Abstract
Little is known about the use of complementary medicines by people living with HIV in Australia since the advent of more effective combination antiretroviral therapy. We conducted an anonymous survey of 1211 adult patients receiving combination antiretroviral therapy from one of eight specialist HIV clinics across Australia, aiming to identify the current patterns of use of ingestible complementary medicines. Data collected included reasons for use, information sources and rates of disclosure of use of complementary medicines to medical practitioners and pharmacists. Ingestible complementary medicine was used by up to 53% of the 1037 patients returning a survey. Complementary medicine was commonly used for general health, to boost immune function and, to a lesser extent, to address co-morbidities. Disclosure of complementary medicines use to doctors was far higher than to pharmacists. Given the potential for interactions, pharmacists should be more aware of patients’ complementary medicines use.
Keywords
Introduction
The early pharmaco-therapeutic treatment of HIV featured complex dosing schedules and significant side-effects, prompting some people to use complementary medicine (CM) as a means of managing treatment-related symptoms. Surveys conducted predominantly in the United States indicate that CM was used by people living with HIV (PLHIV) to address treatment side-effects and as a strategy to improve quality of life.1–4 Similarly, a survey conducted in seven European countries found that CM was used to prevent or alleviate antiretroviral (ARV) drug therapy side-effects; the most popular CM approaches were nutritional supplements and psycho-physiological therapies. 5
During the late 1990s, treatment changed substantially; combination antiretroviral therapy (cART) became simpler to take and less likely to cause problematic side-effects. Despite the evolution of ARV therapies, CM is still utilised by some PLHIV; however, there is relatively little information about the reasons for use of ingestible CM in Australia since the advent of cART. 6
In 1999, a survey of 924 PLHIV in Australia identified that 55% had used CM therapies and supplements, often as an adjunct to ARV drugs. The most popular ingestible therapies reported were nutritional supplements and herbal medicine. 7 In 2001, a study in Melbourne found 49% of 151 patients surveyed had used CM to ‘manage their HIV/AIDS’ and 5% used CM to treat their HIV infection. The main reason for use was to improve personal wellbeing rather than dissatisfaction with conventional treatments. 8 Unfortunately, neither survey provided detailed information about specific CM treatments being used.
The most recent Australian Research Centre in Sex, Health and Society ‘HIV Futures’ survey (HIV Futures Seven, 2013) confirmed PLHIV continue to use CM, identifying that of 1058 respondents, 62.5% used nutritional supplements, 11.6% traditional Chinese medicine and 18% herbal therapies. 9
The primary aim of this study was to estimate the prevalence of ingestible CM use by Australian PLHIV taking cART. Secondary aims were to determine the specific types and reasons for CMs used, the potential for interactions with cART, prescribers of CM products, and information sources and rates of disclosure of CM use to medical practitioners and pharmacists.
Methods and materials
A questionnaire was developed following a literature review. Some questions were adapted from a national pharmacy consumer survey, 10 the HIV Futures Six survey 11 and a safety questionnaire 12 ; other questions were newly devised.
Complementary medicine was defined on the front of the questionnaire as ‘herbal medicines, vitamin and mineral supplements, and other nutritional supplements which can be bought in a supermarket, pharmacy, health-food store, on the internet, from a mail order company or from a practitioner. It does not refer to complementary therapies such as massage, acupuncture or chiropractic, unless specified’. This definition was used in a previous Australian survey. 10
The survey consisted of 37 questions, detailing socio-economic and demographic information, recent medical history, medication and healthcare services used (conventional and CM). Participants reporting CM use in the previous 12 months were asked additional questions pertaining to reasons for CM use, prescribers of CM, information sources, disclosure to medical doctors and pharmacists and attitudes to CM.
Patients attending HIV outpatient clinics at the eight study sites were considered eligible for inclusion if they were over 18 years of age, could read English and were able to complete the survey unaided. The data collection period lasted up to 3 months at each site between October 2011 and November 2012.
