Alternative, complementary and traditional medicine and HIV

Alternative and complementary medicine is quite popular among people living with HIV. For example, around a half of HIV positive Americans report recent use.¹ Many HIV positive people say they feel better after using alternative and complementary medicine, and it is likely that some of these treatments are indeed beneficial, although unproven according to conventional Western medicine.

What are alternative and complementary medicines?

Alternative and complementary medicine is the name generally given to those medical and health care systems, practices, and products that are not presently considered to be part of conventional Western medicine. Well known examples include herbal and other nutritional supplements, acupuncture, aromatherapy and homeopathy.

• Alternative medicine is used in place of conventional medicine
• Complementary medicine is used together with conventional medicine.

The more ancient forms of complementary and alternative medicine are also known as traditional medicine.

What are these therapies used for?

Aromatherapy blends

In relation to HIV, alternative therapies are most commonly used in areas where it is difficult to access Western medicine. In the absence of antiretroviral treatment, people seek other ways to delay the onset of AIDS, or to treat opportunistic infections. In sub-Saharan Africa, for example, traditional healers outnumber medically qualified doctors eighty-to-one.² Traditional healers also usually provide immediate treatment, whereas clinics may have lengthy waiting lists and tests for eligibility.
Most people living with HIV in developed countries have ready access to antiretroviral therapy and conventional treatments for opportunistic infections. Because these treatments are so effective, there is less demand for alternative HIV medicine, except perhaps for addressing relatively minor infections, or when antiretroviral treatment cannot any longer be taken, for example because of drug resistance. Many instead look to complementary medicine as a way to prevent or relieve aids treatment side effects, some of which are not easily treatable with conventional medicine. There is also demand for complementary therapies that might boost immunity, relieve stress, or improve general health and wellbeing.
The people who distrust and avoid Western medicine for HIV include not only individuals, but also some governments. For example, senior politicians in South Africa have promoted unproven therapies while at times disparaging antiretroviral drugs. In Gambia, the president himself has treated patients with a herbal mixture he claims is an AIDS cure.

Do alternative and complementary therapies for HIV and AIDS work?

Western medicine embraces all approaches shown to be safe and effective in rigorous scientific trials. By definition, complementary and alternative medicine consists of therapies that are unproven, at least by the standards of Western medicine. Given the many therapies in existence, there can be little doubt that some of them do what they are supposed to. Many others are likely to be ineffective or can even be harmful. In the absence of good scientific trials, it is impossible to be certain which is which.

Acupuncture

Still it can be argued that, from a scientific point of view, some things are more likely to work than others. Acupuncture, for example, appears to alter brain activity,³ and there is quite good evidence that it can help relieve post-operative nausea.^4 5 Herbal medicines, too, are scientifically plausible: some 25% of modern drugs were derived from plants first used traditionally.⁶ Scientists have already identified one plant extract that acts like an antiretroviral drug;⁷ it is entirely possible that there are others.
At the other end of the scale are therapies that seem to defy the known laws of science. The most notorious of these is homeopathy, which few scientists see as credible and the World Health Organization recommends should not be used to treat HIV.⁸ Homeopathic remedies are so diluted that none of the active ingredient remains.
Yet even if a medicine has no specific effects on an illness, this doesn’t necessarily mean it is worse than nothing. It is widely accepted that patients’ beliefs about a treatment, and the quality of the doctor-patient relationship, can influence health outcomes. This is what is known as the placebo effect. For example, one trial⁹ divided irritable bowel syndrome sufferers into three groups: the first received no treatment, the second underwent sham acupuncture (placebo), and the third got fake acupuncture plus a 45-minute consultation with a friendly doctor. The proportions of patients reporting moderate or substantial improvement were 3% (no treatment), 20% (placebo only) and 37% (placebo plus interaction). This effect may well account for some of the reported benefits of alternative and complementary medicine, as suggested in an editorial that accompanied the study:

“Is it possible that the alternative medical community has tended historically to understand something important about the experience of illness and the ritual of doctor-patient interactions that the rest of medicine might do well to hear? … The meanings and expectations created by the interactions of doctors and patients matter physically, not just subjectively.” ¹⁰

Even if it fails to ease symptoms, the treatment experience may have non-specific effects such as boosting self-confidence and relieving anxiety. Group therapies – such as yoga – are particularly good for meeting new people, who may be able to share knowledge of other treatment options.

