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Adherence to HAART: A Challenge of Non Evidence Based Practice.

Posted by plosmedicine on 31 Mar 2009 at 00:10 GMT

Author: Hundie Tesfaye
Position: Dr.
Institution: Physician/Clinical Pharmacology
Submitted Date: June 19, 2007
Published Date: June 20, 2007
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

Mills et al. provided an excellent analysis with extensive review aimed at elucidating factors related to adherence to highly active antiretroviral therapy (HAART). According to their findings, issues of access to medications were more common in developing countries. It is also true that barriers to adherence can be addressed through patient education. This correspondence is dedicated to draw attention to possible risk carried by combining antiretroviral drugs with traditional practices including the so-called "Holy Water" and non-adherence to evidence-based medicine in Ethiopia.

Introduction: Evidence-based health care is limited in Ethiopia, while growing population under poverty conditions is evident. Traditional treatments mostly offered by religious or spiritual authorities were common [1]. Teka and Dagnew [2] reported that 64.4 % of mothers in one Ethiopian region take their children to a traditional healer or apply butter and herb regarding 95.5% acute respiratory infections. Tekle-Haimanot et al. [3], published that traditional treatment with local herbs, holy water, and amulets was common for epilepsy, where only 1.6 % had been treated with recognized antiepileptic drugs. The practice of unscientific management of serious diseases such as HIV/AIDS by the older traditional methods is not unusual, even today in the era of the so-called evidence based medicine.

Despite, scientifically proved drugs help people living with the virus, unscientific practices may do harms to the victims. Holy water fonts from churches in Spain have reportedly a strong bacterial contamination, where 30 out of the 37 different species isolated were known human pathogens [4].Unfortunately, data on quality and biological safety of Ethiopian „holy water“is hardly available. Only 11.84 % of holy water samples from Buddhist temples in Thailand qualified the World Health Organization's standards for drinking water [5]. Water has been suggested as a source of infection by M. avium complex, which frequently causes disseminated infections in AIDS patients [6]. The variation in water quality may hinder the benefits [7], for instance, high sodium content may increase risk of hypertension, whereas high magnesium content may induce diarrhea compromising bioavailability of aniretrovirals.

Conclusions: Research based on factors including cultural attitudes influential to treatment adherence in developing countries, where unfortunately most of people currently living with HIV/AIDS reside is needed. Patient education, enhancing access to evidence-based therapy, and complex support to AIDS victims, who hopelessly try every thing including "holy water" must be the task and moral responsibility for all concerned.


1.Jacobsson L, Merdasa F (1991) Traditional perceptions and treatment of mental disorders in western Ethiopia before the 1974 revolution. Acta Psychiatr Scand. 84:475-481.
2.Teka T, Dagnew M (1995) Health behaviour of rural mothers to acute respiratory infections in children in Gondar, Ethiopia. East Afr Med J. 72:623-625.
3.Tekle-Haimanot R, Forsgren L, Abebe M, Gebremariam A, Heijbel J, Holmgren G, Ekstedt J (1990) Clinical and electroencephalographic characterstics of epilepsy in rural Ethiopia: a community-based study. Epilepsy Res. 7:230-239.
4.Jurado V, odtiž-Martinez A, Gonzalez-delValle M, Hermosin B, Saiz-Jimenez C (2002) Holy water fonts are reservoirs of pathogenic bacteria. Environ Microbiol. 4:617-620.
5.Phatthararangrong N, Chantratong N, Jitsurong S (1998) Bacteriological quality of holywater from Thai temples in Songkhla Province, southern Thailand. J Med Assoc Thai. 81:547-50.
6.Leclerc H, Schwartzbrod L, Dei-Cas E (2002) Microbial agents associated with waterborne diseases.Crit Rev Microbiol. 28:371-409.
8.Garzon P, Eisenberg MJ (1998): Variation in the mineral content of commercially avilable bottled waters : Implications for health and disease. Am. J. Med.105:125-130.

No competing interests declared.