Introduction

In this paper of medical anthropology, I examine the research concerning HIV/AIDS treatment in the context of medical pluralism in India and specifically in relation to Ayurveda, a non-Western scholarly medical system. I draw upon a comprehensive review of the literature to investigate reasons that patients select therapies of Ayurveda and other Indian Systems of Medicine (ISM) for HIV/AIDS care, specifically exploring such issues as access, cost, and perceptions of efficacy. Delineating the merits of promoting certain Ayurvedic therapies for HIV-positive patients, I critique the official government policies on its use and its most recent censure of Ayurvedic research on HIV/AIDS treatments. I then suggest strategies that promote collaboration between and cross-education of Allopathic and Ayurvedic practitioners. I conclude that these interventions would promote the wider distribution of effective Ayurvedic, other ISM, and Allopathic care; eradicate risky non-Allopathic practices; and ultimately provide more comprehensive, integrative care for HIV-positive patients in India.

Significance of Study

Insufficient research exists which explores the possible positive and/or deleterious effects of a syncretism of Ayurvedic and other traditional therapies with ART [1]. Moreover, research is needed to determine the effects of ISM on the quality of life of HIV-positive patients and to determine which specific ISM therapies are used to treat HIV/AIDS [2]. This study addresses this epistemological gap and explores whether Allopathic and Ayurvedic treatment options can be used synergistically. Because ISM is the most used system in delivering primary care in India, it is important that the Indian Medical Association acknowledges and trains ISM practitioners so that they may provide coordinated, efficacious treatment plans with Allopathic practitioners [2].

As HIV/AIDS has become a significant health issue in India, this pressing epidemic necessitates various forms of treatment that are available and acceptable to patients. From the results of my review of the existing literature, I examine the benefits and disadvantages of the inclusion of Ayurveda as part of HIV/AIDS care in order to propose a more holistic and effective model for treating HIV-positive patients in India.

The State of Treatment Options for HIV-Positive Patients in India

Overview of HIV/AIDS in India

The first cases of HIV in India were noted among female sex workers in Tamil Nadu in 1986. Since then, HIV has spread throughout the country, and the estimated HIV prevalence in India is 0.36 percent. Although this number seems low, it equates to 2.5 million cases of HIV/AIDS out of the current 33.2 million cases worldwide [3]. The increasing prevalence of HIV can be partly attributed to India’s health care system and health status. India ranks poorly even among developing countries in its health infrastructure and its overall burden of disease, of which communicable diseases account for 50 percent [4]. India has, along with various international organizations, implemented programs to increase access to antiretroviral treatment and prevention efforts [5]. In 2004, its public sector ART program was implemented [6]. By 2007, about 107,000 patients were receiving free ART at 133 different public centers throughout India [3]. However, the government program offers free antiretroviral drugs only to infected people who are under the age of 15, pregnant, or have full-blown AIDS and reside within one of the six states with high prevalence [7]. Despite the exorbitant number of people living with HIV/AIDS in India, as of March 2009, only 20 percent of patients who qualified for ART through government centers and programs were receiving it. The limited provision of ART through the public healthcare system is due primarily to India’s low budget for public health care. Moreover, public hospitals are often exceedingly distant from rural populations and, therefore, inaccessible.

A vast majority of the population, 60-85 percent of Indians, seeks primary care in the private sector, which includes both non-public Allopathic care and ISM care [1]. Accordingly, a majority of patients being treated with ART in India utilize the private Allopathic sector [8]. However, a significant proportion of people living with HIV/AIDS (“PLWHA”) cannot afford to buy ART privately [9]. Those who cannot afford ART from the private sector must either forgo ART (and potentially seek out alternative systems of care) or seek ART and other HIV/AIDS therapies from public hospitals, which are overburdened and often provide poor quality care [10]. This situation may limit the ability of impoverished HIV-positive patients to receive adequate care [8].

Thus, existing national public health interventions are not efficiently or effectively addressing the epidemic. This failure can be partly attributed to India’s inadequate health infrastructure and lack of promotion of innovation in expanding options for care. One of these options, I argue, should be expanded Ayurvedic care for certain types of chronic pain management and maladies associated with HIV/AIDS.

Overview of Ayurvedic Therapies

Ayurveda has existed as a prominent and trusted medical system in India for over five thousand years. Ayurveda as a self-proclaimed “comprehensive medicine” since it treats the patient as a whole, incorporating even his or her social situation [11]. As stated in [11], “It [Ayurveda] professes ‘comprehensive medicine’ by interrelating bodily conditions to humors, environmental and climatic factors, psychological dispositions, and moral and spiritual states.” In the diagnostic process, Ayurveda uses palpation, questioning, percussion, inspection, and tongue and pulse diagnosis. In Ayurveda, regulated diet, sleep patterns, and sexual activity are essential to achieve health. Typical treatments are based on the balance of the three humors (vata, pitta, and kapha) and include dietary modifications, cleansing procedures (panchakarma), herbal and mineral supplements, and spiritual healing [10].