Patients presenting their prescription for cART were invited to participate in the study. The anonymous questionnaire was given to potential participants to complete on-site. Patient consent was implied upon return of the completed questionnaire. Human research and ethics committee approval was obtained at each individual study site.
Statistical analysis was performed using SAS version 9.2 (SAS Institute Inc., Cary, NC, USA). Group comparisons were performed using Chi square tests for equal proportions or Fisher’s exact tests where numbers were small. A two sided p value of 0.05 was considered to be statistically significant.
Results
Overall, 1037 surveys were returned (86% response rate). Fifty-eight percent of respondents resided in NSW, 28.5% in Victoria, 12% in Western Australia and 1.5% in other states. Most respondents were men, homosexual, rated their health as very good or excellent and had an undetectable viral load at their last test.
A broad range of ARVs were taken by this group; tenofovir-based therapies were taken by 61% of participants, raltegravir by 20%, efavirenz by 26% and nevirapine by 18%. Of the protease inhibitors, atazanavir (19%), darunavir (10%) and lopinavir (9%) predominated.
Within the previous week, 50% of respondents had taken a CM product, and up to 53% reported CM use during the previous 12 months. Most (79%) were daily users of CM, while 11% used it when required.
Proportion of complementary medicine (CM) users compared to non-users.
ns: not significant.
The most common nutritional supplements and herbal medicines taken in the previous 12 months.
Contents of multivitamins unspecified.
Many CM users (60%) self-prescribed their herbal medicines and nutritional supplements. Some reported taking CMs recommended by others: 31% followed the recommendation of HIV physicians, 22% general practitioners, 11% friends and 6% family. Few people were recommended CMs by pharmacists (4%), dieticians (4%), naturopaths (5%) or health food store staff (5%).
Multiple sources of information about CM were used, in particular; medical doctors (53%), Internet (39%), friends (23%), pharmacists (21%), HIV-related publications (18%), books/newspapers/magazines (16%) and health food store staff (13%).
Most patients (68%) using CM in the previous month spent less than AUS $50 per month on supplements.
Most PLHIV using CM products (77%) had informed their doctor. The main reasons for non-disclosure were that they were not asked (23%) or did not think it was relevant (15.5%).
Fewer people taking CMs had told their pharmacist (35%). The main reasons reported for not discussing use with a pharmacist were not being asked (46%), not thinking it was relevant (36%) and feeling they already had good advice (17%). Additional comments indicated that respondents: felt their medical practitioner provided sufficient advice, had not thought to discuss use with a pharmacist, did not have confidence in pharmacists’ knowledge about CM and were concerned about privacy issues.
The main reasons reported for using CM products are presented in Figure 1. Improving general health and wellbeing, improving immune function, reducing fatigue/increasing energy were the most popular responses.
Top 10 reasons reported for using complementary medicines (n = 580).
Discussion
This multi-centre study identified that up to 53% of PLHIV taking cART are also using ingestible CM. The proportion of people using CM products does not vary significantly by age group, gender, location of residence, sexual orientation, self-reported health status, viral load or CD4 cell count. Over three-quarters of CM users tell their medical practitioner about use; disclosure to pharmacists is less common.
Our study identified that relatively few PLHIV (19%) use CM to address treatment side-effects. This contrasts with past figures of 39% utilising CM to reduce side-effects of drug therapy. 8 The observed decrease may reflect the improved tolerability of modern cART, or a reduced awareness of ARV side-effects. Our questionnaire did not assess participants’ connection between their cART, specific ARV-related adverse events nor choice of CM/conventional medicine to remedy these. However, of 109 respondents using CM to ‘treat ARV side-effects’, 56 also reported sleeping difficulties and 24 hyperlipidaemia, problems associated with efavirenz, and both protease inhibitors and efavirenz, respectively. All those reporting hyperlipidaemia were taking both fish oil and cART associated with this adverse effect. Of 23 respondents using CM to ‘treat insomnia’, 10 used valerian or ‘natural sleep formula’; however, only two were taking efavirenz.
