Introduction

Human immunodeficiency Virus (HIV) continues to be a major global public health issue. Globally, 39.0 million [33.1- 45.7 million] people were living with HIV at the end of 2022. An estimated 0.7% [0.6-0.8%] of adults aged 15-49 years worldwide are living with HIV, although the burden of the epidemic continues to vary considerably between countries and regions [1]. The WHO African Region remains most severely affected, with nearly 1 in every 25 adults (3.2%) living with HIV and accounting for more than two-thirds of the people living with HIV worldwide [2]. Over the years, efforts by drug development companies, government agencies, research institutes and pharmaceutical firms has led to the discovery and provisions of many potent Anti-Antiretroviral Drugs (ARVs).

There is no cure for HIV infection. However, with access to effective HIV prevention, diagnosis, treatment and care, including for opportunistic infections, HIV infection has become a manageable chronic health condition, enabling people living with HIV to lead long and healthy lives [3]. The introduction of Highly active antiretroviral therapy (HAART), has led to a significant reduction in mortality and morbidity of among people living with HIV/AIDS (PLWH) and in turn, a reduced occurrence of opportunistic infections [4] and increase the length and quality of life as well as the productivity of People living with HIV/AIDS (PLWHA) [5,6].

While still elusive, cure remains the ultimate long-term goal for treatment of HIV. A multi-pronged approach will likely be needed to achieve the goal of curing HIV. Herbal medicine may prove beneficial, as herbal medicines have good values in treating many diseases including infectious diseases, hypertension, etc. Herbal medicines have good values in treating many diseases including infectious diseases, hypertension, etc. That they can save lives of many, particularly in the developing countries, is indisputable. However, many studies have identified adverse events associated with use of herbal remedies.

In Nigeria HM have also reported a high prevalence of unprescribed medicine use, ranging from 62.9% to 72.4% across different states [7 -11]. The use of herbs among PLWHA have been reported varying rates in previous studies of use of herbal Medicine among HIV patients; 60% in the United States of America,29.3% in Lebanon, (67%);Thailand (54.7%); KwaZulu-Natal and Pretoria, South Africa (51% and 53%, respectively; Zimbabwe; and Ghana (53.2%). Also, another literature review showed that CAM use among HIV patients ranges from 36 to 68% in Africa [12 -16].

Regions with long-standing practice of Traditional Medicine (TM) such as China, Africa, and India, have a considerable number of patients that visit Traditional Healers (TH) before visiting clinics or hospitals providing ART services and use herbal medicines before starting on ARVs [17,18].

People living with HIV and AIDS (PLWHA) often use African Traditional Herbal Medicines (ATHM) separately or together with conventional medicines including Antiretroviral (ARVs). While the herbal medicine may have beneficial effects in management of HIV//AIDS patients, sharp practices such as the addition of orthodox medicines to herbal preparations by some traditional medical practitioners have been reported [19]. Different orthodox medicines may be added to an herbal preparation with the hope that one of the added drugs may cure the user’s ailment. Just because an herb is natural does not mean that it is safe and claims of remarkable healing powers are often not supported by reliable evidence.

There are anecdotal narratives of the use of herbal medicines among patients receiving Antiretroviral Therapy (ART) in Africa and Nigeria specifically. It was estimated that over 70% of HIV patients taking herbal remedies denied taking them when asked by medical practitioners, even research in the United States has found that up to 70% of patients who use such therapies do not tell their doctors [24,25]. This denial by HIV patients may constitute a deterrent to the medical practitioners in early detection of possible negative drug interactions that could occur with orthodox medicines especially HAART.

It is also important to note that many of the herbal medicines used by several people have not been quantified nor analyzed for its active and inactive components. There is limited data on evidence of why the prevalence and correlative reasons for herbal medicine use in Nigeria. This study is set out to examine the prevalence of concomitant usage of herbal remedies and the factors associated with its use among people living with HIV on Highly Active Antiretroviral therapy (HAART) in Enugu State, Nigeria. Traditional medicine (TM) continues to provide health coverage for most of the people in developing countries and it is equally becoming increasingly popular in western countries [20-22].

A study in Kano, Northwest Nigeria, showed a prevalence of between 4.25% and 27.5% of HIV patients using traditional medication at different stages of their treatment [23]. However, considering the large variety of medicines used in the ART, such combination would increase the possibility for occurrence of drug–medicinal plant interactions that could promote reduction of the therapeutic effects and/or increase the antiretroviral toxicity, as well as reduction on therapeutic effects and/or increase on the medicinal plants or herbal medicine toxicity.

There is, therefore, the need to generate evidence on the magnitude, pattern, and factors that influence the use of TM among PLWHAs in other parts of Nigeria to guide health planners and health communication experts on how to address the issue. The study aims to assess the extent, and document herbal medicine use and their associated factors among people living with HIV/AIDS on ART at Enugu Ezike District Hospital (EEDH) Igbo- Eze North LGA and Udi General. Hospital, both in Enugu State, Nigeria from March to June 2022.