Ayurveda in the Pluralistic Healthcare System of India

The Government of India recognizes Ayurveda, Unani, Siddha, Naturopathy, and Yoga as legitimate systems of medicine and as a group designates these “Indian Systems of Medicine,” or ISM. Although this paper discusses various forms of ISM in relation to HIV/AIDS in this paper, it focuses mainly on Ayurveda because it is the most widely used traditional medical system and has the largest influence on all other forms of ISM. Together, ISM compose the contemporary term AYUSH (meaning “life” in Hindi and serving as an acronym for Ayurveda, Yoga and naturopathy, Unani, Siddha, and Homeopathy) [12].

While Allopathy is the most highly regarded system of medicine in India, Ayurveda is the second. Rhode et al. (1995) claims that ISM practitioners are “the most accessible and most used source of medical care in the country” [6]. Within ISM, Ayurveda is the most frequently used system and has the most practitioners. Despite the growth of biomedicine in India, many Indians continue to seek out Ayurvedic practitioners, also known as vaidyas. After its suppression during colonial times, Ayurveda has seen a resurgence over the past few decades in India and a growing interest worldwide [1]. In fact, the number of practitioners of ISM has almost doubled since 1980 [6]. According to the Department of Indian Systems of Medicine, there are 600,000 registered traditional practitioners while other sources report an excess of 2 million in rural parts of India [13]. Approximately 70-80 percent of the Indian population uses ISM at some point in life, and Ayurveda is the ISM sought most throughout India [1]. In addition, according to the Patil et al. study presented in [14], 75 percent of the formal health sector is concentrated in urban areas where only 27 percent of the population resides; this fact indicates that almost three-quarters of the Indian population resides in rural areas with limited access to biomedicine. Therefore, a vast majority of the country depends on traditional medicine (mostly Ayurveda) for at least part of its health care.

In India, Ayurvedic practitioners currently fall into a two-track system: those who are institutionally trained and registered by the Central Council for Ayurveda and those who are non-institutionally trained. While the percentage and number of ISM practitioners who are institutionally-trained were relatively low in the 1980’s, the numbers have been steadily rising. As of 2005, three-quarters of all registered Ayurvedic practitioners had received degrees from institutions. Overall, the number of institutionally-trained practitioners has almost quadrupled since 1980 [6].

The Parliament of India has standardized qualifications for Ayurvedic practice, and several government-recognized (and even government-funded) institutions exist for training these practitioners. The Central Council for Ayurveda registers qualified practitioners and oversees the requirements necessary to obtain a degree in Ayurveda. Those who are non-institutionally trained are not excluded as practitioners but are not registered as qualified by the Central Council for Ayurveda. In India, there are over 196 undergraduate medical colleges that offer training in Ayurveda [6]. Graduates of these colleges receive a Bachelor of Ayurveda, Medicine, and Surgery (B.A.M.S.) after three years of training, and students can continue with three years of postgraduate study [15].

Despite progress in institutional training for ISM practitioners, regulation of ISM practices remains substandard. ISM is not included in the public healthcare system; thus, Ayurveda and other ISM operate almost exclusively in the growing private sector. ISM is nominally regulated by the Government of India’s Ministry of AYUSH. The Central Council for Ayurveda does not, however, adequately monitor Ayurvedic practitioners and the therapies they employ. Regarding ISM drugs, the Government of India attested in its “National Policy on Indian Systems of Medicine and Homeopathy-2002” that “the safety, efficacy, quality of drugs and their rational use have not been assured” [6]. Thus, especially in rural areas, vaidyas are largely left to employ either effective or harmful therapies with little to no oversight or regulation of their practices.

Government Policies on Ayurvedic Therapies for HIV/AIDS Care

Ayurveda constitutes a significant part of the national AIDS response in India because it, along with other ISM, is arguably more accessible, sometimes less expensive, and more culturally appropriate for much of the population [14]. Various effective Ayurvedic remedies exist for treating opportunistic infections, associated illnesses of HIV/AIDS, and side effects of ART. In 2003, the Government of India recognized these aspects and officially stated in its AIDS policy the following:

There is an urgent need to look for cost-effective alternatives to antiretroviral drugs in the indigenous system of medicine like Ayurveda, Unani and Siddha apart from Homoeopathy. Some of the medicines in these systems have the potential of reducing the viral load in the body of the patient thus ensuring a healthier and longer life with the infection. […] At the same time, it is necessary to be vigilant against unscrupulous persons claiming a cure for HIV/AIDS by magic remedies. [18]

The policy further states, “The government has sponsored research projects in ISM and is receiving encouraging response [sic]” [13]. Despite numerous successful findings, NACO is still skeptical of the inclusion of ISM in HIV/AIDS treatment. As this policy notes, quackery constitutes a grave concern in the field of Ayurveda as does its lack of regulation.

Perhaps for these reasons and others, India’s National AIDS Control Organisation (NACO) has recently reversed its opinion and in August of 2010 asked all medical colleges in India to suspend experimentation on Ayurvedic HIV/AIDS treatments. While the Government of India had been previously funding research on Ayurvedic remedies for HIV/AIDS, Dr. S. S. Kudalklar, the project director of the Mumbai District AIDS Control Society, stated, “Ayurvedic treatment or any other kind of immune boosters is not the mandate of NACO” [19]. He also noted that NACO’s pronouncement was in part based on the assumption that that when HIV-positive patients use alternative therapies, such as those of Ayurveda, they “underestimate the importance of ART and other prescribed drugs” [19]. Several researchers and health officials disagree with this controversial statement. A senior professor at King Edward Memorial Hospital in Mumbai stated, “The student’s research was on neem, tulsi, haldi, cloves, and other such harmless items as immune boosters for HIV patients. If the lifespan of an HIV patient can be increased through such easy techniques, then such studies should be promoted by NACO instead of discontinuing them” [19]. The conclusions of this paper align with this professor’s opinion that Ayurveda and other ISM can, beyond effective remedies, help provide both more accessible and more comprehensive care for PLWHA.