Why is there such a lack of evidence?

Supporters of complementary and alternative medicine propose a number of reasons why their therapies have not been subjected to thorough testing. For one thing, major medical trials are highly expensive; if there is no prospect of a patent then there is less of an incentive to invest in research. Reliable, ethical trials also require a considerable amount of expertise. Many scientists with the necessary skills are reluctant to investigate therapies they think are implausible.
Yet it is misleading to suggest that no research takes place. The US government has an agency (NCCAM) dedicated to complementary and alternative medicine, and in 2008 allocated nearly $300 million to this field (around 1% of all federal funding for medical research). Potential HIV therapies investigated in government-sponsored trials include acupuncture, yoga, Reiki and distant healing.¹¹
Although practioners of complementary and alternative medicine generally voice support for scientific research, they are often unwilling to accept negative findings. In 2005, medical journal The Lancet published the most thorough review of homeopathy trials ever conducted.¹² Having analysed more than one hundred trials related to a wide range of illnesses, the authors concluded,

“there was no convincing evidence that homeopathy was superior to placebo.”

Homeopaths united in objecting to the methodology of both the trials and the review. ¹³ Some even suggested that placebo-controlled randomised trials (regarded as the gold-standard of medical science) were inappropriate for testing their system of healing.¹⁴

Potential for harm

Some forms of complementary and alternative medicine can cause harmful side effects. Words like “natural” and “traditional” are certainly no guarantee of safety.
Herbal or nutritional therapies (notably St John’s Wort) may also interact with other medications, making them less effective or worsening their side effects.
In general, herbal remedies and dietary supplements are not covered by the strict regulations that govern pharmaceutical drugs. Quality is inconsistent even among popular commercial formulations; tests have shown that the concentrations of active ingredients can vary greatly from the amounts listed on the packaging.¹⁵
The standard of complementary and alternative practioners is similarly uneven. Although some countries regulate certain types of practioners (such as osteopaths in the US and UK), many people practise without any formal qualifications.
Even if a therapy carries little risk of direct physical harm, it may still turn out to be a waste of time and money. Relying on alternative medicine instead of scientifically proven treatment can have very serious consequences. Once HIV has severely weakened the immune system, antiretroviral drugs are less likely to be life-saving.

Advice for those seeking complementary medicine

HIV positive people have a long history of taking control of their own healthcare decision-making. Those interested in complementary medicine can take steps to maximise their chances of success.
The Canadian AIDS Treatment Information Exchange (CATIE) suggests ten questions for assessing a new therapy:¹⁶

• What am I hoping to get out of this therapy?
• Do other HIV positive people use it?
• Am I able to talk to any of these other people about their experiences?
• Is there any research or additional information about this therapy?
• What are the side effects, if any?
• What sort of commitment do I have to make to use this treatment?
• Where can I get this treatment, and will it be regularly available?
• How much of this treatment is too much and what are the early signs of taking too much?
• Does this treatment interact with anything else I’m taking?
• How much does it cost?

Careful research is needed to answer these questions. Good sources of information include reference books on complementary medicine (available in many libraries), medical journals (which can be searched using the PubMed website), and the publications of reputable health organisations. Many AIDS organisations and other bodies, including NCCAM, will answer enquiries over the phone or online.
As already discussed, all forms of complementary medicine are unproven; each individual must make their own assessment of likely risks and benefits based on the available data. The most reliable evidence comes from large human trials – preferably randomised trials in which the treatment is compared to a placebo. Personal testimonies and laboratory findings should be given less weight, especially if they appear only in promotional material. Anyone who makes sensational claims (such as being able to cure many unrelated diseases with a single therapy), or who attacks conventional treatment, is probably a quack and best avoided.
If you have done your research and wish to try a complementary therapy, the next step is to talk to your personal doctor or HIV specialist. This is important because there may be a risk of interactions with other medications.
Some medical doctors have received training in complementary medicine. If your doctor lacks such expertise then it may be sensible to also find a complementary practioner, ideally one with experience in treating people with HIV. Help finding a practioner may be obtained from your doctor, an AIDS service organisation, or a professional body such as the Institute for Complementary Medicine in the UK, or the American Holistic Medical Association in the US. There are many practioners available; it is worth taking the time to find one you trust and feel comfortable with. Look for experience, qualifications and references you can verify.
When purchasing a herbal medicine or nutritional supplement, try to choose a reputable seller and manufacturer. Large, long-established companies are generally the most trustworthy because they have more to lose from selling poor quality goods. If possible, look for a company that submits its products for independent quality testing.
Having started a new treatment, it is a good idea to keep a diary of your symptoms. This will help you assess whether the therapy is having the desired outcome, or whether it may be causing unwanted side effects.