Materials and Methods

This an observational study, with Cross-sectional Study technique. The study was conducted over a four-month period (March, 2022 – June, 2022) in Enugu state. The population of this study comprises of 8,066 people who are currently living with HIV in two selected LGAs, Igbo Eze North and Udi Local Government Areas, Enugu state. Of this total number, 4,243 are from Igbo Eze North while 3,823 are derived from Udi Local Government Area. From available data, 2000 out of 8,066 PLHIV in these 2 selected LGAs, are combining ARVs with herbal concoctions [8]. This study focuses on these sub populations who are combining herbal remedies with ARV in the selected two Local Governments of Enugu State. These two local governments were selected based on the preponderance of herbal medicine usage and their rural location. Furthermore, the targeted population in these LGAs were easily accessible as there is easy and good road network, which was of an advantage to the researcher.

In this study, the sample size was calculated by using single proportion formula with the following assumptions: 95% confidence interval, 5% margin of error, 70.8% prevalence of herbal use, which determine a final sample size of 318. A convenient sampling technique in which all participants who voluntarily give verbal consent were interviewed until the final sample size was reached. Structured questionnaires was administered to elicit data from the respondents.

Data Analysis

The data was entered and analysed using SPSS version 23 [26]. The descriptive statistics like frequency distribution and percentages was determined. Binary analysis using a chi-square test was used to determine the independent association of herbal medicine use to demographic and clinical characteristics. The p-value of <0.05 is considered as significant.

Ethical Considerations

Ethical approval will be obtained for the study, from (Enugu state ministry of health, department of Health and Human Service Secretariat Enugu) or from both Hospital Management Ethics Committee, and individual informed consent sought from the respondents.

Results

Sociodemographic Profiles of Respondents

A total of 300 research respondents completed a paperbased questionnaire and returned. This constitutes of 181 (60.3%) females and 119 (39.7%) males who participated in the study (Table 1). Majority of participant 40% (n=120) are between 35-45 age groups, with mean age (31.25 ±6.29 SD) years. Nearly half (45.7%) of the participants were married and about 81% were literate (able to read and write) with educational qualification fairly uniform distribution. This is show with 33% (n=99) had secondary level of education, 25% (n=75) had tertiary level, 23% (n=69) had primary education while 19% (n=57) respectively.

Table 1: Shows Bio-demographic characteristics of the Participants.

With regard to employment status, most respondents (30.7% (n=92) were business owners/farmers/herders/motorcyclists, with average monthly income of N10, 000 -N50, 000.00 Nigerian Naira [i.e., 21.7 -108.7 USD] (Figure 1). Clinical Characteristics of the Participants. All of the participants knew their HIV status some and had been HAART for at 1-4 years (59.0%) back from the date of data collection period.

Figure 1 shows income categories of the respondance, with participants in low income category forming 44.7% who earned between N10,000 and N25,000 ( 21.7 USD - 54.3 USD) and 27.7% earning between N25,000 and 50,000 ( 54.3 USD - 106.7 USD) only 1.7% earned above N250000 (54.3 USD).

Figure 1: Showing the economic status of the participants.

Herbal Traditional Medicine

Table 2 of this study shows the utilization of traditional medicine concurrently with antiretroviral therapy. More than half (59.7%) of the participants reported that they used Herbal Medicine (HM) for the management of HIV/AIDS among which 31% had used traditional medicine to treat other diseases. Also over 74.3% had ever used traditional medicine at one time in their life. The study revealed however, that only 25.7% had disclose to their doctors of their concurrent use of HM.

Table 2: Traditional Medicine Practice.

Consistently, women had admitted to practice traditional medicine and concurrent use of HM with ART than men, and however, as can only 12.0% of men in this study, compared to women (13.7%) had disclose concurrent use of HM with their ART (Table 2).

The most frequently used herbal products, alongside ART regimens, included pure herbs (54.0%), multivitamins supplements, (21.0%), and immune boosters (17.0%) (Traditional and synthetics) (Figure 2).

Figure 2: Showing total number of patients taking Herbal Medication concurrently with HAART.

With regard to the sources of the traditional medicines, the majority of patients who used TM reported that their sources were obtained from herbal shops and traditional medicine clinics (41.7%), while 25% cultivate the herbs they used. (41.22%), followed by home made preparations (32.82%) and preparations from traditional healers (16.03%). (Table 3).

Table 3: Factors associated with HM Use.

Only 31.3% believed that herbal medications are safe to use with ART and, among those that actively use ART and Herbal medications, 56.4% actively consider it safe to use ART with herbal medication. Significant proportion of the 300 respondents (45.7%) considered HIV treatment as the primary reason for using herbal medications; it was different for respondents who actively use ART and herbal medications, only 30 respondents, 10% of the entire respondents considered herbal medications as complementary to HIV treatment (Table 4). Respondents were also asked about how effective they considered the combination use of ART and herbal medications. Although 62.3% felt herbal medications affect the effectiveness of ART, 78.1% of those that actively use herbal medication agrees that it affect ART.

Table 4: Respondance awareness of impact/complication of the concurrent herbal medication among patient on HAART.

Only 3 respondents (4.1% of those that responded) agreed that there may be beneficial effects of using ART and herbal medication. However, interestingly, most of the respondents 45.9% (n=34) considered the drug resistant effect and 28.4% (n=21) and failure of ART as the effect of concomitant use. Also, 16 respondents consider allergy as an impact of concomitant use of ART and herbal medication (Table 5).

Table 5: Multivariate regression analysis.