Research Methods

The comprehensive review of the literature was conducted over the course of several months, between November 2009 to January 2011. The following electronic databases were searched from their respective inceptions: AMED; BIOSIS; History of Science, Technology, and Medicine; Orbis; Scopus; PsycINFO; PubMed; Sociological Abstracts; Web of Science; and Google Scholar. The search terms used were Ayurved (for Ayurveda or Ayurvedic), India, traditional medicine, HIV, AIDS, and complementary medicine. All papers searched were in English. Approximately 1,000 papers’ titles, keywords, and abstracts were reviewed. Based on the titles, keywords, and abstracts, 21 of these papers and chapters of books were deemed relevant and were read in full. The bibliographies of certain papers were further searched for articles. In addition, 20 other articles, website pages, chapters, and government documents concerning the individual topics of HIV/AIDS, HIV/AIDS in India, complementary and alternative therapies for HIV/AIDS, medical anthropology, healthcare-seeking behavior, medical pluralism, and India’s healthcare system were read in order to ground the chosen articles in the latest germane literature. Also, books on Ayurveda were consulted for background information. IV.

Findings

Current Ayurvedic Therapies for HIV/AIDS Care and Their Applications

In Ayurveda, there are seven vital components to food, one of which is ojas, which stimulates the body, heart, and brain, similarly to the biomedical term metabolism. AIDS is associated in Ayurveda with a depletion of ojas, or “vital essence” [20]. In Ayurveda, there is no comparable classification of HIV/AIDS. However, there are recognized illnesses associated with AIDS, including “sannipatik jwara (fever), pratiloma rjyakshma (tuberculosis) and ojakshaya (inmmunodeficiency/general debility)” [21]. In addition, the symptomatic manifestations of different stages of AIDS can be seen as kshaya (deficiency) symptoms, including majj shukra ojakshaya (full-blown AIDS) [21]. As a result of these understandings, vaidyas have adapted their practices for dealing with this new disease.

Since the introduction of ART, Ayurveda and other alternative medicines have been used to prevent the onset of AIDS, to kill viruses, to delay the need for ART, and to treat opportunistic infections [22]. Other herbal medicines have been used to alleviate symptoms, reduce viral load, and increase CD4 cell counts for PWLHA [1]. Another systematic review of the literature [23] found that most HIV-positive patients seek out complementary and alternative medicine (CAM) in order to improve immunity, treat adverse symptoms and increase quality of life. In terms of the biological impacts of HIV/AIDS, patients reported using CAM in order to delay the onset of AIDS, to prevent symptoms of HIV/AIDS including weight loss, nausea or diarrhea, and also to reduce side effects of Allopathic therapies. In addition, patients reported using CAM to relieve stress and depression, to improve mental health, to gain greater agency over combating their illness, and to obtain superior doctor-patient relationships. These findings are expounded upon below.

Other immunomodulatory drugs help to restore health while on ART and to alleviate adverse side effects of ART, which can negatively affect quality of life. For example, a study performed in Kerala administered to patients NCA, a jeevaneeya drug which maintains oja; AC-2, a pachaniyum drug which strengthens metabolism; and SA-III, a Brahmanum drug which maintains body weight. Over the course of nine months, the patients experienced an increase in appetite, body weight, and metabolic activity. This study concluded that this drug regimen is a relatively inexpensive way to manage symptoms associated with HIV/AIDS and ART [24]. Thus, while ART can be used to prolong life, Ayurvedic medicines can be used to improve quality of life by diminishing or eliminating less severe side effects.

Fig. 1: Therapeutic and Non-Therapeutic Reasons for the Use of Ayurvedic Therapies for HIV/AIDS

Non-Medical Reasons for the Use of Ayurvedic Therapies by PLWHA

Based on the comprehensive review of the literature, HIV-positive patients seem to seek out Ayurveda and other ISM for a diversity of considerations ranging from cost and accessibility to perceived efficacy. Healthcare seeking behaviors are extremely complex and can be influenced by a range of factors including one’s location, caste, educational status, age, and gender. Ozsoy & Ernst [23] aptly notes:

The motivations to use complementary therapies are complex and differ from population to population. Several general themes do, however, emerge. These range from a different world view to wanting to take control over one’s own illness and from wanting to try all options in hoping to minimize adverse effects of conventional treatments.

In a pluralistic medical system such as that in India, patients are able to exert great agency in choosing how to treat their health problems. As claimed in [25], alternative forms of care for HIV/AIDS are “gaining popularity because of several advantages such as often fewer side effects, better patient tolerance, relatively less expensive [sic] and acceptance due to long history of use.” While researchers have identified a variety of factors that influence the use of Ayurveda and other ISM, this study focuses primarily on five non-medical factors. These factors can be seen in Figure 1. It must be conceded that while Ayurvedic therapies may be preferable to HIV-positive patients for a number of therapeutic and non-therapeutic reasons, the efficacy of many Ayurvedic therapies have not been substantiated due to a lack of systematic drug trials, and some therapies can, in fact, cause further harm to patients.

