Complementary Therapies in Medicine 35 (2017) 14–19

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Complementary Therapies in Medicine

journal homepage: www.elsevier.com/locate/ctim

Traditional herbal medicine use among people living with HIV/AIDS in MARK
Gondar, Ethiopia: Do their health care providers know?
⁎
Kaleab Taye Hailea,1, Asnakew Achaw Ayeleb, , Abebe Basazn Mekuriac, Chilot Abiyu Demekea,
Begashaw Melaku Gebresillassieb, Daniel Asfaw Erkub,1
a
Department of Pharmaceutics and Social pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
b
Department of Clinical Pharmacy, School of Pharmacy, University of Gondar, Gondar, Ethiopia
c
Department of pharmacology, School of Pharmacy, University of Gondar, Gondar, Ethiopia

A R T I C L E I N F O A B S T R A C T

Keywords: Background: People living with HIV/AIDS (PLWHA) are increasingly using herbal remedies due to the chronic
Traditional herbal medicine nature of the disease, the complexities of treatment modalities and the difficulty in adhering to the therapeutic
HIV/AIDS regimens. Yet, research on herbal medicine use in this patient population is scarce in Ethiopia. The present study
Gondar aimed at investigating the prevalence and factors associated with the use of traditional herbal medicine among
Ethiopia
PLWHA in Gondar, Ethiopia.
Methods: A cross sectional survey was conducted on 360 PLWHA attending the outpatient clinic of University of
Gondar referral and teaching hospital from September 1 to 30, 2016. A questionnaire about the socio-demo-
graphic, disease characteristics as well as traditional herbal medicine use was filled by the respondents.
Descriptive statistics, univariate and multivariate logistic regression analyses were performed to determine
prevalence and correlates of herbal medicine use.
Results: Out of 360 respondents, 255 (70.8%) used traditional herbal medicine. The most common herbal pre-
parations used by PLWHA were Ginger (Zingiber officinale) (47%), Garlic (Allium sativum L.) (40.8%) and
Moringa (Moringa stenopetala) (31.4%). Majority of herbal medicine users rarely disclose their use of herbal
medicines to their health care providers (61.2%). Only lower educational status was found to be strong pre-
dictors of herbal medicine use in the multivariate logistic regression.
Conclusions: The use of herbal medicine among PLWHA is a routine practice and associated with a lower edu-
cational status. Patients also rarely disclose their use of herbal medicines to their health care providers. From the
stand point of high prevalence and low disclosure rate, health care providers should often consult patients
regarding herbal medicine use.

1. Background
HIV/AIDS is one of the biggest health challenges faced by many
African nations and the number of people infected is steadily mounting
especially in the sub-Saharan countries.1 Although the introduction of
highly active antiretroviral therapy (HAART) dramatically reduced the
development and progression of HIV-related diseases,1,2 it has also
caused a variety of side effects, affecting multi organ systems.3 As a
result of the chronic nature of the disease, the complexities of treatment
modalities and troublesome adverse events associated with HAART,
many people living with HIV/AIDS (PLWHA) try to manage their dis-
ease through the use of traditional herbal remedies and other com-
plementary and alternative (CAM) modalities along with HAART 2.
World Health Organization (WHO) defined traditional medicine as
“health practices, approaches, knowledge and beliefs incorporating
plant, animal and mineral based medicines, spiritual therapies, manual
techniques and exercises, applied singularly or in combination to treat,
diagnose and prevent illnesses and maintain well-being” 4. Among the
traditional medicine practices, herbal medicine use is the most popular
and practiced by many chronically ill patients including PLWHA 5.

Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; HIV/AIDS, human immune-deficiency virus/acquired immune-deficiency syndrome; OR, odds ratio; SPPS, statistical
package for the social sciences; PLWHA, people living with HIV/AIDS; USD, United States dollar; UOGRTH, university of Gondar referral and teaching hospital; WHO, world health
organization
⁎
Corresponding author.
E-mail address: asnake.21.uog@gmail.com (A.A. Ayele).
1
These authors contributed equally to this work.

