Reasons, Perceived Efficacy, and Factors Associatedwith Complementary and Alternative Medicine Use Among

Malaysian Patients with HIV/AIDS

Syed Shahzad Hasan, MClinPharm,1 Choon Keong See, BPharm,1

Christopher Lee Kwok Choong, MBBS, MRCP,2 Syed Imran Ahmed, MClinPharm,1

Keivan Ahmadi, MClinPharm,1 and Mudassir Anwar, MSc1

Abstract

Objectives: The primary objective of this study was to evaluate the pattern of use, reasons for use, and perceivedeffect of complementary and alternative medicine (CAM), accompanied by identification and comparison of thefactors that are potentially associated with CAM use.Design: This cross-sectional study was carried out in 325 randomly sampled patients with human immunode-ficiency virus/acquired immune deficiency syndrome (HIV/AIDS), at HIV/AIDS referral clinics in the HospitalSungai 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 totype, 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 educationlevel ( p¼ 0.021, rs¼ 0.148), monthly income ( p¼ 0.001, rs¼ 0.260), and family history of CAM use ( p¼ 0.001,rs¼ 0.231) were significantly associated and positively correlated with CAM use. However, the majority of thesepatients (68%) did not disclose CAM use to health care professionals. About half of those who rated their healthas 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 otherhand some forms of CAM produced a detrimental effect on the virological suppression, opening this platform tomore research and investigation in order to optimize the use of CAM among patients with HIV/AIDS.

Introduction

In Malaysia, use of complementary and alternativemedicine (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 tra-ditional medicine as the primary therapeutic modality.5 Si-milarly, 70%–80% of the population in developed countrieshas been using CAMs for decades.5 The cumulative incidencerate 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 be-tween CAM and conventional therapies is the reason for suchvariation.7

CAM use has increased in popularity among HIV-positiveindividuals in recent years. Vitamins and dietary supple-ments, massage, and acupuncture are the most commonCAM modalities used by these individuals.7,8–12 Despiteundergoing highly active antiretroviral therapy (HAART), asignificant number of patients with HIV/AIDS use CAM asadditional armament in their combat against HIV/AIDS,regardless of the regions in which they live. A study byFairfield et al. reported that 76% of HIV-infected patients use

1Department of Pharmacy Practice, School of Pharmacy and Health Sciences, International Medical University, Kuala Lumpur, Malaysia.2Department of Medicine, Hospital Sungai Buloh, Selangor, Malaysia.

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINEVolume 16, Number 11, 2010, pp. 1171–1176ª Mary Ann Liebert, Inc.DOI: 10.1089/acm.2009.0657

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CAM.7 In Europe, approximately 60% of HIV/AIDS re-spondents were using CAM, while 42.9% reported usingmore than two types.8 In Uganda, about 64% of respondentswere using CAM after they were diagnosed with HIV, and32.8% of them were taking CAM together with antiretroviraldrugs.13 In the Asia-Pacific region, it was found that 56% ofAustralians14 and 95% of Thais15 with HIV/AIDS were usingCAM. Interestingly, it was found that only 4.0% of partici-pants in South Africa16 and 1.4% of participants in Boston,US7 had refused to take HAART and utilized CAM exclu-sively to treat their infection.

Despite the widespread use of CAM, little is known aboutthe characteristics of HIV-infected CAM users. Studies con-ducted on a general population in Australia and the UnitedStates showed that CAM use is more commonly reportedamong more educated, younger females with higher in-come.17,18 However, HIV-positive individuals in SouthAfrica, who were rural residents with no or little income andmore HIV-related symptoms, were also found to use CAM.16

The findings of this study were similar to those of a Swedishstudy except for education level, which was not found to beassociated with CAM use.19 Moreover, no correlation wasfound between income level and CAM use in United States.20

Nonetheless, traditional medicine was the most commonCAM among HIV-infected individuals in Uganda (90.4%),14

while religious healing such as ritual remedies were com-monly used in Thailand (84%).15