Despite the continued good to excellent self-reported general health of PLHIV since 2001,7,8 37% of our participants reported depression or anxiety as a health concern. Twenty-three percent of participants described using CM to reduce stress and anxiety, and 9% for depression, however, the use of St John’s wort, often used to treat depression, was low.
The majority of people in this study used vitamin and mineral supplements, a pattern of use consistent with the general Australian population.10,13 Additionally, the use of fish oil and glucosamine supplements was similar to the general population. 10 The high use of fish oils and vitamin D in our study may be related to prescribing by HIV physicians, ready availability at the centres where the survey was conducted and the evidence suggesting potential benefits relevant to this population such as increased mortality with low vitamin D status. 14
Other popular CMs amongst our study cohort were probiotics and protein supplements, a pattern of use which differs from the general population 10 and may reflect the demographics of this cohort.
Comparison of specific complementary medicine use in Australia and London.
In our study both Siberian and Korean ginseng were used by ∼2%. Ginseng type unspecified by the London group.
Although the demographics of the London cohort are not specified, the differences between our populations may be marked. The proportion of women, sexual preference and subject age may differ due to varied immigration patterns. Differences in socio-economic backgrounds, ARV taken and CM product availability may also be significant.
The British study reported 10% of CM users were taking products that could cause serious health risks when taken with cART. 15 Compounds taken in our study which could be problematic with cART were garlic (6%), which may reduce absorption of protease inhibitors, 16 and St John’s wort (2%), which may lower levels of some ARVs through induction of cytochrome P450 3A4 liver enzymes. 17 Additionally, the chelation effect of bi- and trivalent cations (such as magnesium, iron and calcium) with raltegravir 18 may be problematic in our study group. Data were not collected about the specific ingredients of multivitamin preparations nor about separating these or other supplements from ARV.
Very few participants in this study saw a CM practitioner. Friends, family and the internet were more popular information sources, consistent with studies of the general Australian population.10,13
Similar rates of disclosure to medical practitioners were reported in our study (77%) as previously (85%). 8 A new finding in our group was that less than half disclosed use to their pharmacist. This is somewhat surprising; pharmacists in hospital or clinic outpatient settings encourage patients to ask about medication, however this survey did not differentiate between hospital and community pharmacists. Others have identified that people do not view pharmacists as CM specialists 10 and our results suggest that pharmacists, including those working in specialised practice, should ensure that CM is considered when discussing medication with patients.
Limitations
Our sample was drawn from most major centres dispensing cART in Australia, but did not include smaller or regional centres where there may be a greater diversity of migrant and alternative lifestyle populations. PLHIV not taking cART were not targeted in this study. Failure to include these populations may limit the generalisability of the findings across all PLHIV. Nevertheless, the comparability of the data to other published reports of CM use by Australian PLHIV suggests that these limitations are not of great significance.
Self-administered surveys in English are more likely to appeal to people with an interest in the topic being investigated, and who can read and write English. Ethnicity was not assessed in our study. Other limitations include the validity and reliability of self-reported data, and incomplete responses by some participants.
Conclusion
Few studies have examined the use of CM by PLHIV in the past 5 years, when significantly better-tolerated and more effective ARV choices have been available. We identified that at least 50% of Australians taking cART use ingestible CM products.
CM is used mainly to promote general wellbeing; fewer people use it to treat symptoms related to HIV. Some PLHIV utilise CM to treat ARV drug side-effects, depression or anxiety, but less commonly than in the past. Most patients disclose CM use to or are prescribed CM by their doctors. Commonly used CM, such as calcium or magnesium, may interact with modern cART; pharmacists should pro-actively discuss CM with patients as part of standard care in providing best outcomes for patients
Footnotes
Acknowledgements
The authors thank pharmacy staff for their assistance with data gathering.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.