http://dx.doi.org/10.1016/j.ctim.2017.08.019
Received 24 May 2017; Received in revised form 26 July 2017; Accepted 28 August 2017
Available online 02 September 2017
0965-2299/ © 2017 Elsevier Ltd. All rights reserved.
K.T. Haile et al.
Reported prevalence estimates of traditional herbal medicine use
among PLWHA reached up to 90% 2,5. The high magnitude of use of
herbs and other forms of CAMs among PLWHA could be attributed to a
variety of reasons including boosting immunity, improving overall
health condition and reducing the adverse events associated with HA-
ART and limited availability and accessibility of HAART in resource
constrained settings.6–8 The majority of the population in Ethiopia use
traditional medicine, largely owing to its cultural acceptability and ease
of access.4 The use of herbal medicine in different patient groups in-
cluding hypertension and cancer are well documented in various re-
gions of Ethiopia.9,10 However, data on the prevalence and correlates of
herbal medicine use among PLWHA in Ethiopia is still scarce. Fur-
thermore, awareness and discussion of the health care providers (HCPs)
about the patients’ use of herbal medicines, their efficacy and possible
untoward effects is highly recommended for improving adherence to
HAART and improving health care provider-patient relationship.11,12
Hence, the assessment of prevalence, predictors, and characteristics of
traditional herbal medicine use among PLWHA is important and has
critical implications for optimal patient care. The aim of the present
study was, therefore, to explore the prevalence and factors associated
with the use of traditional herbal medicine among PLWHA attending
University of Gondar Referral and Teaching Hospital (UoGRTH),
Ethiopia
1.1. Methods Study design and setting
A hospital-based cross-sectional study was conducted on PLWHA
who visited UoGRTH outpatient clinic. UoGRTH is found in Gondar
town, located in Amhara regional state, 750 km Northwest of Addis
Ababa (the capital city of Ethiopia). According the recent population
and housing census report, Gondar town has a total of 207,000 popu-
lation. The hospital is the only referral and teaching center in the area
with multiple specialized wards including HIV treatment and follow up
clinic. The study was conducted from September 1 to 30, 2016.
1.2. Sampling and recruitment strategies
All adult (≥18 years old) PLWHA who had been diagnosed with
HIV/AIDS and who took HAART for at least 1 year prior to recruitment
were taken as our source population while those patients who visited
the outpatient clinic of UoGRTH for follow up and medication refill
during the data collection period were taken as a study population.
Single population proportion formula was used with the assumption of
95% confidence interval, 5% margin of error, 72.3% prevalence,9,10 of
herbal medicine use and 5% for possible non-response was taken to
determine a final sample size of 396. A systematic random sampling
technique was then applied to select participants until the final sample
size was reached.
1.3. Survey instrument
Data collection was performed by two of the principal investigators
through interviewer-administered questionnaire. The data collection
tool was created by modifying items in three previously used instru-
ments regarding the use of herbal remedies in different chronic disease
patients 7–10 and items were thoroughly reviewed for relevance by a
team of experts including experienced pharmacists and public health
experts. The survey instrument was further validated by pre-testing on
20 PLWHA who were not included in the final analysis. After the pre-
test, we instituted slight modifications to the final questionnaire in-
cluding the addition of the reason for disclosing or not disclosing their
use of herbal medicines to their health care providers.
The data collection tool has two major parts. Part one questions
regarding the socio-demographic and disease related characteristics
and the second section aimed at exploring the use and type of herbal
medicines, purpose of use, source of information and any untoward
15
Complementary Therapies in Medicine 35 (2017) 14–19
effects encountered while using herbal medicines. Herbal medicine use
is defined as self-management of a disease condition with any plant
derived preparations with presumed therapeutic benefits, and contain
raw or processed active ingredients from one or more plants and re-
spondents were said to be herbal medicine users if they have taken any
herbal remedies via any route of administration. Routine meal and
animal preparations, traditional medical practices other than herbal
remedies such as spiritual healing and those that are taken as nutrients
(vitamin supplements) were excluded. The questionnaire along with a
cover letter is provided in Additional file 1.
1.4. Statistical analysis
All the statistical analyses were done using Social Sciences (SPSS)
software version 21.0 for Windows (SPSS Inc., Chicago, IL). Frequencies
and percentages were used to express different variables. Univariate
analysis and multivariate logistic regression analysis were used to de-
termine factors associated with herbal medicine use. The results were
adjusted for patients’ demographic and disease characteristics. Odds
ratio (OR) with 95% confidence interval (CI) were also computed along
with corresponding p-value (p < 0.05) as cut off points for de-
termining statistical significance.
2. Results
2.1. Prevalence of herbal medicine use
Out of 396 PLWHA invited to participate, 360 of them completed
the survey giving a response rate of 90.9%. Fears of personal identifi-
cation, lack of interest as well as lack of time were the main reasons
cited for not participating among non-respondents. Among the total
respondents, 61.4% of them were females and a mean age with stan-
dard deviation (SD) of participants was 32.5 ± 8.6. Socio-demo-
graphic characteristics and factors associated with herbal medicine use
among respondents are summarized in Table 1. Of the total re-
spondents, 255 (70.8%) used traditional herbal medicine whilst 105
(29.2%) were non-users. The most common herbal preparations used by
PLWHA were Ginger (Zingiber officinale) (47%), Garlic (Allium sativum
L.) (40.8%) and Moringa (Moringa stenopetala) (31.4%). Herbal medi-
cines relevant for the treatment and management PLWHA are sum-
marized Table 2.
2.2. Characteristics of herbal medicine use
Characteristics of herbal medicine use among PLWHA are tabulated
in Table 3 and Fig. 1. The most commonly cited source of information
about herbal medicine was families and friends (61.2%) followed by
other PLWHA who used herbal medicine (34.7%). Dissatisfaction with
conventional therapy (39.6%) and belief in advantages of herbal
medicines (31%) are the most frequent reasons for herbal medicine use.
Around two third (61.2%) of herbal medicine users did not discuss their
use with their health care providers. Furthermore, about 69% of herbal
medicine users did not know about the potential herb-drug interaction.
Most of herbal medicine users (74.1%) reported that they haven’t ex-
perienced any apparent adverse events from herbal medicine use and
more than half of users (53.7%) reported that they were satisfied with
the result of herbal medicines.
2.3. Factors associated with herbal medicine use
According to the results from univariate logistic regression, there
were statistically significant differences in age, marital status and
educational status between herbal medicine users and non- users
(Table 1). Variables that were significantly associated with herbal
medicine use in the bivariate analysis were further examined in mul-
tivariate logistic regression. Accordingly, only educational status
K.T. Haile et al. Complementary Therapies in Medicine 35 (2017) 14–19

