Herbs, Supplements and HIV

In South Africa, Botswana and Lesotho, traditional herbal medicines are used by up to 80% of people living with HIV. In London, traditional medicines are also widely used by people originally from Africa now settled in the UK. Herbal medicines are used to treat illnesses and complaints in a similar fashion to Western allopathic medicines. There is a major area of concern with the use of traditional herbal medicines by people with HIV: a few of the most commonly used herbs have been shown to negatively interact with antiretroviral medicines and prevent them working properly, allowing the human immunodeficiency virus to flourish and become resistant to those ARVs.

Whilst discussing HIV and nutrition in South Africa and Botswana issues around herbal medicine have been near the top of the agenda, but even more so here in Lesotho. In South Africa and Botswana, a person living with HIV collecting allopathic medicines prescribed by a doctor is unlikely to pay anything more than an administration fee. In Lesotho however the state cannot afford to subsidise medicines. Other than ARVs themselves which are provided free, the cost of medicines must be covered in full. Some antibiotics and painkillers are relatively cheap, but multivitamins and medicines to combat gastrointestinal problems can be quite expensive. No wonder that people turn to cheaper traditional remedies.

The largest hospital in Lesotho, the Queen Elizabeth II in Maseru, has a busy HIV clinic. I followed a patient through his clinic visit, observing his time with the doctor, nursing sister, lay counsellor and pharmacist. The patient, back in Maseru on a break from working in the mines near Johannesburg, had two main issues: he was finding it hard to cope with a rash that he thought might be due to his ARVs and TB medicines, and he was underweight despite having a good appetite. His doctor was concerned about something else – his liver was showing signs of stress with high enzyme levels.

The patient had raised concerns about the rash previously, and another doctor had advised him to stop one of the ARVs, but this had no effect. The patient was questioned about using traditional medicines, and initially he said he had not used any; later he admitted to seeking help from a traditional healer for the rash.

Several doctors talked about the incidence of raised liver enzyme levels in patients in Lesotho. This was said to be common in all patients, not just those with HIV, and was thought to be correlated to traditional herb use. Consistently raised liver enzymes are often the first sign of liver damage occurring.

Sadly the patient I was following did not see a dietitian that day, despite his concerns around his nutritional status. The Queen Elizabeth II Hospital is Lesotho’s main medical facility, with 500 beds and busy outpatient departments. However the Nutrition and Dietetic Department consists of only four dietitians and one nutritionist. Indeed, until 2004, the team consisted of one person only. Obviously work has to be prioritised, and so the Adult HIV clinic does not have a dietitian in situ – patients must be referred on. I felt that a detailed dietetic assessment might bring together several of the issues that were concerning the patient and concerning the medical team.

As far as I am aware, the herbs traditionally used in Africa that negatively interact with ARVs include African Potato, Sutherlandia, and Leonotis (Wild Dagga). All of these herbs are widely sold, even in supermarkets on the shelves next to vitamins and paracetamol. African Potato, for example, sells for about £8 for a month’s supply (about half of a week’s wage in Lesotho), with names such as “Immunoboost”.

At rural Maluti hospital here in Lesotho, the team encourages HIV patients to buy a vitamin and mineral formula which also contains substantial amounts of African Potato. They argue that this formulation is the cheapest available which contains decent levels of a wide range of vitamins and minerals. They also suggest this formulation to those patients not yet on ARVs. Patients are counselled to cease using the product when they commence on ARVs. I understand the need for patients not yet on ARVs to have a decent multivitamin and mineral intake to help slow the decline of the immune system, and therefore delaying initiation onto antiretrovirals. However using a product which contains African Potato may lead to confusion. A friend or relative of a patient using this product who is on ARVs themselves might think that as the doctor has recommended it, they should also use it.

My concerns with traditional herbal medicines are twofold. As I have said already, they may stop ARVs working, and may lead to liver damage. However, I also think that sensible, supported and supervised use of herbal medicines can be part of a holistic approach to disease management.

Herd boys in the Lesotho Highlands working alone for long periods depend on picking wild medicinal plants for treating routine ailments. There is a project here educating which herbs can be used safely, with a special emphasis on HIV and ARVs.

I spent some time with Georgina McAllister from Garden Africa, a British-based NGO facilitating projects including appropriate medicinal plant use. With so many people ill with HIV, demand for herbs has increased dramatically. Traditional healers have always picked small amounts of wild herbs, usually keeping secret the location of the plants. Now, many of the plants are completely uprooted and sold in markets, depleting the wild stock. Garden Africa are involved with a project looking at cultivation of medicinal plants, identifying the active ingredients, and monitoring levels in cultivation versus wild plants. A University-based unit in the Western Cape of South Africa is fully investigating efficacy of traditional medicines, and any negative interactions with allopathic medicines.

Responsible, evidence-based use of traditional herbal medicines, with widespread education warning of any potential problems will provide both a solution acceptable to all parties and a range of treatments acceptable to all those living with HIV in Southern Africa.