room.

Both descriptive and inferential data analyses were applied with the aid of SPSS^® version 13.0, and variables were taken to be statistically significant at p ≤ 0.05. Statistical tests, such as χ² test or multinomial test (to examine the association between variables), Spearman's correlation test (to examine the correlation between variables), and the Mann–Whitney test (to find the difference between variables), were used where appropriate. The study was approved by the research and ethics committee, director of the hospital, head of the infectious diseases department, and the pharmacy department.

Results

Sociodemographic characteristics

Out of 325 patients interviewed, 254 of them were using some kind of CAM and were labeled as “case,” while 71 patients were labeled as “control” or non-CAM users. The majority of the CAM users were male (225/254), aged between 31 and 45 years (142/254), and were Chinese (142/254). Most of the CAM users (120/254) were educated up to secondary school level, working adults (188/254), and resided in urban areas (212/254). About three quarters of CAM users reported earning at least RM 1000 (USD 293.169) per month. The sociodemographic characteristics of CAM and non-CAM users are presented in Table 1. 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.

Table 1.

Comparison of Sociodemographic Characteristics of CAM and Non-CAM Users

Variables	CAM users n/N^*	Non-CAM users n/N^**
Gender
Male	225/254	59/71
Female	29/254	12/71
Age groups
18–30	43/254	12/71
31–45	142/254	43/71
46–60	65/254	15/71
>60	4/254	1/71
Ethnic groups
Malay	74/254	13/71
Chinese	142/254	42/71
Indian	23/254	7/71
Others	15/254	9/71
Education
No formal education	4/254	1/71
Primary education	43/254	16/71
Secondary education	120/254	43/71
Graduate	82/254	11/71
Postgraduate	5/254	0/71
Employment status
Unemployed	50/254	20/71
Labor	125/254	37/71
Professional	63/254	8/71
Student	4/254	1/71
Housewife	7/254	4/71
Retired	5/254	1/71
Residence
Rural	42/254	15/71
Urban	212/254	56/71
Household income
No income	23/254	21/71
<1000 RM (<USD 293.169)	43/254	16/71
1100–3000 RM (USD 322.486–879.507)	116/254	25/71
3100–5000 RM (USD 908.824–1465.84)	38/254	8/71
>5000 RM (>USD 1465.84)	34/254	1/71

N* = 254, N** = 71.

CAM, complementary and alternative medicine.

Types of CAM utilized by the study participants

Among the types of CAM, vitamins and supplements were found to be the most frequent CAM used by the participants (52.6%), followed by herbal products (33.8%) and massage (16.6%). Among the herbal products, Traditional Chinese Medicine (25.2%) was the most frequently used CAM compared to traditional Malay medicine (5.5%). Only 20.3% of participants reported visiting CAM practitioners such as masseur/masseuse (16.6%), traditional healer (1.5%), and acupuncturist (1.2%). The types of CAM utilized by the study participants are listed in Table 2.

Table 2.

List of CAM Utilized by the Study Sample (n = 254)

Type	N	%
Vitamins & supplements	171	52.6%
Vitamins	159	48.9%
Supplements	12	16.0%
Herbal products	110	33.8%
TCM	82	25.2%
TMM	18	5.5%
TIM	6	1.8%
Others	4	1.2%
Massage	54	16.6%
Energy drink	53	16.3%
Spiritual praying	46	14.2%
Yoga	16	4.9%
Natural product	13	4.0%
Meditation	13	4.0%
Diet-based therapy	8	2.5%
Traditional healers	5	1.5%
Resdung	2	0.6%
Malay bomoh	2	0.6%
Chinese bomoh	1	0.3%
Acupuncture	4	1.2%
Homeopathy	3	0.9%
Qigong	3	0.9%
Aromatherapy	3	0.9%
T'ai chi	2	0.6%
Colon hydrotherapy	1	0.3%
Candle therapy	1	0.3%
Urine	1	0.3%
Color therapy	1	0.3%
Ice therapy	1	0.3%
Step on hot stone	1	0.3%

CAM, complementary and alternative medicine; TCM, Traditional Chinese Medicine; TMM, traditional Malay medicine; TIM, traditional Indian medicine.

