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Mhame, P.P., Nyigo, V.A; Mbogo, G.P; Wiketye, V.E., Kimaro, G; Mdemu, A., Ogondiek, J.W, Imeda, C.P; Malecela-Lazaro, M.N. and Kitua, A.Y.NATIONAL INSTITUTE FOR MEDICAL RESEARCH Traditional Medicine Research Department P.O.Box 9653 Dar-es-salaam, Tanzania. 
Title: THE MANAGEMENT OF HIV/ AIDS-RELATED CONDITIONS USING A TRADITIONAL HERBAL PREPARATION-MUHANSE M4® IN TANZANIA: A CASE STUDY IN DAR-ES-SALAAM, TANZANIA
Key words: Dar-es-salaam, Tanzania, HIV/AIDS, PLWHA, Traditional medicine, Muhanse M4®, ARVs, Medicinal plants
ABSTRACT: Tanzania is one of the countries that have embarked on the programme of providing ARVs to her citizen in order to prolong their life. Muhanse M4® a traditional herbal preparation prescribed by Munufu traditional medicine research clinic has been in use by PLWHA since 1987 to date. The objectives of this study were to determine the effectiveness, the reasons for its continual use despite the availability of ARVs now and its affordability. In this study thirty-one adult persons PLWHA were interviewed, 67.74% were women and 32.26 % men and 5 children. Their age ranged between 25 and 50 years, in the order of 25-49-years 93.55 %, and above 49 years 6.45 % and children’s age ranged from 7-14 years. Muhanse M4® like any traditional herbal preparation is a life long medication, during the survey it was noticed that 31 adults, 9.68% were on treatment for 10 year now, 25.81% for 7-9 years, 12.90% for 4-6 years, 35.48% for 1-3 years, 6.45% for 4-6 months and 9.68% within 3 months. Besides the availability of ARVs in Tanzania yet all interviewed patients, 83.87% preferred to continue using Muhanse M4® to ARVs, 3.23% prefers both and 12.90% had no answer. Only one out of 31 was in the opinion to shift to ARVs. 31 PLWHA adults and 5 children have improved much and have resumed their daily normal life activities except 1 Case. 4 couples managed to get seven children, six of them delivered normally and one through operation. Muhanse M4® was found to be cost acceptable by the users since the payment is done by installments. * * All communications shall be addressed to Paulo P.Mhame**
INTRODUCTION HIV-1 infection and AIDS is still a global public health problem particularly in the sub-saharan Africa.Recent data from UNAIDS indicate that in 1998, nearly 33.4million people were living with HIV/AIDS worldwide.Of these 5.8million people were infected in 1998 alone, out of these 4million of infection (70%) occurred in sub-saharan Africa including Tanzania. 2.5million people died due to HIV/AIDS Worldwide making the cumulative AIDS death to 13.9million.Out of these 2.5million, 250,000 deaths occurred in sub-saharan Africa, making the cumulative AIDS death in sub-saharan Africa be 11.5million, while this region has a total population of only 10% of the World total population. In Tanzania during the year 2001 a total of 14,112 AIDS cases were reported making an acumulation total of 144,498 cases since 1983 when the first cases were reported.The Govenrment estimates that the number of people living with HIV infection is probably five times that of the cumulative number of AIDS cases, making a total of 722,490, with the overall HIV prevalence of 9.6% for Tanzania mainland. Dar-es-salaam City is one of the highly affected areas in the country where people living with HIV/AIDS, it is the second after Mbeya region. For many years now there have been no drug for the management of the disease.Due to scarcity of drugs for the management of the disease many of PLWHA opt for traditional health services for the control of the disease. About 60% of the population depends on traditional medicine for the management of various diseases and or ailments including HIV/AIDS. In Tanzania, traditional medicine is a system of medicine, which is not yet formalized, contrary to the formal health sector; although it shares with the formal health sector the common goal and that is “to improve the quality of health services of the Tanzanian population in line with the goal of the National Health Policy”. Muhanse M4® has a long history in herbal medicine for boosting body immunity of people in some parts of Tanzania particularly Mufindi and Kilombero districts. Muhanse M4® is just a standard infusion or weak decoction of ready prepared powder from whole plant or its parts. The product is one among the many products produced and dispensed by Munufu traditional medicine research clinic. Munufu traditional medicine research clinic was established in 1987 at Ubungo. Since then the centre has been dispensing herbal medicines to PLWHA in order to improve the quality of life of people living with HIV/AIDS. OBJECTIVES Broad Objective: The broad objective of the study was to determine the effectiveness of Muhanse M4® in managing HIV/AIDS related conditions. Specific Objectives: The specific objectives, which underlined the investigations, were:
METHODOLOGY Survey designThis study used both qualitative and quantitative research methods. Survey areasThis survey was conducted to PLWHA using Muhanse M4® in Dar-es-Salaam City. Sampling MethodMunufu Traditional Medicine and Research Clinic assisted by systematic notifying people living with HIV/AIDS using Muhanse M4®. Respondents were obtained through clinic registry and followed them at their homes and those who visited the clinic for the collection of their herbal medicines. Survey populationIn this study the survey unit was PLWHA attending Munufu Traditional Medicine and Research Clinic who are on Muhanse M4® for the management of HIV/AIDS. A total of 31 adults living in Dar-es-salaam were enrolled for the study. Sample sizeThere were no intended sample size, however, at the end of the survey 36 PLWHA (31 adults and 5 children) were identified to be on Muhanse M4® , only 31 adults were enrolled for the study. Data collectionSwahili language is commonly used in Dar-es-Salaam City; hence, it was used during the survey. The in-depth interview was conducted to PLWHA attending Munufu Traditional Medicine and Research Clinic and using Muhanse M4®. A structured questionnaire was used to collect the information needed. Data Management, Processing and AnalysisThe quantitative was analyzed through cross-tabulations and MS excel. A systemic comparison of the findings from the in-depth interview and observations was also made. RESULTS Social-demographic characteristics of the survey population Age. 31 PLWHA attending Munufu Traditional Medicine and Research Clinic and using Muhanse M4® who were included in the survey, were of age ranging from 25 to 50 years in the order of 25-29 years 19.35%, 30-34 years 12.90%, 35-39 years 32.26%, 40-44 years 19.35%, 45-49 years 9.69%, and 6.45% were of age above 49 years. The survey noticed that, 7 children were born after their parents were using Muhanse M4® although they themselves are not using the regime. 5 children aging 7-14 years were found to be on Muhanse M4® introduced to them by their parents, the two groups of children were not counted in our survey. 
Gender/sex. HIV/AIDS is a disease, which affects all gender, but treatment-seeking behaviour may vary from one sex to another. In this survey it was found that out of 31 adult PLWHA 67.74% who sought traditional medical services are adult women and 32.26% are adult men. 
MarriageHIV/AIDS affects both married and singles who are sexually active and also some of the children born to parents who are living with HIV/AIDS. In this survey out of 31 adult PLWHA, 77.42% were found to be HIV positive after they were married, 12.90% were HIV positive before they were married, 9.68% were found HIV positive while they are single and they are still single. Some of them have managed to have children while they are on Muhanse M® . Seven children not on the regime have been born to parents who are using Muhanse M® , six of them were delivered normally and their mother breast fed them, one was born through cesarian section and the child is not being breast fed, all are in good health. Three of the seven children are in primary school and three in nursery. Five children on Muhanse M® born to some of the parents before enrolling for Muhanse M® and who were diagnosed were found to be health and actively attending school. 
Education. HIV/AIDS patients like any other patients; there is no educational difference. In this survey it was found that out of 31 PLWHA, 58.06% of the adult patients are diploma holders, 19.36% are secondary school leavers, 9.68% are primary school leavers and 12.90% are graduate. 
Treatment Reasons for seeking medicationAny person found to be HIV sero positive alone without any medical complaints is not the satisfactory reason to seek medical help. PLWHA also do seek medical assistant when there is a need. In this survey PLWHA responded that, 6.45% had a complain of pruritic skin rashes and black spots; 9.68%abdominal pains accompanied with on and off diarrhea; 12.90% had a history of severe headache; 16.13% had persistence fever and chest infection which presented with dry cough; 54.84% had severe headache and oral thrush. 
Duration of treatment Muhanse M4® like any other anti-retroviral therapies they are for life long treatment. During the survey it was found that 9.68% were on treatment for 10 year now, 22.58% for 7-9 years 12.90% for 4-6 years, 38.71% for 1-3 years, 6.45% for 4-6 months and 9.68% within 3 months. 