Improvement of Mental Health and Well-being

As holistic care, Ayurveda takes into account physical, psychosocial, and spiritual aspects of disease, recovery, and health [10]. This approach is especially relevant for HIV/AIDS patients. In [13] Bodeker et al. notes the importance of “living positively” and of psychosocial wellbeing for PLWHA in addition to medication. The authors contend that coping mechanisms and relaxation techniques can help improve the quality of life for patients living with such a socially and physically taxing disease. Remarking on the emerging field of psychoneuroimmunology, Bodeker et al. [13] stresses the profound impact that mental states can exert over the immune system, an influence that makes counseling all the more important for PLWHA. In fact, the authors claim, “psychological wellbeing is correlated with a delay in the onset of full-blown AIDS” [13]. The psychological component of healing often included in Ayurvedic care constitutes a seemingly necessary aspect that is neglected in much Allopathic care, especially in India’s overburdened public sector.

Ayurvedic practitioners provide a much-needed service for many PLWHA. As seen above in its therapies for body pain, weakness, weight loss, depression, among others, Ayurveda takes a more comprehensive approach to health and to care than does Allopathy. As stated in [6], “Illnesses that are seen as non-life threatening, mental illnesses, chronic and lingering ailments are generally seen by people as belonging to the domain of non-allopathic systems.” PLWHA may be able to use Ayurveda for such ailments to improve both their psychological wellbeing and their overall quality of life.

Perceptions of Greater Efficacy

According to [1], although most patients believe biomedicine to be more effective in treating HIV/AIDS, they continue to seek out alternative therapies. In a study conducted in 4 regions of India, while 41 percent of respondents reported using ISM, only 5 percent believed that it was more effective than Allopathic ART for HIV/AIDS [2]. These beliefs differ by region. In the city of Vellore, which is in the state of Tamil Nadu where Siddha is practiced widely, a study concluded that many infected individuals believe in traditional medicine’s efficacy. Over all of India, about 40 percent – 90 percent of HIV positive people use dietary supplements and complementary and alternative medications [1]. This phenomenon can be attributed to the cultural preference as noted above, problems with biomedicine, cost, and availability.

Concerns about the Effects of Allopathy

PLWHA in India may seek out ISM because of the problems they see in Allopathic treatment. For example, in [1], reasons that patients reported for seeking ISM included: fear of Allopathic side effects, direct experience with Allopathic side effects, and the recurrence of symptoms despite Allopathic treatment. Making durable alterations to these fundamental processes is seen to engender positive long-term effects whereas Allopathy is seen only to remedy the superficial symptoms of deeper imbalances. In addition, Chomat et al. [1] found that, because Ayurveda promotes lifestyle changes, employs herbal remedies, and applies less invasive treatments, the therapies of Ayurveda are perceived to have fewer side effects than Allopathic treatments.

Greater Accessibility

The accessibility of Ayurveda is another one of its main advantages. A 2003 Population Research Centre & JSS Institute of Economic Research study of patients with sexually-transmitted infections found that a majority of individuals living in urban and rural areas in the state of Karnataka first seek out traditional medical practitioners due to lower costs and easier accessibility [17]. In the sample region in Karnataka, half of practitioners in urban areas were non-Allopaths while in rural areas three-fourths were non-Allopaths, indicating a greater use of ISM in rural areas. The greater number of traditional healers per patient compared to that of Allopathic physicians per patient reflects the high rates of ISM use and disproportionate lack of access to biomedicine. The Bhat (1999) study approximated that India had 390,000 registered Allopathic doctors and 650,000 registered practitioners of other systems of medicine, mostly of Ayurveda and Homeopathy [17]. Because ISM serves as the most accessible source of primary care for many, especially rural, patients, they are likely to use it to treat HIV/AIDS.

A wide variety of factors play into the issues of accessibility and cost, which go hand-in-hand. PLWHA in India often consider Allopathic care for HIV/AIDS as both inaccessible and too expensive [2]. A study’s [1] sample population, residing in Vellore, India, expressed an inability to afford Allopathic treatment because of transportation costs, among other reasons. While ART is distributed for free by the state at major public hospitals in India, those distribution sites are often distant from rural areas where most Indians live contributing to high transportation costs. Another study [8] distributed a questionnaire to participants from six different healthcare facilities across India. This study found that 29 percent of the sample population reported travel time to a clinic to be greater than five hours and 45 percent of those who expressed having barriers to care reported the site of care to be too distant. Moreover, out of those participants who expressed experiencing barriers to care, 42 percent stated that they could not afford the loss of wages. “Free” ART comes at some cost to nearly every patient due to India’s poor health infrastructure and its widespread poverty. Thus, the inaccessibility of ART for many HIV-positive individuals contributes to the use of ISM to manage HIV-related illnesses [13]. The high percentage of Indians living in rural areas, along with cost, presents a major hurdle in the effective distribution of ART.