Reasons for using CAM

Recommendation from health care professionals was the most common reason for participants to use vitamins and supplements (41.8%), followed by maintaining good health (38.5%). Similarly, reduce body heat (14.8%) and improve health (12.9%) were the two main reasons reported by the herbal drug users. Significant numbers of participants reported seeking help from traditional healers (14.2%) to cure or treat HIV/AIDS. Besides that, different types of massage and energy drinks were also used by the participants to combat fatigue (5.5%) and replenish energy (9.2%), respectively. A significant number of participants were using CAM to treat HIV/AIDS (25.8%) and its associated symptoms (17.2%).

Perceived efficacy of CAM

One third of the study participants felt that they are as healthy as people without HIV/AIDS and 34.7% of them felt that they have poor health compared to 24.9% who perceived that they are healthier than HIV-negative individuals. Among the participants who perceived themselves healthier, 13.8% of them reported CAM as the underlying reason that keeps them healthier than individuals without HIV/AIDS. About 35% felt that CAM utilization has nothing to do with self-perceived poor health. Interestingly, 40% of the participants felt that CAM has improved their health, and none of them felt that his/her health condition has deteriorated after CAM use. The details of CAM use and their effects reported by the participants is presented in Table 3.

Table 3.

Detail of CAM Use and Its Perceived Effect Reported by Study Population (n = 325)

Variables	n	%
Visit to CAM practitioner
Monthly	59	18.2%
Once daily	32	9.8%
Weekly	22	9.8%
2–3 times weekly	3	0.9%
Type of combination
CAM + OCM + ART	105	32.3%
CAM only	63	19.4%
CAM + ART	61	18.8%
ART + OCM	27	8.3%
ART only	26	8.0%
CAM + OCM	23	7.1%
No medication	12	3.7%
OCM only	8	2.5%
Purpose of CAM
Health management/boosting immune system	220	67.7%
HIV/AIDS	84	25.8%
Symptomatic treatment	56	17.2%
Other co-morbidity	0	0%
Rating of health by the patients
Fair	122	37.5%
Poor	71	21.8%
Very poor	51	15.7%
Good	43	13.2%
Very good	38	11.7%
If health is good or very good, is it due to CAM use?^*
Yes	35	50.7%
No	34	49.3%
If health is poor or very poor, is it due to CAM use?^**
Yes	4	4.4%
No	87	95.6%
Desired effect from prescribed medication
Yes	213	65.5%
No	44	13.5%
Not taking Rx medication	68	20.9%

n = 69, **n = 91.

CAM, complementary and alternative medicine; OCM, other conventional medication, ART, antiretroviral therapy; HIV/AIDS, human immunodeficiency virus/acquired immune deficiency syndrome.

Factors associated with CAM use

Factors such as maintaining general health (21.5%), family history of CAM use (20.6%), and own belief (10.2%) were the three most common factors reported by the participants for using CAM. In addition, participants reported family members (27.1%), friends (20.3%), and health care professionals (16.6%) as the main influential factors to start CAM. The majority of the CAM users did not consult doctors (68%) or pharmacists (83.7%) regarding their CAM use, where most of them reported that it is not important to inform health care providers (29.5%). The list of factors associated with CAM use reported by the study population is presented in Table 4. No significant differences were found between CAM and non-CAM users in terms of their current and within last 3 months CD4 count and viral load recorded readings. However, CD4 count beyond 3 months' time was found to be significantly different (p = 0.003), where CAM users were found to have higher CD4 counts and reduced viral load.

Table 4.

Factors Associated with CAM Use Reported by the Study Population (n = 325)