Table 1
Socio-demographic characteristics and factors associated with traditional herbal medicine use among PLWHA, Gondar, 2016 (N = 360).

Variables Overall (n = 360) Use of traditional herbal medicine

Yes (n = 255) No (n = 105) COR (95%CI) AOR (95%CI)

Age
< 35 years 123 (34.2%) 76 (29.8%) 47 (44.8%) 1 1
≥35 years 237 (65.8%) 179 (70.2%) 58 (55.2%) 2.11 (0.76–7.71) 0.91 (0.56–1.44)

Gender
Male 139 (38.6%) 96 (37.6%) 43 (40.9%) 1 –
Female 221 (61.4%) 159 (62.4%) 62 (59.1%) 0.77 (0.69–1.72) –

Educational status
Tertiary education 39 (10.8%) 25 (9.8%) 14 (13.3%) 1 1
Secondary education 73 (20.3%) 40 (15.7%) 33 (31.4%) 1.43 (0.96–2.34) 1.78 (1.71–7.29)
Primary education 116 932.2%) 89 (34.9%) 27 (25.7%) 2.65 (1.16–8.01) 1.91 (1.89–5.17)
*
Illiterate 132 (36.7%) 101 (39.6%) 31 (29.5%) 3.12 (1.89–11.22) 2.22 (1.29–5.91)

Marital status
Unmarried 169 (46.9%) 115 (45.1%) 54 (51.4%) 1 1
Ever married 191 (53.1%) 140 (54.9%) 51 (48.6%) 2.85 (1.89–6.16) 1.17 (0.66–8.19)

Average monthly Income

< 150 USD 191 (53.1%) 145 (56.8%) 46 (43.8%) 1 –
> 150 USD 169 (46.9%) 110 (43.2%) 59 (56.2%) 0.98 (0.35–1.52) –

Employment status
Employed 96 (26.7%) 54 (21.2%) 42 (40%) 1 –
Unemployed 264 (73.3%) 201 (78.8%) 63 (60%) 0.88 (0.41–1.31) –

Duration of disease
1–5 years 104 (28.9%) 72 (28.2%) 32 (30.5%) 1 –
> 5 years 256 (71.1%) 183 (71.8%) 73 (69.5%) 0.83 (0.22–1.05) –

Presence of co-morbidity
No 151 (41.9%) 109 (42.7%) 42 (40%) 1 –
Yes 209 (58.1%) 146 (57.3%) 63 (60%) 0.56 (0.27–1.03) –

Abbreviation; USD; United States dollar.