On the other hand, in regard to the frequency of visitingCAM providers, participants with higher education levels aswell as those who were perceived as having poor healthconsulted CAM providers more frequently than the rest.19

Similarly, a study by Agnoletto et al. reported that CAM useis less common in patients who adhere to HAART and morecommon in patients who experience side-effects of HAART.8

It was also found that people living with HIV/AIDS do notlike to inform health care professionals about CAM use.16 Incontrast, many studies reported that almost half of the par-ticipants would discuss with health care providers beforethey start taking CAM.7,21,22 Consequently, people who aretaking ART give priority to strengthening the immune sys-tem as well as relieving symptoms by taking CAM.7,10,13 Ithas been observed that advice from family and friends onCAM may influence patients with HIV/AIDS to use CAM.Seventy percent (70%) of the participants felt that CAM hadimproved their quality of life.12 However, the researcherswere not able to find a correlation between CAM use andCD4 counts and viral load readings.8,9,11,12,16,20,22,23 A studyin Uganda showed that 93.9% of participants on CAM had aCD4 count lower than 200 cells/mL.16

The use of alternative medicine may be triggered by var-ious factors that eventually could direct the person towardCAM, such as discontent with conventional medicine, theneed for ideological congruence, and the need for personalcontrol. This cross-sectional study was intended to assess theuse of CAM among individuals infected with HIV/AIDS,reasons for CAM use, perceived effect of CAM, and factorsassociated with CAM use.

Materials and Methods

This was a cross-sectional study carried out on randomlysampled individuals infected with HIV/AIDS, at Malaysian

HIV/AIDS referral clinics in the Hospital Sungai Buloh,Malaysia. The sociodemographic characteristics and clinicalvariables such as diagnosis, CD4 count, viral load and con-ventional treatment were recorded from the computerizedmedical records. However, to minimize the ambiguity, so-ciodemographic characteristics were reconfirmed at the startof the interview. The sample consisted of individuals eitherinfected with HIV/AIDS alone or in combination with othermedical conditions, whether on conventional treatment forHIV/AIDS (antiretroviral drugs) with or without CAM.

The calculated sample size was 377 with an estimateddropout rate of 20%. Out of a total HIV/AIDS population ofabout 94,573, prevalence is highest among Malays (0.461%),followed by Chinese (0.221%).24 The simple random samplingtechnique was used, where randomization was carried outusing patients’ medical record numbers. Based on the ran-domization procedure adopted for this study, every fifth pa-tient attending the clinic was selected from a pool of an average60 patients per day. A total of 400 patients with HIV/AIDSattending the clinics were randomly approached. However, atthe end of the data collection phase, 330 patients agreed to beinterviewed. Five (5) of them were excluded because they didnot meet the inclusion criteria. Thus, the final sample size was325. The data collection form that was used as a tool in thisstudy consisted of four sections: section A for sociodemographicfactors, section B for clinical variables, section C for details ofCAM use, and section D for factors associated with CAM.

A 15–20-minute interview was carried out to gather thenecessary information regarding perceived efficacy of CAMon disease status, influential factors to start CAM, reasons fortaking CAM, types of CAM used, number of visits to thepractitioner, and disclosure of CAM use to the health careprofessionals. The study information sheet was shown andconsent (either verbal or written) was obtained from all therecruited patients prior to the interview. Then each subjectwas asked, ‘‘Have you ever used CAM for HIV/AIDS orHIV related problems?’’ This question was considered thescreening question. A study participant was defined as‘‘case’’ when answer was ‘‘yes,’’ while the control was theHIV-positive subject who answered ‘‘no’’ to the screeningquestion. Information confidentiality was assured to all thestudy participants. Name and identity card number of studyparticipants were not taken so as to assure the confidentialityand anonymity of the patients. Depending on their willing-ness, participants were given an option for an interview to beconducted in a waiting area or in a seminar room.

Both descriptive and inferential data analyses were appliedwith the aid of SPSS� version 13.0, and variables were taken tobe statistically significant at p� 0.05. Statistical tests, such as w2

test or multinomial test (to examine the association betweenvariables), Spearman’s correlation test (to examine the corre-lation between variables), and the Mann–Whitney test (to findthe difference between variables), were used where appro-priate. The study was approved by the research and ethicscommittee, director of the hospital, head of the infectiousdiseases department, and the pharmacy department.