Variables	N	%
Factors that encourage patients to use CAM
Health maintenance	70	21.5%
Family history of CAM use	67	20.6%
Own belief	33	10.2%
Self-explore	20	6.2%
Health care providers (doctor)	17	5.2%
Religion	11	3.4%
Boost immune system	11	3.4%
Due to adverse effects of drugs prescribed by the doctors	8	2.5%
Tradition	8	2.5%
Friends	4	1.2%
Rehab center	4	1.2%
Lack of trust on medical treatment	3	0.9%
Curiosity	3	0.9%
Job exposure	2	0.6%
Due to price of allopathic drugs	0	0%
Reasons for nondisclosure
Not important for them to know	96	29.5%
Doctor/pharmacist never asked	57	17.5%
Not ready to inform	24	7.4%
Never thought of that	7	2.2%
Doctor/pharmacist would disapprove	6	1.8%
Doctor/pharmacist don't know about CAM	1	0.3%
Effect of CAM use on patients' health
Improved	160	40.2%
No changes	86	26.5%
Improved but developed unwanted effects	8	2.5%
Worse than before	0	0%
Not applicable	71	21.8%
Reporting of CAM use to doctors
Yes	104	32.0%
No	221	68.0%
Consultation of CAM use with pharmacist
Yes	53	16.3%
No	272	83.7%

CAM, complementary and alternative medicine.

Discussion

About 78% of the study subjects reported using CAM. This percentage of CAM use is relatively higher than those found in studies conducted in Australia (55%)²⁵ as well as in Canada (39%).²⁶ However, it is almost similar to the study by Fairfield et al.,⁷ where 76% of the participants were CAM users, the percentage that fell within the range of 30%–100% reported by the British Medical Association.⁶ It was found that education level (p = 0.021,r_s = 0.148), household income (p = 0.001,r_s = 0.260) as well as family history of CAM use (p = 0.001, r_s = 0.231) were significantly associated and positively correlated with CAM use. This finding is supported by studies carried out on individuals with HIV/AIDS that reported that CAM use is most prevalent among individuals having better education, sustainable monthly income, and family history of CAM use.^17,18 Although the prevalence of HIV/AIDS is highest among Malays (0.461%) followed by Chinese (0.221%), CAM use was found to be more prevalent among Chinese compared to Malays in this study. This could be explained by the participation of a larger number of Chinese participants than Malays. This in turn could over-represent CAM use as more prevalent among Chinese than Malays.

Vitamins and supplements were the most frequent types of CAM used by the participants, where nearly half of them were taking vitamins such as vitamin C, E, and multivitamins. This finding is in line with the studies carried out in the United States⁷ and Canada.¹⁰ According to the ART policy in Malaysia, 2 weeks of vitamin therapy is prescribed when a subject is qualified to be on ART. The purpose of vitamin therapy is to ensure medication compliance in order to achieve a sustainable viral suppression. It is supported by a study that effective viral suppression can only be seen in subjects who were having at least 95% of ART compliance.²⁷ Nevertheless, people who are receiving indinavir should be advised to stop taking vitamin C because the concentration of indinavir in blood decreases by 20% when indinavir is given concurrently with vitamin C.²⁸ Therefore, disclosure of CAM use to health care professionals plays a vital role in minimizing undesired effects. A substantial number of participants were using massage therapy to relieve body fatigue or to rejuvenate mentally. A study suggested that massage could reduce stress level by lowering cortisol and thereby increase the levels of CD4 and CD8 counts, which in turn boost the immune system.²⁹

Currently, herbal products are gaining popularity in the treatment and prevention of various diseases. In Africa, studies reported that herbal products are mainly used to relieve the symptoms associated with HIV/AIDS.^14,30 Similarly, herbal products such as Chinese herbal tea, ginseng (Quinquefolium), and Tongkat Ali (Eurycoma longifolia) were the most commonly used herbal products among participants in this study to relieve body heat and maintain health. In this study, about 20% of participants reported visiting CAM practitioners. This finding is in accordance with a study done by London et al., ²³ wherein about 15% of study participants reported visiting practitioners. Interestingly, significant numbers of study participants (19.4%) used CAM exclusively as compared to 4% in South Africa¹⁶ and 1.4% in the United States.⁷

Regarding perceived effect of CAM use, nearly 38% of those studied reported that they were as healthy as normal HIV-negative individuals. Surprisingly, 27% (69/254) of CAM users claimed that they were healthier than normal HIV-negative individuals, which might be due to the beneficial outcome of positive mindset. Although more than one third of CAM users (35.8%, 91/254) reported poor health, the majority of them (95.6%) believed that CAM was not the source that made them unhealthy, suggesting a reality based approach of these HIV-positive patients along with awareness towards their condition. They also thought that it is the HIV that weakens their immune system. Most of them (40.2%) reported that their health status had improved, while none of them complained of poor health after taking CAM. In addition, no significant differences were found between CAM and non-CAM users in terms of their CD4 and viral load readings. However, CAM users found to have relatively lower CD4 counts and viral load. Similarly, about 70% of the CAM users in the United States perceived that CAM had improved their quality of life. However, no correlation was found between CAM use and CD4 and viral load readings.¹²