Health improvementTanzania is providing ARVs to her citizen in order to prolong their life as well as to improve their quality of life. 96.77% of all interviewed adult patients, responded to have improved their health conditions in comparison to the time they were not on Muhanse M4® and that have assisted them to resume their daily normal life activities. Although by the time of visiting one client appreciated the service, however, she was still weak and sick and she was ready to shift to ARVs if she could get such an opportunity. Information on Munufu clinic Information on Munufu Traditional Medicine and Research Clinic and its traditional medical care is not secretly done, hence many people know. 45.16% of the customers got the information through Amana Counseling Office, 32.26% through mass media, 12.90% through friends, 6.45% through AMREF and 3.23% through contact with the own of the facility. Preference between ARVs and Muhanse M4® HIV/AIDS is one of the commonest diseases of human health to day. All patients have knowledge about HIV/AIDS and that all patients have information about ARVs availability. 74.20% of them have heard through mass media about the availability of ARVs, 19.35% have heard through hospital workers and 6.45% through friends. The government has embarked in the efforts to provide ARVs to her citizen in order to prolong their life. All of the interviewed patients who are under Muhanse M4® regime, 83.87% preferred Muhanse M4® to ARVs and that they are not ready to shift to the ARVs available now, 3.23% said both are better for their health and 12.90% had no answer. Of all 31 adults interviewed, only one was in the opinion to shift to ARVs if such opportunity will be available. 
Advice to other people Community has various ways of communicating things to others, people who are under Muhanse M4® regime are now the ones spreading information about the medications to other people. During the interview about 83.87% of the interviewee have informed other people about Muhanse M4® regime, 9.68% have not done so and 6.45% had no answer. Besides the advice to other people, 90.32% of the interviewee had the opinion that the government should commit herself in supporting such individual effort by being serious with research and 9.68% had no opinion. Service costs In all societies, people are remarkably pragmatic in testing and evaluating new alternatives in deciding even though it is to their advantage. This is true of health behaviour, where we can almost speak of a cost-benefit mode of analysis. Medical services are often more attractive to users if value is placed on them in the form of at least a token fee. Traditional medicine is said to be more acceptable to the community simply because at cultural based cost its value is almost a token fee. In this survey although it was noticed that the cost is not so cultural but customers do pay by installments hence it is customer friendly. Sometime they are given medicines without having money at all and later on do pay as they get money. Besides the fact that the owner is so generous to his customers but some of them they feel that it would be wealth if the government could assist them by providing funds to such centres. They agree that the disease is a chronic condition, which need long term use of medications whether traditional, or not hence it needs much money to maintain their health to normal level in order to make them continue with their daily activities. ObservationIn this cross-sectional survey, we observed 31 adults PLWHA who are on Muhanse M4® to improve much and they have resumed their daily normal life activities. 1 Case was improved but not to the extend of resuming her daily normal life activities although she was thanking the centre for allowing her condition to improve to that extend. To our surprise, out of 31 PLWHA two couples claimed that they have been converted sero-negative after several months of being on Muhanse M4® and they no longer continue with the treatment. DISCUSSION Traditional systems of medicine in general have had to meet the needs of local communities of many countries like Tanzania. The already reported fact that over 60% of Tanzanians living in rural areas rely on herbal remedies for their primary health care, similarly to our findings showed that even people living in Dar-es-salaam do rely on herbal medicine for the management of HIV/AIDS. People in Dar-es-salaam have been enjoying with Muhanse M4® for the management of HIV/AIDS related conditions. Currently there are no documented records on the use of pure compounds from Tanzanian plants for immune modulations specifically in HIV victims. However, there is substantial information and anecdotal evidence on the use of crude plant materials for the same. The many plants that are used as immunomodulators in HIV affected individuals are also used to treat other viral diseases such as measles, hepatitis B and influenza. Phyllanthus niruri /Amarus and Cajanus Cajan are currently being used to traditionally as remedy for hepatitis B in Tanzania and many other countries in the World. In India for example Phyllanthus amarus is used in the treatment of viral hepatitis and jaundice. The active constituents contained in Phyllanthus have been shown to inhibit the surface antigens of some viruses. In 1992 laboratory investigation of water extract of P. niruri by Japanese research group, exhibited an inhibition activities of HIV-1 reverse transcriptase enzyme. Similarly in 2003 a German research organization found that the plant do have 70-75% inhibition of virus besides it has other antimicrobial effects. Muhanse M4® which is made up of mixtures of medicinal plants may have ingredients which has anti-viral effect similar to the example made. The survey noticed that Muhanse M4® like any other medicines is highly appreciated by people for the management of HIV/AIDS and its opportunistic infections. 