Lower Cost

Both Fritts [2] and Bodeker et al. [13] report that many patients consider the cost of Allopathic therapies, including ART, prohibitive. As discussed previously, a considerable majority of Indian patients seek care and ART in the more geographically accessible private sector. Through the private sector, patients must pay out-of-pocket for ART. In one study [8], 33 percent of participants stated that they could not afford ART. These patients often turn to ISM for lower cost alternative therapies.

Indeed, this study [8] found that the use of Ayurveda is correlated with patients of lower socio-economic status. In this study, which surveyed 1,667 HIV-positive patients at six public and private health care centers in India, 65.4 percent of the HIV-positive patients who visited public health centers (indicating a lower socioeconomic status) took herbal medicines while only 2.7 percent of those visiting private clinics took these medicines. This study also found that, as expected, patients who sought care at public clinics were less aware of ART and less likely to be able to afford ART. This correlation between poverty and greater use of Ayurveda may reflect not only the prohibitively high cost of biomedicine in the private sector but also cultural preference, education level, region of residence, or other demographics.

This study demonstrates that marginalized and poorer populations generally use the overburdened public healthcare sector, in which they often receive lower quality care. In order to avoid the public sector, indigent populations may use Ayurveda or if they can access public sector care, they may use Ayurvedic therapies in tandem with Allopathic ones. Because practitioners of ISM generally operate on a sliding-scale type payment system in which they adjust the prices of treatments according to what their customers can pay, ISM can be more affordable than either private or public Allopathic options when indirect costs such as those for transportation are taken into account [26]. Thus, Ayurvedic medicine seems to serve as a first resort for many who cannot afford either public or private care due to inaccessibility and cost.

Harmful Interactions of HIV and Ayurveda

Harmful practices of ISM practitioners include administering potentially harmful substances and drug combinations, advising patients not to use treatments of known effectiveness, or claiming that their treatments have cured patients of HIV/AIDS [11]. Not only can some Ayurvedic courses of therapy inhibit use of medicines proven effective but also some of the Ayurvedic drugs can actually exacerbate the patient’s existing health problems and lead to adverse interactions of medicines. Although some drugs used by Ayurvedic and other ISM practitioners can boost the immune system, exert antimicrobial activity, and relieve symptoms, other ISM drugs may contain heavy metals or steroids that can cause toxicity or even immunosuppression [1]. Some herbs and vitamins have been found to put patients taking ART at risk of treatment failure, viral resistance, or drug toxicity. The drug regimens of ISM are individualized and as such have advantages and disadvantages. Such personalized care attracts many patients since the practitioner must assess the patient as a whole, in his psychosocial context and his specific symptoms. However, this means that treatments are not standardized, validated, or approved [1].

In addition, like NACO, Allopathic physicians generally discourage the use of CAM out of fear of delayed use of ART and non-adherence to ART [22]. As a result of ISM practices, HIV patients may not seek out Allopathic treatment of proven effectiveness, waste significant amounts of money on ineffective treatments, experience negative side effects of ISM therapies and health deterioration, and/or feel a false sense of restored health [1]. Some patients seek out various forms of care in search for a miracle cure [27]. Less educated, poorer patients are usually much more likely to trust such vaidyas and their therapies, some of which can render the patients even more vulnerable to disease.

NACO’s policy acknowledges this problem and warns against such detrimental practices although it has no course of action for dealing with this unregulated sector. The growing unregulated private sector presents a problem not only in the HIV/AIDS therapies of ISM but also of Allopathy since no guidelines exist for prescribing ART. As a result, the course of therapy is often dictated by the extent of the Allopathic practitioner’s knowledge of and experience with HIV/AIDS. Incorrect dosages of ART could, in turn, lead to drug resistance, harmful side effects and other problems [27]. Therefore, while ISM therapies for HIV/AIDS may hinder patients from taking ART, as NACO recently alleged, unregulated private Allopathic care may be similarly noxious to HIV-positive patients.

Discussion

In summary, the comprehensive literature review reveal that for some HIV-positive patients, Ayurvedic care provides improved mental health, greater perceived efficacy, amelioration of side effects of Allopathic treatment, greater accessibility, and lower cost. In this section, I present my argument against the National AIDS Control Organisation’s (NACO) recent opinion. Then, I delineate proposed strategies to expand and to augment the breadth of HIV/AIDS care in India through the incorporation of ISM practitioners into the national AIDS response.

Argument against NACO’s Recent Opinion

The National AIDS Control Organisation’s policy, as noted above, previously expressed “an urgent need to look for cost-effective alternatives to antiretroviral drugs in the indigenous system of medicine like Ayurveda…” [13]. However, there was no explicit policy on the role traditional medical practitioners should play in regards to HIV/AIDS. Then, this past summer NACO denounced the use of Ayurvedic therapies for HIV/AIDS, stating that they are undermining the significance of Allopathic treatment including ART. NACO’s most recent mandate is detrimental to the HIV/AIDS response in India for two reasons that are supported by the results of the literature review. First, while Allopathy has the capacity to prolong life, Ayurveda can be applied synergistically with Allopathy to provide more comprehensive care for HIV/AIDS patients and to enhance quality of life. Second, since Ayurvedic healers are numerous, are often more accessible, and are used by a significant portion of the population, they could, and should, serve as a valuable resource for the increased provision of effective HIV/AIDS care. People should have a right to health, which in a broad definition includes the right to good physical, mental, and psychosocial wellbeing. Gangolli et al. [6] sums up this overall argument stating, “The ISM sector expands health care choices available to people as it operates with a broader concept of health taking into account various social and cultural dimensions of illness and care.” Ayurvedic and other ISM options for care, which are not injurious, should be scaled up and made more accessible to PLWHA in India in order to promote the broader definition of health.