Results

Sociodemographic characteristics

Out of 325 patients interviewed, 254 of them were usingsome kind of CAM and were labeled as ‘‘case,’’ while

1172 HASAN ET AL.

71 patients were labeled as ‘‘control’’ or non-CAM users. Themajority of the CAM users were male (225/254), aged be-tween 31 and 45 years (142/254), and were Chinese (142/254). Most of the CAM users (120/254) were educated up tosecondary school level, working adults (188/254), and re-sided in urban areas (212/254). About three quarters of CAMusers reported earning at least RM 1000 (USD 293.169) permonth. The sociodemographic characteristics of CAM andnon-CAM users are presented in Table 1. Sociodemographicfactors including education level ( p¼ 0.021, rs¼ 0.148),monthly income ( p¼ 0.001, rs¼ 0.260), and family history ofCAM use ( p¼ 0.001, rs¼ 0.231) were significantly associatedand positively correlated with CAM use.

Types of CAM utilized by the study participants

Among the types of CAM, vitamins and supplementswere found to be the most frequent CAM used by the par-ticipants (52.6%), followed by herbal products (33.8%) andmassage (16.6%). Among the herbal products, TraditionalChinese Medicine (25.2%) was the most frequently usedCAM compared to traditional Malay medicine (5.5%). Only20.3% of participants reported visiting CAM practitionerssuch as masseur/masseuse (16.6%), traditional healer (1.5%),and acupuncturist (1.2%). The types of CAM utilized by thestudy participants are listed in Table 2.

Reasons for using CAM

Recommendation from health care professionals was themost common reason for participants to use vitamins andsupplements (41.8%), followed by maintaining good health(38.5%). Similarly, reduce body heat (14.8%) and improvehealth (12.9%) were the two main reasons reported by theherbal drug users. Significant numbers of participants reportedseeking help from traditional healers (14.2%) to cure or treatHIV/AIDS. Besides that, different types of massage and energydrinks were also used by the participants to combat fatigue(5.5%) and replenish energy (9.2%), respectively. A significantnumber 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 ashealthy as people without HIV/AIDS and 34.7% of them feltthat they have poor health compared to 24.9% who per-ceived 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 thatkeeps them healthier than individuals without HIV/AIDS.About 35% felt that CAM utilization has nothing to do withself-perceived poor health. Interestingly, 40% of the partici-pants felt that CAM has improved their health, and none ofthem felt that his/her health condition has deteriorated afterCAM use. The details of CAM use and their effects reportedby the participants is presented in Table 3.

Factors associated with CAM use

Factors such as maintaining general health (21.5%), familyhistory of CAM use (20.6%), and own belief (10.2%) were thethree most common factors reported by the participants forusing CAM. In addition, participants reported family mem-

bers (27.1%), friends (20.3%), and health care professionals(16.6%) as the main influential factors to start CAM. Themajority of the CAM users did not consult doctors (68%) orpharmacists (83.7%) regarding their CAM use, where most ofthem reported that it is not important to inform health careproviders (29.5%). The list of factors associated with CAMuse reported by the study population is presented in Table 4.No significant differences were found between CAM andnon-CAM users in terms of their current and within last3 months CD4 count and viral load recorded readings.However, CD4 count beyond 3 months’ time was found tobe significantly different ( p¼ 0.003), where CAM users werefound to have higher CD4 counts and reduced viral load.