96.77% of all interviewed patients, responded to have improved their health conditions in comparison to the time they were not on Muhanse M4® and that have assisted them to resume their daily normal life activities. People have been using the medications since 1994 to date and some of them have managed to get children while using Muhanse M4® . People have improved their health status and they are now back to their normal life, carrying out their normal activities. Due to that 83.87% prefers Muhanse M4® to ARVs for prolonging their life because they believe that the government programme has its end, and once such reaches they will have no other alternative. Muhanse M4® has no time limit and the person who supplies the product is always available, he has no political influence controlarly to the government programme which depends highly on the political situation and availability of government funds. Mass media are informing people on the side effects of those ARVs, we have been on Muhanse M4® for many years now and we have not experienced any side effects then why move to another with a lot of side effects. “…remember people are being warned that the ARVs have many side effects why then one rush to take such a drug…………..” “…….free is expensive…..” Traditional medicine like modern medicine is costly in the provision of health services and for chronic illnesses like HIV/AIDS the situation is even more worse, yet people prefer to use Muhanse M4® because they can negotiate the price and the modalities of payment. People would like to continue using Muhanse M4® for the management of HIV/AIDS related conditions despite the fact that the government is now providing free of charge ARVs to patients who meets the conditions to use them. This is because some of them developed faith in it as they have been using for ten years and some have managed to get children who are health and are schooling. Some even said what I want, ARV like Muhanse M4® all are elongating my life one I know the source while another I do not know the source what will happen when there is no more drug supply I will have to die but Muhanse M4® is always available. CONCLUSION AND RECOMMENDATIONS Conclusion. Our findings indicate that, Muhanse M4® has customers who has faith in it and more people are being informed about its importance. Clinical evidences given by the respondents who uses Muhanse M4® shows that Muhanse M4® has been effective in clearing opportunistic infections to PLWHA and hence caused them to rely entirely on it in the management of HIV/AIDS related conditions. Muhanse M4® is believed by users for the management of HIV/AIDS related conditions and opportunistic infections such information forms a strong evidence for considering this remedy as effective. The findings in this study show that all 31 patients interviewed were very familiar with the existence of ARVs to be provided to people living with HIV/AIDS but almost all have decided not to mix the two regimes. This is an indication that, Muhanse M4® do offer what clients want for the maintenance of their health. Recommendation The already reported fact that over 60% of Tanzanians living in rural areas rely on herbal remedies for their primary health care, similarly to our findings showed that even people living in Dar-es-salaam do rely on herbal medicine for the management of HIV/AIDS related conditions, pose a scientific challenge to scientists to establish the efficacy, safety and quality of Muhanse M4® preparation. This calls for an urgent need to; firstly, carry out an inventory of traditional health practitioners who does provide remedies for the management of HIV/AIDS related conditions and their opportunistic infections. Secondly carry out an observational study on the effectiveness of the therapies supplied to the existing opportunistic infections. Thirdly, to conduct extraction and establish pre-clinical safety of the traditional herbal preparation. Fourthly, confirm the safety and efficacy of the safe traditional herbal preparation in clinical trials in humans. Basing on the fact that, our fore fathers survived on the traditional herbal preparation, and that, the majority of Tanzanians still rely on these remedies for the management of HIV/AIDS related conditions and other ailments, the chances of obtaining safe new phytochemical drugs with good anti-retroviral properties are high. ACKNOWLEDGEMENTThis report is the outcome of the survey in Dar-es-Salaam City to people living with HIV/AIDS related conditions who use Muhanse M4® prescribed by Munufu Traditional Medicine and Research Clinic that was undertaken from 21st November –5th December 2004. The survey was made possible by the active support from Munufu Traditional Medicine and Research Clinic, the Ministry of Health financially and National Institute for Medical Research for accepting and facilitating the survey. The survey team wishes to thank all those who supported the idea and later the activity. We wish to express our sincere gratitude to customers of Muhanse M4® who have generously provided most of the information included in this report to the survey team. This information constitutes the most important and valuable part of innovations of Munufu Traditional Medicine and Research Clinic. Lastly we wish to express our sincere gratitude to them all for being willing to share their experiences with us on the use of herbal medicines and for trust, confidence and cooperation, which their contributions imply. REFERRENCES G.L.Chavunduka and M.Last (1986). The professionalization of African Medicine, Manchester. Manchester University Press With International African Institute (eds). G.O.Sofoluwe (1992). Principles and Practice of public health in Africa Vol.I Kirk and Miller (1988). Reliability and Validity of Qualitative research. Research method series, sage publications, Berkeley Lyoyd Swantz (1990). The Medicine Men Among the Zaramo of D`Salaam. Dar-es-Salaam University press. Dar-es-Salaam. MoH (2002) Health Statistic Abstract, Ministry of Health, Dar es Salaam, Tanzania MoH NACP(2004), Behavioural Surveillance Surveys Report Ramjit Roy Chaudhury-Herbal Medicine for Human Health-WHO-South-East-Asia region,New Delhi,1992. Ukoko-Herbal Medicine for Human Health-WHO-South-East-Asia region, New Delhi 1992 UNAIDS 2004 |