* statistically significant (p value < 0.05).

remained to be significant in the multivariate logistic model. The odds transcriptase inhibitors used for the management of HIV/AIDS 17. Si-
for herbal medicine use among patients who were illiterate (unable to milarly, Aloe vera, which is used commonly for the treatment of burns
read and write) were 2.22 times higher than in patients with tertiary and minor skin conditions, may cause acute hepato-renal toxicity if
education. taken orally in large amounts.18–22 Through understanding such unto-
ward effects of herbal remedies and facilitating evidence-based dis-
cussions with patients, health care providers could be able to provide
3. Discussion
health care to PLWHA in a more effective and patient-centered way.
Contrary to previous studies,23,24 a lower educational status was found
The present study aimed to assess the prevalence and factors asso-
to be strongly associated with use of herbal medicine in the multivariate
ciated with herbal medicine use among PLWHA in Gondar, Ethiopia
regression analysis. This difference might be due to lack of access to
and to assess their disclosure rate to health care providers. We included
basic education and healthcare infrastructure in the majority of rural
90.9% of the proposed sample size, which increased the representa-
population of Ethiopia, an area where majority of our respondents came
tiveness of our study. According to the finding of our study, more than
from. Due to this, PLWHA usually tend to consult the local traditional
two third (70.8%) of respondents were traditional herbal medicine
healers and use herbal remedies for the management of their medical
users. This finding is comparable with a study conducted in South
conditions. Furthermore, patients with higher educational status tend
Africa.7.However, our finding was higher compared to the study con-
to depend on the medical decisions of their healthcare providers.
ducted in Lebanon (46%) 13 The higher prevalence of herbal medicine
Herbal medicine users in our study rarely disclose their use to their
use in our study could be partly explained by the fact that Ethiopia is
health care providers, an issue which warrants particular attention.
endowed with rich and diverse flora that comprised a foundation for
Anticipating the negative response about from the health care providers
primary health care.4 The relatively higher proportion of respondents
was the main reason for not discussing their use of herbal medicine. The
with lower educational status included in our study could also explain
rate of nondisclosure reported in our study is comparable to the finding
the high prevalence of herbal medicine use reported as these patient
of a study conducted in Malaysia (68%) 25. Healthcare providers in
population usually came from rural places, an area where there lacks
Ethiopia are usually reluctant to probe for information related to their
primary healthcare access, and more likely dependable on traditional
patient’s use of herbal medicine and there is no well-organized system
healers.
in place that facilitates patients with chronic disease to disclose their
The traditional herbs identified in our study contain many phar-
CAM use including traditional herbal remedies. The marginal role of the
macologically active compounds exhibiting a variety of clinically re-
health care providers in PLWHA who use herbal remedies is further
levant effects. Apart from their important clinical effects, most of the
underscored by the fact that the majority of patients have relied mainly
identified herbs in our study also exhibit a variety of untoward effects
on non-health care related sources such as media, friends, and family.
such as herb-drug interaction, mild to severe hepatotoxicities and de-
This finding corroborates with previous studies which reported per-
creased the efficacy of HAART. For example, Clausena anisataa (com-
sonal knowledge, media, friends, and family as the main sources of
monly known as ‘Limche’ in Ethiopia) has a number of potentially useful
information for herbal medicine.25,26 To prevent the possible harm
pharmacologic effects.14–16 However, it also inhibits reverse

16
K.T. Haile et al. Complementary Therapies in Medicine 35 (2017) 14–19

Table 3

Severe allergic reactions, changes in the menstrual cycle, nausea; sweating, hypoglycemia, interact

When taken in large doses, it can lead to toxic effects, such as abortion, confusion, gastroenteritis
Causes uterine contractions, Inhibits CYP3A4 (inhibits metabolism of anti-diabetic drugs in the
Prevalence and characteristics of herbal medicine use among PLWHA, Gondar, 2016
(N = 360).

