Traditional Herbal Medicine Use Associated with Liver Fibrosis in Rural Rakai, Uganda

Background: Traditional herbal medicines are commonly used in sub-Saharan Africa and some herbs are known to be hepatotoxic. However little is known about the effect of herbal medicines on liver disease in sub-Saharan Africa. Methods: 500 HIV-infected participants in a rural HIV care program in Rakai, Uganda, were frequency matched to 500 HIV-uninfected participants. Participants were asked about traditional herbal medicine use and assessed for other potential risk factors for liver disease. All participants underwent transient elastography (FibroScan®) to quantify liver fibrosis. The association between herb use and significant liver fibrosis was measured with adjusted prevalence risk ratios (adjPRR) and 95% confidence intervals (CI) using modified Poisson multivariable logistic regression. Results: 19 unique herbs from 13 plant families were used by 42/1000 of all participants, including 9/500 HIV-infected participants. The three most-used plant families were Asteraceae, Fabaceae, and Lamiaceae. Among all participants, use of any herb (adjPRR = 2.2, 95% CI 1.3–3.5, p = 0.002), herbs from the Asteraceae family (adjPRR = 5.0, 95% CI 2.9–8.7, p<0.001), and herbs from the Lamiaceae family (adjPRR = 3.4, 95% CI 1.2–9.2, p = 0.017) were associated with significant liver fibrosis. Among HIV infected participants, use of any herb (adjPRR = 2.3, 95% CI 1.0–5.0, p = 0.044) and use of herbs from the Asteraceae family (adjPRR = 5.0, 95% CI 1.7–14.7, p = 0.004) were associated with increased liver fibrosis. Conclusions: Traditional herbal medicine use was independently associated with a substantial increase in significant liver fibrosis in both HIV-infected and HIV-uninfected study participants. Pharmacokinetic and prospective clinical studies are needed to inform herb safety recommendations in sub-Saharan Africa. Counseling about herb use should be part of routine health counseling and counseling of HIV-infected persons in Uganda

Characteristics of participants reporting current herb use.

<p>L (Liters), HBsAg (Hepatitis B Surface Antigen), HIV (Human Immunodeficiency Virus).</p

Association of herbs with significant liver fibrosis in HIV-infected participants.

<p>Multivariate model for HIV-infected participants adjusts for: age, occupational fishing, positive Hepatitis B surface antigen, gender, heavy liquor use (≥1.25 L/week), ART, and CD4 nadir. Only participants with a valid TE scan (468/500) were included in the model. CI (Confidence Interval).</p

Characteristics of known herbs in the Asteraceae, Fabaceae, and Lamiaceae families.

*<p>one patient took both Ocimum gratissimum and Hoslundia oopposita. mg (milligrams), kg (kilograms).</p

Characteristics of known herbs in remainder of plant families.

<p>APV (amprenavir), ATV (atazanavir), AZT (zidovudine), EFV (efavirenz), IDV indinavir), LPV (lopinavir), NFV (nelfinavir), NVP (nevirapine), SQV (saquinavir).</p