Comprehensive Care

With the burgeoning field of psychoneuroimmunology, the spiritual and mental care delivered by many vaidyas and the attention paid to the psychosocial aspects of illness constitute critical components of care for PLWHA. Being healthy, many argue, is not merely the absence of disease; rather, in the words of Levin & Browner [28] “being healthy usually involves the ability to fulfill basic social role expectations, and particularly, the ability to work or engage in subsistence activities. Also, that concepts of health in many societies have spiritual components as well [sic].”

Moreover, the PLWHA may use Ayurveda when Allopathy did not meet their healthcare needs and especially for chronic health problems. Gangolli et al. [6] posits:

[…]there is a growing disenchantment with the claims of allopathy in providing satisfactory cures for many ailments and also with rising unethical practices such as excessive medication and use of unnecessary and invasive methods of diagnosis, with the side effects of several medications used in the treatment of chronic ailments […]

All of these issues have served as an impetus for patients to select the use of Ayurveda in combination with, or in lieu of, Allopathy.

While Allopaths often overlook the seemingly less serious afflictions such as fatigue and weight loss (mostly because they have no pills to prescribe for these problems), the suffering incurred as a result can gravely reduce a patient’s quality of life. Nichter denounces what he terms “defective modernization,” the mostly Allopathic trend to promote health through the distribution of pharmaceuticals, because he believes it to oversimplify the definition of health and to give a “false sense of health security” [26]. In line with this theory, distribution of ART does not suffice as adequate care for HIV-positive patients since the idea of good health is much broader than simply the absence of biological disease. Enhancing patients’ agency and empowering them can exert positive effects on their quality of life, mental state, and potentially even their immune systems. Therefore, Ayurveda and other ISM may be more capable than Allopathy of delivering more comprehensive care that can improve the overall wellbeing of PLWHA and help them achieve their definition of good health. In this way, medical pluralism can positively empower and benefit patients.

Increased Provision of Effective, Supplementary HIV/AIDS Care

In some areas of India, ART and other Allopathic medical treatments are unavailable due to such factors as remoteness of public clinics and paucity of Allopathic practitioners. NACO’s ban on research of Ayurvedic therapies seems particularly inappropriate in light of such gaps in Allopathic health care coverage for PLWHA. Rather than hinder research that could potentially expand treatment for PLWHA, NACO should seek to empower those health care providers to undertake the best practices possible to assist the communities that rely on them. Thus, NACO’s mandate impedes the potential for expanded HIV/AIDS care. In light of such problems as the expanding population, limited numbers of health professionals, and the growing epidemics such as HIV/AIDS, traditional medicine should be seen “as a potential ally of the medical system rather than as an enemy” [15]. By halting all research on Ayurvedic treatment for HIV/AIDS and publicly alleging harmful consequences of Ayurveda on HIV/AIDS care, NACO defines traditional Indian Systems of Medicine as an enemy. Traditional medical practitioners have the potential to contribute in a variety of ways to the fight against HIV/AIDS in India as respected health personnel and healers.

Although prevention efforts through ISM practitioners and clinics have not been examined in this paper, such efforts could be a way to engage the vast resource of ISM practitioners in the fight against HIV/AIDS. In South Africa, 1510 traditional healers were educated on HIV/AIDS and prevention methods. As a result of this program, an estimated 850,000 of their patients may have received HIV/AIDS prevention information in the first 10 months of this program [16]. Bodeker & Dvorak-Little [16] boldly declare:

If the South African experience has any relevance, India’s community of more than 2.5 million traditional practitioners has the potential to reach the population of India in less than a year with HIV prevention messages. They are well situated to communicate a credible message to the poor and to at-risk groups in both rural and urban-context settings, as their role is an established one in these community settings.

Moreover, in Uganda, where there are about 60 times more traditional healers than doctors, the national public health response has been able to significantly lower the HIV rate in part due to the use of traditional healers as educators on HIV prevention [16]. Vaidyas and other ISM practitioners contribute similarly to halting the epidemic in India.

In India, since many Ayurvedic and other AYUSH healers are already in place and are often well-respected members of rural communities, they could serve as invaluable sources of influence for healthier sexual behaviors in their communities as traditional healers have in Uganda and South Africa. They could also encourage patients to get tested and seek out Allopathic care if they see patients with common symptoms of HIV/AIDS. Instead of deeming Ayurveda the adversary of the Allopathic AIDS response as NACO has in its August 2010 edict, NACO and Indian governmental agencies should encourage the cooperation between ISM and Allopathic healers. In this synergistic and integrative approach, ISM practitioners, who are often the first resort for many HIV-positive patients, could refer PLWHA to Allopathic care. As stated in [16], “Clearly, such partnerships not only make good public health sense but, based on a growing body of pharmacological evidence, may also yield important preventative and treatment modalities.” Certainly, several complex factors could hinder this program, including the imposition of the biomedical approach to HIV/AIDS on practitioners of ISM.