List of common complementary and alternative therapies

Complementary and alternative therapies can be divided into five main categories. The list below contains a few of the most popular examples.
Whole medical systems

• Naturopathic medicine (mostly practised in the West; includes diet modification, herbal medicine, acupuncture and massage)
• Traditional Chinese medicine (includes herbal medicine, acupuncture and massage)
• Ayurveda (ancient Indian healing system; includes diet modification, herbal medicine, cleansing therapies, massage, meditation and yoga)
• Homeopathy (most commonly prescribes extremely diluted solutions of natural substances)

Mind-body medicine

• Relaxation techniques, meditation and visualization
• Spirituality and prayer
• Yoga (may incorporate spirituality, meditation and body postures)
• Tai Chi (a Chinese martial art incorporating meditation and breathing exercises)
• Qi gong (includes meditation, body postures and breathing exercises)
• Aromatherapy (uses remedies derived from plants that are inhaled, applied to the skin or used internally)

Biologically based practices

• Vitamins and minerals
• Herbal remedies
• Animal-derived extracts
• Prebiotics and probiotics (aim to encourage the growth of beneficial microbes)

Manipulative and body-based practices

• Massage
• Chiropractic (invented in America; manipulates the spine)
• Osteopathy (invented in America; manipulates the spine, joints and muscles; American osteopathic physicians are also trained in conventional medicine)
• Shiatsu (traditional form of Japanese massage therapy)
• Reflexology (invented in America; applies pressure to the feet, hands or ears)
• Rolfing (named after American Ida Pauline Rolf; manipulates soft tissue)

Energy medicine

• Acupuncture (involves inserting fine needles into the body)
• Reiki (practioners claim to channel healing energy through their palms)
• Therapeutic touch and distant healing (practioners claim to manipulate energy “biofields” with their hands)
• Bioelectromagnetic-based therapies (involve unconventional use of sound, light, magnetism, and other forms of electromagnetic radiation)

African traditional healers and HIV

Traditional medicine for sale in Malawi

Sub-Saharan Africa is the region worst affected by AIDS; it is also a region in which most people turn first to traditional healers when they fall ill. There is potential for traditional healers to play an important role in responding to the epidemic.
Although few have been scientifically tested, there can be little doubt that some of the remedies given by traditional healers are effective in treating HIV-related opportunistic infections and drug side effects. However, in common with all forms of medicine, these therapies may also do harm through side effects, drug interactions, or delaying use of conventional treatment. In addition, the reuse of implements for rituals such as scarification, tattooing and circumcision can transmit infections, including HIV. Some African healers blame illness on witchcraft, which can lead to ostracism of those accused.
Collaboration between traditional healers and Western doctors has the potential to improve safety, for example by encouraging better hygiene. Training can also assist traditional healers in identifying illnesses beyond their capacity to treat, hastening referral to a clinic when necessary. In South Africa, The Traditional Health Practitioners Act includes a council to oversee and provide training to traditional health practitioners to protect the interests of the patient. As yet, the Act has not been fully enforced; there have been calls to implement the Act alongside a robust system of scientific testing of 'remedies'. ¹⁷
Traditional healers are respected within their communities, and know how to convey health information in a culturally appropriate manner. They are ideally placed to teach HIV prevention, distribute condoms, conduct counselling, encourage HIV testing, and set up support groups for affected people.
Yet although traditional healers are generally eager to learn from other health workers, experience has shown it is not easy to establish successful collaboration.¹⁸ Traditional theories of disease causation are very different to those of Western science. Traditional healers – suppressed during the colonial era, and often demonised in the media – are understandably suspicious of authority. Many are reluctant to reveal details of their remedies for fear that their ideas will be stolen. Likewise, conventional doctors are inclined to be prejudiced against treatments that lack scientific foundation. These are not the only difficulties:

“How can healers give their clients a diagnosis of AIDS when it means possibly losing their business? How can a traditional healer – the traditional advocate of a clan’s fertility – counsel an HIV-positive woman who wants to have a child? And how can a traditional healer turn away a sick patient who has become dependent on his or her care and support?” ¹⁹

It may take months or even years to establish mutual trust, confidence and respect. Success depends on being sensitive to the local context, and cooperation must be on equal terms, regardless of level of education. Rather than trying to change traditional belief systems, research has shown it is better to stress what is common to both forms of medicine, and to establish a common language.²⁰
The best way to maximise the reach of training is to first identify and train a group of the most influential and respected healers, who can each then train many others. This method, however, requires ongoing support if it is to be sustainable.²¹
Despite the challenges, a number of organisations – such as THETA in Uganda and TAWG in Tanzania – have demonstrated the benefits of collaborating with traditional healers in HIV prevention and care.²² Much could be gained from replicating these programmes more widely.

References

1. Hsiao A.F. et al (1 June 2003) “Complementary and alternative medicine use and substitution for conventional therapy by HIV-infected patients”, JAIDS 33(2)
2. Mills E. et al (17 June 2006) “The challenges of involving traditional healers in HIV/AIDS care” Int J STD & AIDS 17(6)
3. Lewith G.T. et al (September 2005) “Investigating acupuncture using brain imaging techniques: the current state of play” Evidence-based complementary and alternative medicine 2(3)
4. Lee A and Done M.L. (2004) “Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting” Cochrane Database of Systematic Reviews
5. Lee A et al (September 2006) “Publication bias affected the estimate of postoperative nausea in an acupoint stimulation systematic review” Journal of Clinical Epidemiology 59(9)
6. World Health Organisation (May 2003) “Fact Sheet No. 134: Traditional Medicine”
7. Eiznhamer D.A. et al (November-December 2002) “Safety and pharmacokinetic profile of multiple escalating doses of (+)-calanolide A, a naturally occurring nonnucleoside reverse transcriptase inhibitor, in healthy HIV-negative volunteers” HIV Clinical Trials
8. Mashta, O (2009, 24th August), 'WHO warns against using homeopathy to treat serious diseases' British Medical Journal 339(b3447).
9. Kaptchuk T.J. et al (3 May 2008) “Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome” BMJ 336(7651)
10. Spiegel D. and Harrington A. (3 May 2008) “What is the placebo worth?” BMJ 336(7651)
11. NCCAM: All Clinical Trials
12. Shang A. et al (27 August 2005) “Are the clinical effects of homoeopathy placebo effects? Comparative study of placebo-controlled trials of homoeopathy and allopathy.” Lancet 366(9487)
13. The Society of Homeopaths press release (19 September 2005) “Universal Condemnation for The Lancet's Stance on Homeopathy”
14. Chatfield K. and Relton C. (September 2005) “Are the clinical effects of homeopathy placebo effects? - A full critique of the article by Shang et al”
15. Harkey M.R. et al (June 2001) “Variability in commercial ginseng products: an analysis of 25 preparations” American Journal of Clinical Nutrition 73(6)
16. CATIE (2004) “A Practical Guide to Complementary Therapies for People Living With HIV”
17. TAC (Dec 2009) 'Equal Treatment Magazine'
18. Kayombo E.J. et al (26 January 2007) “Experience of initiating collaboration of traditional healers in managing HIV and AIDS in Tanzania” Journal of ethnobiology and ethnomedicine 3:6
19. UNAIDS (2000) “Collaboration with traditional healers in HIV/AIDS prevention and care in sub-Saharan Africa – A Literature Review” [PDF]
20. UNAIDS (2006) “Collaborating with Traditional Healers for HIV Prevention and Care in sub-Saharan Africa: suggestions for Programme Managers and Field Workers” [PDF]
21. Mills E. et al (June 2006) “The challenges of involving traditional healers in HIV/AIDS care” Int J STD & AIDS 17(6)
22. UNAIDS (2000) “Collaboration with traditional healers in HIV/AIDS prevention and care in sub-Saharan Africa – A Literature Review” [PDF]