Heavy metal bio-accumulation (Iron, cadmium, manganese), Hypoglycemia, Gastritis 14,15

Volume depletion, Hypoglycemia, Photosensitivity, Hepatotoxicity, Nephrotoxicity 18–22
Variables Frequency (%)

Herbal medicine use since diagnosis, (n = 360)

No 105 (28.9%)

37,38
Yes 255 (71.1%)
with some medicines like HIV protease inhibitors (eg, Saquinavir) 27–30

Increased risk of bleeding, potential teratogenicity and hypoglycemia

Reasons for herbal medicine use, (n = 255)
Family, tradition or culture 54 (21.2%)
Belief in advantages of herbal medicine 79 (31%)
meglitinide class), Chronic kidney disease, Hepatotoxicty 31–34
Herbal medicine is accessible and available 74 (29%)
Dissatisfaction with conventional therapy 101 (39.6%)
Hepatotoxicity, Diarrhea, Gastritis, Optic atrophy 35,36

Others 20 (7.8%)

Discuss with HCPs about herbal medicine use, (n = 255)

No 156 (61.2%)
Yes 99 (38.8%)

Reason for not discussing with HCPs (n = 156)

Anticipating negative response about herbal medicine use 110 (70.5%)
Potential side effects and toxicities

Insufficient information of herbal medicine 51 (32.7%)

It is not important for doctor to know about my herbal medicine 21 (13.5%)
use

Awareness of drug-herb interaction, (n = 255)

No/I don’t know 176 (69%)
and vomiting 39–41.

Yes 79 (31%)

Side effects experienced (n = 66) *

Digestive symptoms 41 (62.1%)
Generalized body pain and headache 24 (36.4%)
Infectious symptoms 33 (50%)
Metabolic symptoms (wasting or weight gain) 19 (28.8%)

Satisfaction with herbal medicine use, (n = 255)

Satisfied 137 (53.7%)
Decoctions of the leaves or roots are taken via drinking for

The leaves grounded into powder for mixing and drinking.

Average 62 (24.3%)
The rhizome is chewed for stomachache and respiratory

The leaves are chewed for unexplained stomach ache

Dissatisfied 56 (22%)
gastro-intestinal disorders, fever and pneumonia

Abbreviation; HCPs: Health care practitioners.

* More than one option possible.
Flower and leaf extracts taken via drinking
Bulb, taken with ‘injera’ before breakfast

Gel extract, Leaves Rind Stem, drinking

Parts used and method of application

imposed by the use of herbal remedies, health care providers should

emphasize safety issues to PLWHA and make an effort to endow them
with evidence-based information.

4. Limitations

Even though this survey highlights an area of research where there

problems.

is lack of literature in the Ethiopia, caution should be taken when

Plant-based traditional medicines used by PLWHA, Gondar, Ethiopia (N = 360).

generalizing to other regions in Ethiopia as the study was a cross-sec-

tional and conducted only in Gondar. Nevertheless, this survey has
significant implications for improving the rational and evidence-based
use of traditionally claimed medicinal herbs in PLWHA. A larger-scale
Nech shinkurt

and multi centered survey that includes more diverse participants is

Local name
(Amharic)

warranted to validate our findings and to provide more accurate find-

Tenadam
Sheferaw

Zingibil
Limche

Kosso

ings.
Eret

Moringa, cabbage-

5. Conclusions
East African
Horse wood

Fringed rue

The use of herbal medicine among PLWHA is a routine practice and

Aloe Vera

rosewood
English

Ginger

associated with lower educational status. Commonly used herbs among

Garlic

tree

PLWHA were Ginger (Zingiber officinale), Garlic (Allium sativum L.) and
Moringa (Moringa stenopetala). Patients depend mainly on family and
Aloe vera (ferox species)

friends as a source of information about herbal medicines and patients

Moringa. stenopetala

Hagenia abyssinicaa

rarely disclose their use of herbal medicines to their health care pro-
Ruta chalepensis L.
Clausena anisataa

Zingiber officinale
Allium sativum L.

viders. The patients’ higher prevalence of herbal medicine use coupled

Nomenclature

with a higher non-disclosure rate to their health care providers could

Scientific

have a marked potential to cause ineffective disease management and

Table 2

treatment failure. Hence, a provision of customized health education

about herbal remedies to patients is recommended.

17
K.T. Haile et al.
Ethics approval and consent to participate
This study was approved by the ethical committee of University of
Gondar. Written informed consent from the patients was also obtained
before conducting this study. Participants’ information obtained was
kept anonymous.
Consent for publication
Not applicable.
Availability of data and materials
The materials and data supporting the findings of this study are
available from the corresponding author upon request.
Competing interests
The authors declare there is no competing interest.
Funding
No financial support was gained to conduct the study
Authors' Contributions
All authors involved in the conceptualization of the study, data
collection supervision and write up of the first draft of the manuscript
as well as submission of the manuscript. All authors read and approved
the final manuscript.
Acknowledgements
The authors acknowledge the support of University of Gondar and
UOGRTH in facilitating the data collection process.
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