As previously stated, Ayurvedic and other ISM practitioners can provide care where Allopathic care is limited. As healers, they may be able to distribute a diversity of herbal remedies that have been tested and have proven to be effective immunomodulators to those patients who cannot readily access ART, who cannot afford ART, or simply who do not yet qualify for ART. In its 2002 policy NACO acknowledged the potential for Ayurveda to provide more cost-effective remedies for HIV/AIDS. This need still exists. Research on such treatments should not be halted because some vaidyas are inappropriately distributing injurious therapies. Rather, the private sector, including both Allopathy and ISM, should be better regulated, and more research should be conducted on Ayurvedic therapies that are currently being used and those that could be used for various illnesses associated with HIV/AIDS.

Numerous examples reveal the positive contribution of ISM to expanding the provision of HIV/AIDS care. For example, in Tamil Nadu—an epicenter of the virus in India—is a hospital committed to providing free Siddha treatments for HIV/AIDS. Siddha and Ayurveda approach health very similarly, taking into account the prakriti, or constitution, of a patient to determine the most effective therapy. In the district of Nammakkal in Tamil Nadu, an estimated 6.5 percent of the population is infected and there exist only two public hospitals that have in-patient facilities for HIV/AIDS patients and provide free care in the state. With the high demand for care, the hospital Gandeepam is providing a much-needed service by not only treating HIV-positive patients free of charge but also by leading prevention and awareness campaigns in many communities. Furthermore, as noted above, Gandeepam provides Siddha therapies including those for depression and anxiety while many public hospitals provide only ART [16]. Therefore, Ayurvedic clinics, similarly to Siddha clinics, have great potential to contribute to both prevention efforts and care for PLWHA and should absolutely not be simply deemed harmful and inhibitory. Doing so only limits possibilities and innovation in HIV/AIDS prevention and care in a country that has the third largest burden of HIV worldwide [29].

Proposed Strategies

In order to improve care for the population of HIV-positive individuals in India, I propose the following strategies: (1) reduction of harmful ISM practices and promotion of effective ISM therapies through (a) education on HIV/AIDS for ISM practitioners, (b) a standardized baseline of care in all ISM HIV/AIDS therapies, and (c) research and development of effective ISM drugs; and (2) collaboration between Allopathic and ISM practitioners, which would include (a) mutual understanding of ISM and Allopathic therapies for HIV/AIDS by respective practitioners, (b) a system of cross-referrals, and (c) complementary, integrative care. However, the implications of integrating these systems are multiple and complex, and consequently, the process of integration would be exceedingly difficult. For example, Allopathic and ISM practitioners may have vested interests in retaining their patient base and may not want to refer out. On the other hand, if an Allopathic doctor does not have a therapy option to treat weight loss and a vaidya does not have medicine to treat AIDS, then perhaps it would be in their best interests to refer their patients to therapies that are more effective for the patients. If the patient’s ailments are ameliorated as a result, the practitioner may gain more trust from that patient and even attract more patients. Nevertheless, by placing the interests of the patients above those of the government or the practitioners, an integrative system of medicine would benefit those most in need of expanded and supplementary healthcare options.

The Reduction of Harmful ISM Practices and Promotion of Effective ISM Therapies

In order to improve alternative treatment of HIV/AIDS, the pressing problem of the use of physically injurious ISM practices and drugs must be corrected. Since such treatment options are often prescribed due to the ISM practitioner’s lack of knowledge about the disease, HIV/AIDS education must be integrated into Ayurvedic and other ISM institutions’ curricula. Such education would include information on the modes of HIV transmission, HIV prevention, ART, and potentially deleterious practices. While the imposition of an Allopathic understanding of HIV/AIDS seems culturally insensitive, it may be necessary to combat this epidemic. Moreover, if treatments—whether Ayurvedic, Allopathic, or other ISM—exacerbate existing conditions of HIV patients due to the practitioners’ disregard of the course of disease, the practitioners’ actions are ethically wrong and should not be allowed even in light of cultural sensitivities. Education and regulation must be enforced in this matter. The first step in augmenting HIV/AIDS education would be to increase the number of vaidyas and other practitioners of ISM being trained in regulated ISM institutes. When vaidyas are institutionally-trained, they can and should become registered with the Central Council for Ayurveda.

The Central Council for Ayurveda should, in turn, ensure the adherence of practitioners to ethical standards of care for all treatments including those for HIV/AIDS, and quacks should be banned. South Africa has attempted to accomplish this goal with its traditional healers. According to [15], in part in response to the HIV/AIDS epidemic and a growing population, the government of South Africa instituted in 2004 a Council “to oversee the licensing and regulation of the country’s estimated 200,000 African traditional healers – who are consulted by about 70 percent of the population – with the aim of ensuring ‘the efficacy, safety, and quality of traditional health care services.’” India should follow suit.

In relation to the prescription of some ISM drugs containing toxic agents, [6] affirms that “At present, the mechanisms by the state to control such practices are inadequate and there are no internal safe guards developed by ISM to curb such perilous practices.” Since, as in South Africa, a significant portion of the Indian population consults practitioners of ISM, the Council needs to increase the number of licensed practitioners and to ensure that these practitioners abide by certain codes of ethics and regulations. Although vaidyas treat AIDS patients as individuals and, therefore, may not be willing to standardize all treatments, they must be held accountable to provide non-injurious therapies and to do no harm to their patients. For example, ISM practitioners must not advise patients to delay ART or prescribe drugs that interact negatively with ART. Education through institutions and enforcement of a baseline standard of care would reduce and hopefully eliminate deleterious practices.