Discussion

About 78% of the study subjects reported using CAM.This percentage of CAM use is relatively higher than those

Table 1. Comparison of Sociodemographic

Characteristics of CAM and Non-CAM Users

VariablesCAM users

n/N*Non-CAM

users n/N**

GenderMale 225 /254 59/71Female 29/254 12/71

Age groups18–30 43/254 12/7131–45 142/254 43/7146–60 65 /254 15/71>60 4 /254 1/71

Ethnic groupsMalay 74/254 13/71Chinese 142/254 42/71Indian 23/254 7/71Others 15/254 9/71

EducationNo formal education 4/254 1/71Primary education 43/254 16/71Secondary education 120/254 43/71Graduate 82/254 11/71Postgraduate 5/254 0/71

Employment statusUnemployed 50/254 20/71Labor 125/254 37/71Professional 63/254 8/71Student 4/254 1/71Housewife 7/254 4/71Retired 5/254 1/71

ResidenceRural 42/254 15/71Urban 212/254 56/71

Household incomeNo 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*¼ 254, N**¼ 71.CAM, complementary and alternative medicine.

CAM USE AMONG MALAYSIAN PATIENTS WITH HIV/AIDS 1173

found in studies conducted in Australia (55%)25 as well as inCanada (39%).26 However, it is almost similar to the study byFairfield et al.,7 where 76% of the participants were CAMusers, the percentage that fell within the range of 30%–100%reported by the British Medical Association.6 It was foundthat education level ( p¼ 0.021,rs¼ 0.148), household income( p¼ 0.001,rs¼ 0.260) as well as family history of CAM use( p¼ 0.001, rs¼ 0.231) were significantly associated and pos-itively correlated with CAM use. This finding is supportedby studies carried out on individuals with HIV/AIDS thatreported that CAM use is most prevalent among individualshaving better education, sustainable monthly income, andfamily history of CAM use.17,18 Although the prevalence ofHIV/AIDS is highest among Malays (0.461%) followed byChinese (0.221%), CAM use was found to be more prevalentamong Chinese compared to Malays in this study. This couldbe explained by the participation of a larger number ofChinese participants than Malays. This in turn could over-represent CAM use as more prevalent among Chinese thanMalays.

Vitamins and supplements were the most frequent typesof CAM used by the participants, where nearly half of themwere taking vitamins such as vitamin C, E, and multivita-mins. This finding is in line with the studies carried out in theUnited States7 and Canada.10 According to the ART policy in

Malaysia, 2 weeks of vitamin therapy is prescribed when asubject is qualified to be on ART. The purpose of vitamintherapy is to ensure medication compliance in order toachieve a sustainable viral suppression. It is supported by astudy that effective viral suppression can only be seen insubjects who were having at least 95% of ART compliance.27

Nevertheless, people who are receiving indinavir should beadvised to stop taking vitamin C because the concentrationof indinavir in blood decreases by 20% when indinavir isgiven concurrently with vitamin C.28 Therefore, disclosure ofCAM use to health care professionals plays a vital role inminimizing undesired effects. A substantial number of par-ticipants were using massage therapy to relieve body fatigueor to rejuvenate mentally. A study suggested that massagecould reduce stress level by lowering cortisol and therebyincrease the levels of CD4 and CD8 counts, which in turnboost the immune system.29

Table 2. List of CAM Utilized by the Study

Sample (n¼ 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, TraditionalChinese Medicine; TMM, traditional Malay medicine; TIM, tradi-tional Indian medicine.

Table 3. Detail of CAM Use and Its Perceived Effect

Reported by Study Population (n¼ 325)

Variables n %

Visit to CAM practitionerMonthly 59 18.2%Once daily 32 9.8%Weekly 22 9.8%2–3 times weekly 3 0.9%

Type of combinationCAMþOCMþART 105 32.3%CAM only 63 19.4%CAMþART 61 18.8%ARTþOCM 27 8.3%ART only 26 8.0%CAMþOCM 23 7.1%No medication 12 3.7%OCM only 8 2.5%

Purpose of CAMHealth management/boosting

immune system220 67.7%

HIV/AIDS 84 25.8%Symptomatic treatment 56 17.2%Other co-morbidity 0 0%

Rating of health by the patientsFair 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 medicationYes 213 65.5%No 44 13.5%Not taking Rx medication 68 20.9%

*n¼ 69, **n¼ 91.CAM, complementary and alternative medicine; OCM, other

conventional medication, ART, antiretroviral therapy; HIV/AIDS,human immunodeficiency virus/acquired immune deficiency syn-drome.