Regarding influential factors, most of them reported using CAM upon the influence of family members (27.1%). In addition, some of them were also seeking information from the mass media (8.6%) after being infected with HIV/AIDS. This finding is consistent with the study conducted in Thailand.¹⁵ People living in Malaysia grow up in an environment where CAM is commonly use for minor to severe ailments. CAM practices among family members, relatives, and friends also help in spreading CAM use and its practice. Besides that, about 17% of the study participants reported that their CAM use was inspired by health care professionals and the same situation was highlighted in a study done by Duggan et al.¹²

Interestingly, none of the participants reported using CAM due to the unaffordable price of ART. ART subsidization is believed to be the most appropriate underlying rationale. The government of Malaysia made a historical decision in June 2004 to subsidize at least two ART drugs.³¹ According to the National HIV/AIDS Treatment Registry,³¹ 84% of the recruited participants were either fully or partially subsidized by the government, and only 13% of them were self-funded. Despite the side-effects experienced by the study participants, about 68% and 84% of them did not disclose their CAM use to doctors and pharmacists, respectively. Underlying reasons for nondisclosure were (1) unnecessary to disclose, and (2) health care professionals never asked regarding CAM use. Besides that, some studies reported mandatory disapproval from doctors and their negative opinion toward choice of CAM as perceived reasons of nondisclosure of CAM use.^32,33 Nevertheless, the majority of the participants in other studies were not reluctant to discuss CAM use with health care professionals.^7,22,28

Conclusions

This study confirmed the range of 30%–100% CAM use among individuals infected with HIV/AIDS. CAM use was significantly associated and positively correlated with education level, monthly household income, and family history of CAM use. About half of those who rated their health as good or very good perceived it to be as a result of CAM use. On the other hand, nondisclosure to health care professionals was prevalent among CAM users living 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 people with HIV/AIDS.

Footnotes

Disclosure Statement

No competing financial interests exist.

References

Hasan

, Ahmed

, Bukhari

, Cheah

. Use of complementary and alternative medicine among patients with chronic diseases at outpatient clinics. Complement Ther Clin Pract, 2009; 15:152–157.

Mahfudz

, Chan

. Use of complementary medicine amongst hypertensive patients in a public primary care clinic in Ipoh. Med J Malaysia, 2005; 60:454–459.

Mokhtar

, Chan

. Use of complementary medicine amongst asthmatic patients in primary care. Med J Malaysia, 2006; 61:125–127.

Remli

, Chan

. Use of complementary medicine in systemic lupus erythematosus patients in Malaysia. APLAR J Rheumatol, 2003; 6:21–25.

World Health Organization (WHO). Media Centre. Traditional Medicine. 2008. www.who.int/mediacentre/factsheets/fs134/en/index.html. 2009 July 4.

British Medical Association (BMA). Complementary Medicine: New Approaches to Good Practice. 2004. www.bma.org.uk/ap.nsf/content/publicpetitioncam. 2009 July 1.

Fairfield

, Eisenberg

, Davis

. Patterns of use, expenditures, and perceived efficacy of complementary and alternative therapies in HIV-infected patients. JAMA, 1998; 158:2257–2264.

Agnoletto

, Chiaffarino

, Nasta

et al. Use of complementary and alternative medicine in HIV-infected subjects. Complement Ther Med, 2006; 14:193–199.

Mikhail

, DiClemente

, Person

et al. Association of complementary and alternative medicines with HIV clinical disease among a cohort of women living with HIV/AIDS. J Acquir Immune Defic Syndr, 2004; 37:1415–1422.

10.

Dhalla

, Chan

, Montaner

JSG

, Hogg

. Complementary and alternative medicine use in British Colombia: A survey of HIV positive people on antiretroviral therapy. Complement Ther Clin Pract, 2006; 12:242–248.