Effective ISM drugs and therapies have great potential to increase the availability of HIV/AIDS care. As noted above, many effective drugs exist, and more clinical research and evaluation of Ayurvedic treatments for HIV/AIDS must be created [30]. Furthermore, many Ayurvedic practitioners are open to working with Allopathic physicians to develop effective therapies for HIV/AIDS and vice versa [13,31]. Research and development to test and document the effectiveness of ISM drugs would not only identify the most successful therapies but would also give more credibility to the role of ISM in the AIDS response.

Collaboration between Allopathic and ISM Practitioners

I agree with Fritts [2] who advocates an empirically-based integrative model of care for HIV/AIDS patients in which ISM and Allopathic physicians collaborate and actively attempt to understand other methods of care. Through Allopathic and ISM practitioners’ mutual understanding and recognition of the various systems of medicine and their HIV/AIDS therapies, collaboration would be facilitated. For example, Allopathic physicians would need to understand the importance of ISM methods for improving psychosocial wellbeing and the beneficial neuroimmunological responses of such therapies for PLWHA. While Allopathic practitioners should appreciate the effectiveness of certain alternative drugs, vaidyas should accept the empirically-proven effectiveness of ART. As a result of improved understandings, each of these types of practitioners would be more likely to trust other medical systems.

In turn, with increased education and communication, practitioners would be more likely to participate in the proposed system of cross-referrals and complementary, integrative care for PLWHA. Various studies have illustrated this system in practice. A study [27] conducted in Pune, India determined that, because private practitioners perceived themselves as having inadequate skills to treat HIV/AIDS and considered ART exceedingly inaccessible and complex, they often prescribed mixed therapies; the private practitioners used or suggested traditional therapies for symptomatic and supportive treatments. In the proposed system, various modalities of treatment, such as panchakarma, antiretroviral treatment, and therapies to enhance quality of life, would be used in complement. As argued in [6], “What ISM really needs to do at the practical level is to critically interrogate its knowledge bases and practices while at the theoretical level provide an alternate world-view, by strengthening its ecological and holistic view of health.” In this way, Ayurveda and other ISM could capitalize upon their historical strengths of holism and psychosocial support and develop efficacious drugs, which would in turn give the systems more credibility. With integration of the various medical systems, diverse types of care would be more adequately monitored and coordinated. Moreover, both patients and practitioners would benefit from the delegation of care for certain health needs to other types of practitioners who are more skilled, experienced, or knowledgeable in those areas.

Conclusion

As of 2011, India stands at a crossroads in its pluralistic healthcare system. Under colonial rule, Allopathy was promoted while indigenous systems of medicine were discredited and suppressed. These policies have resulted in Indian patients, especially urban and older ones, being more familiar with the Allopathic approach to healthcare. However, over the past few years, ISM has been experiencing a resurgence in India. Currently, some patients seeking ISM care have an Allopathic understanding of illness, and some practitioners of ISM have adapted their practices to more closely resemble those of Allopathy. On the other hand, some patients approach Allopaths with more diverse health needs than Allopathy can accommodate, especially those needs concerning psychosocial health. Consequently, integration of the systems could benefit practitioners and patients alike for sociocultural reasons.

For public health reasons, I conclude that the scope and coverage of healthcare for PLWHA in India should be improved and that Ayurveda could contribute to accomplishing this goal. This review of the literature supports the conclusion that ART alone, as currently administered in India, cannot meet the needs of the country’s growing population. With India’s present health infrastructure, Ayurvedic therapies should be recognized as perhaps the only care realistically available to those PLWHA in remote, resource poor areas. Regardless of future ART availability, certain Ayurvedic therapies should be acknowledged as valuable supplementary care for those who have not yet progressed to the AIDS stage and even for those taking ART.

I conclude that more affordable, accessible, and holistic Ayurvedic therapies could be used in combination with Allopathic treatments to treat some HIV/AIDS associated health problems, such as weight loss, skin lesions, fatigue, nausea, and depression, and possibly to improve psychoneuroimmunological outcomes. For these and other reasons, Ayurvedic therapies should be further researched and promoted, contrary to NACO’s August 2010 policy statement. At the same time, ISM therapies that do harm to already physically and mentally vulnerable patients must be eradicated. I believe that India’s healthcare policy should be one that is inclusive in an effort to educate ISM practitioners about effective HIV/AIDS care rather than one that officially excludes ISM from offering innovation in healthcare options. Bodeker et al. [13] arrives at conclusions similar to those listed above and asserts that, because of the widespread demand for indigenous medicine by PLWHA and its undeniable influence on HIV/AIDS treatment in India, partnerships between Allopathic and traditional medical sectors in research, policy, and practice are necessary for a comprehensive and effective HIV/AIDS response. In the context of India’s pluralistic medical system, ISM (particularly Ayurveda) and Allopathy should adapt their approaches in order to collaborate synergistically. Together, the medical subsystems could produce a broader spectrum of care for the diverse health needs of PLWHA and augment availability of effective therapies for the significant population of HIV-positive Indian patients in need.