1174 HASAN ET AL.

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

Regarding perceived effect of CAM use, nearly 38% ofthose studied reported that they were as healthy as normalHIV-negative individuals. Surprisingly, 27% (69/254) ofCAM users claimed that they were healthier than normalHIV-negative individuals, which might be due to the bene-ficial outcome of positive mindset. Although more than onethird of CAM users (35.8%, 91/254) reported poor health, the

majority of them (95.6%) believed that CAM was not thesource that made them unhealthy, suggesting a reality basedapproach of these HIV-positive patients along with aware-ness towards their condition. They also thought that it is theHIV that weakens their immune system. Most of them(40.2%) reported that their health status had improved, whilenone of them complained of poor health after taking CAM.In addition, no significant differences were found betweenCAM and non-CAM users in terms of their CD4 and viralload readings. However, CAM users found to have relativelylower CD4 counts and viral load. Similarly, about 70% of theCAM users in the United States perceived that CAM hadimproved their quality of life. However, no correlation wasfound between CAM use and CD4 and viral load readings.12

Regarding influential factors, most of them reported usingCAM upon the influence of family members (27.1%). In ad-dition, some of them were also seeking information from themass media (8.6%) after being infected with HIV/AIDS. Thisfinding is consistent with the study conducted in Thailand.15

People living in Malaysia grow up in an environment whereCAM is commonly use for minor to severe ailments. CAMpractices among family members, relatives, and friends alsohelp in spreading CAM use and its practice. Besides that,about 17% of the study participants reported that their CAMuse was inspired by health care professionals and the samesituation was highlighted in a study done by Duggan et al.12

Interestingly, none of the participants reported usingCAM due to the unaffordable price of ART. ART subsidi-zation is believed to be the most appropriate underlyingrationale. The government of Malaysia made a historicaldecision 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 partiallysubsidized by the government, and only 13% of them wereself-funded. Despite the side-effects experienced by the studyparticipants, about 68% and 84% of them did not disclosetheir CAM use to doctors and pharmacists, respectively.Underlying reasons for nondisclosure were (1) unnecessaryto disclose, and (2) health care professionals never askedregarding CAM use. Besides that, some studies reportedmandatory disapproval from doctors and their negativeopinion toward choice of CAM as perceived reasons ofnondisclosure of CAM use.32,33 Nevertheless, the majority ofthe participants in other studies were not reluctant to discussCAM use with health care professionals.7,22,28

Conclusions

This study confirmed the range of 30%–100% CAM useamong individuals infected with HIV/AIDS. CAM use wassignificantly associated and positively correlated with edu-cation level, monthly household income, and family historyof CAM use. About half of those who rated their health asgood or very good perceived it to be as a result of CAM use.On the other hand, nondisclosure to health care professionalswas prevalent among CAM users living with HIV/AIDS.Although on the one hand, some types of CAM reduced viralload and enhanced the immune system; on the other hand,some forms of CAM produced a detrimental effect on thevirological suppression, opening this platform to more re-search and investigation in order to optimize the use of CAMamong people with HIV/AIDS.

Table 4. Factors Associated with CAM Use Reported

by the Study Population (n¼ 325)

Variables N %

Factors that encourage patients to use CAMHealth 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 doctors8 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 nondisclosureNot 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’ healthImproved 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 doctorsYes 104 32.0%No 221 68.0%

Consultation of CAM use with pharmacistYes 53 16.3%No 272 83.7%

CAM, complementary and alternative medicine.

CAM USE AMONG MALAYSIAN PATIENTS WITH HIV/AIDS 1175

Disclosure Statement

No competing financial interests exist.

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Address correspondence to:Syed Shahzad Hasan, MClinPharm

Department of Pharmacy PracticeSchool of Pharmacy and Health Sciences

International Medical UniversityNo. 126, Jalan 19/155B

Bukit JalilKuala Lumpur 57000

Malaysia

E-mail: shahzad_hasan@imu.edu.my

1176 HASAN ET AL.