11.

Kirksey

, Goodroad

, Kemppainen

et al. Complementary therapy use in persons with HIV/AIDS. J Holist Nurs, 2002; 20:264–278.

12.

Duggan

, Peterson

, Schutz

et al. Use of complementary and alternative therapies in HIV-infected patients. AIDS Patient Care STDS, 2001; 15:159–167.

13.

Klassen

, Kipp

, Jhangri

, Rubaale

. Use of traditional herbal medicine by AIDS patients in Kabarole District, Western Uganda. Am J Trop Med Hyg, 2007; 77:757–763.

14.

Visser

, Ezzy

, Bartos

. Alternative or complementary? Nonallopathic therapies for HIV/AIDS. Altern Ther Health Med, 2000; 6:44–52.

15.

Wiwanitkit

. The use of CAM by HIV-positive patients in Thailand. Complement Ther Med, 2003; 11:39–41.

16.

Peltzer

, Preez

, Ramlagan

, Fomundam

. Use of traditional complementary and alternative medicine for HIV patients in KwaZulu-Natal, South Africa. BMC Public Health, 2008; 8:255.

17.

Eisenberg

, Davis

, Ettner

et al. Trends in alternative medicine use in the United States 1990–1997: Results of a follow-up national survey. JAMA, 1998; 280:1569–1575.

18.

Goldbeck-Wood

, Dorozynski

, Yamauchi

et al. Complementary medicine in booming worldwide. BMJ, 1996; 313:131–133.

19.

Windi

. Determinants of complementary alternative medicine (CAM) use. Complement Ther Med, 2004; 12:99–111.

20.

Felton

, Vosvick

, Power

et al. Alternative therapies: A common practice among men and women living with HIV. J Assoc Nurses AIDS Care, 2003; 14:17–27.

21.

Piscitelli

, Burstein

, Chaitt

et al. Indinavir concentrations and St John's wort. Lancet, 2000; 355:547–548.

22.

Chang

, Servellen

, Lombardi

. Factors associated with complementary therapy use in people living with HIV/AIDS receiving antiretroviral therapy. J Altern Complement Med, 2003; 9:695–710.

23.

London

, Foote-Ardah

, Fleishman

, Shapiro

. Use of alternative therapists among people in care for HIV in the United States. Am J Public Health, 2003; 93:980–987.

24.

Malaysian AIDS Council. 2008. Annual Report. www.mac.org.my/attachment/report2008.pdf. 2009 October 20.

25.

Visser

, Grierson

. Use of alternative therapies by people living with HIV/AIDS in Australia. AIDS Care, 2002; 14:599–606.

26.

Ostrow

, Cornelisse

, Heath

et al. Determinants of complementary therapy use in HIV-infected individuals receiving antiretroviral or anti-opportunistic agents. J Acquir Immune Defic Syndr Hum Retrovirol, 1997; 15:115–120.

27.

Paterson

, Swindells

, Mohr

et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Ann Intern Med, 2000; 133:21–30.

28.

Palmer

. Use of complementary therapies to treat patients with HIV/AIDS. Nurs Stand, 2008; 22:35–41.

29.

Deigo

, Field

, Hernandez-Reif

et al. HIV adolescents show improved immune function following massage therapy. Int J Neurosci, 2001; 106:35–45.

30.

Mills

, Singh

, Wilson

et al. The challenges of involving traditional healers in HIV/AIDS care. Int J STD AIDS, 2006; 17:360–363.

31.

Christopher Lee

. The first report of the National HIV/AIDS Treatment Registry, 2003 Kuala Lumpur: National HIV/AIDS Treatment Registry (NHATR), 2005.

32.

Southwell

, Valdez

, Lederman

, Gripshover

. Use of alternative therapies among HIV-infected patients at an urban tertiary care center. J Acquir Immune Defic Syndr, 2002; 31:119–120.

33.

Hsiao

, Wong

, Kanouse

et al. Complementary and alternative medicine use and substitution for conventional therapy by HIV-infected patients. J Acquir Immune Defic Syndr, 2003; 33:157–165.