Alternative Therapies: A Common Practice among Men and Women Living with HIV

Features ARTICLE JANAC Vol. 14, No. 3, May/June 2003 10.1177/1055329003252049 Gore-Felton et al. / Alternative Therapies

Alternative Therapies: A Common Practice Among Men and Women Living With HIV Cheryl Gore-Felton, PhD Mark Vosvick, PhD Rachel Power, PhD Cheryl Koopman, PhD Eric Ashton, BS Michael H. Bachmann, MD, DSc Dennis Israelski, MD David Spiegel, MD

This study examined the prevalence and factors associated with alternative therapy use in an ethnically diverse, gender-balanced sample of persons living with HIV/AIDS. More than two thirds (67%) of the participants who were taking HIV-related medications were also taking an alternative supplement. Half of the sample (50%) reported that they took one or more multivitamins, 17% reported using mineral supplements, 12% reported using Chinese herbs, and 12% reported using botanicals. Substantial proportions of the sample also reported using acupuncture (31%), massage (23%), and meditation (28%) to specifically treat HIVrelated symptoms. Women were four times more likely to use alternative therapies than men. Also, Caucasians were nearly four times more likely to use alternative treatments compared to other ethnic groups. The results of this study indicate a strong need to assess individual patients’ use of alternative treatment approaches as well as to further investigate their efficacy among HIV-positive patients. Key words: complementary treatment, alternative supplements, HIV

T he emergence of combinations of potent antiretroviral treatments (ARVT) to treat HIV disease has helped many people improve immune functioning, which is determined by an increase in CD4 T-cell

counts (Arici et al., 2001; Kitchen, Kitchen, Dubin, & Gottlieb, 2001; Mezzaroma et al., 1999; Tsoukas et al., 2001) resulting in a decrease in mortality and AIDSdefining events (Arici et al., 2001; Correll, Law, McDonald, Cooper, & Kaldor, 1998; Ives, Gazzard, & Easterbrook, 2001; Maisels, Steinberg, & Tobias, 2001; Moore, 2000). However, previous research has indicated that due to a variety of factors, not all individuals benefit from combination antiretroviral therapy (ARVT). Such factors include regimen complexity (i.e., dosing frequency and food-dosing Cheryl Gore-Felton, PhD, is an assistant professor of psychiatry & behavioral medicine at Medical College of Wisconsin, Center for AIDS Intervention Research. Mark Vosvick, PhD, is an assistant professor of health psychology & behavioral medicine at the University of North Texas. Rachel Power, PhD, is a project director at Stanford University. Cheryl Koopman, PhD, is an associate professor (research) of psychiatry and behavioral sciences at Stanford University. Eric Ashton, BS, is a medical student at Columbia University. Michael H. Bachmann, MD, DSc, is a research fellow at Stanford University. Dennis Israelski, MD, is a clinical associate professor in the Division of Infectious Diseases and Geographic Medicine at Stanford University. David Spiegel, MD, is the Jack, Lulu and Sam Willson Professor in the School of Medicine and associate chair of psychiatry & behavioral sciences at Stanford University.

JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 14, No. 3, May/June 2003, 17-27 DOI: 10.1177/1055329003252049 Copyright © 2003 Association of Nurses in AIDS Care

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restrictions; see Roberts & Mann, 2000; Stone et al., 2001), depression (Catz, Kelly, Bogart, Benotsch, & McAuliffe, 2000; Holzemer et al., 1999; Safren et al., 2001), lack of social support (Catz et al., 2000; Safren et al., 2001), substance use (Altice & Friedland, 1998), medication beliefs (Roberts & Mann, 2000), strict adherence (Catz et al., 2000), and problems managing side effects (Altice & Friedland, 1998; Catz et al., 2000). Many HIV-infected persons are exploring alternative medical therapies as a means to relieve HIVrelated symptoms and, in some cases, even to inhibit viral activity (Patrick, 2000; Wu, Attele, Zhang, & Yuan, 2001). The widespread use of complementary and alternative medicine (CAM) in persons with HIV suggests the need for more scientific research examining the effectiveness of these treatments. Indeed, the identification of patterns of use, characteristics of those who use alternative medical therapies, and factors associated with use are important initial steps in understanding the potential health benefits as well as health hazards of CAM use among HIV-positive men and women. This information is particularly important for HIV primary care providers who need to be aware of possible interactions and side effects caused by the use of CAM by their patients, particularly those patients who are on ARVT regimens. Nearly one third of the general population of adults living in the United States has used herbal medicines, with echinacea and garlic being among the most popular (Lin, Nahin, Gershwin, Longhurst, & Wu, 2001). Considerably higher rates of use have been reported among persons with chronic illnesses when compared to the general population (Duggan, Peterson, Schutz, Khuder, & Charkraborty, 2001; Fairfield, Eisenberg, Davis, Libman, & Phillips, 1998). Most recent studies report CAM therapy utilization rates to be between 67% and 84% in the HIV-infected population (Knippels & Weiss, 2000; Sparber et al., 2000; Standish et al., 2001). Commonly used forms of CAM substances in this population are nutritional supplements, herbal medicines, and marijuana. Moreover, popular CAM therapies include massage, acupuncture, meditation, imagery, yoga, and aerobic exercise (Duggan et al., 2001; Fairfield et al., 1998; Greene et al., 1999; Standish et al., 2001). A nationwide study of CAM use patterns was conducted between 1995 and 1997 among 1,675 HIV-

positive men (79%) and women (21%). The participants in this study were from alternative medical clinicians’ practices and advertisements (Standish et al., 2001). Forty-five percent of the most common health-related service professionals with whom participants consulted for the treatment of HIV-related symptoms were acupuncturists, and 49% were massage therapists. Participants reported the use of 1,210 types of CAM substances and 282 types of CAM therapeutic activities for treatment of HIV disease. In addition, the most frequently used CAM therapies were vitamin C (63%), aerobic exercise (63%), prayer (58%), multiple vitamin and mineral supplements (54%), vitamin E (53%), garlic (53%), massage (53%), and meditation (46%). These findings are consistent with other research conducted among HIVpositive patients, in which participants reported using exercise (43%), dietary supplements (37%), herbal medications (26%), and megavitamins (24%) to maintain their health (Duggan et al., 2001). HIV-infected individuals use CAM therapies for relief from a variety of HIV-related symptoms. In a clinical trial study among HIV-positive patients, the most commonly reported reasons for using CAM were nausea, insomnia, dermatological problems, depression, and weakness (Sparber et al., 2000). Moreover, among 180 HIV-positive patients attending a general medicine practice, symptoms such as weight loss, nausea, and diarrhea prompted many of the patients to try taking herbs, vitamins, and supplements for symptom relief (Fairfield et al., 1998). Primary reasons for seeking CAM therapies such as acupuncture and massage were pain, depression, and stress (Fairfield et al., 1998). Furthermore, in this same study, marijuana was used by 53% of patients to relieve nausea and weight loss. Indeed, current research suggests that a growing number of persons are turning outside of the traditional medical setting in the hope of reducing symptomatology associated with HIV/AIDS, managing the side effects of drug therapies, maximizing quality of life, slowing disease progression, and as a way to better cope with their illness (Calabrese, Wenner, Reeves, Turet, & Standish, 1998; Patrick, 2000; Pawluch, Cain, & Gillett, 2000; Wu et al., 2001). Many HIV-positive persons report that they experience health benefits from the use of alternative therapies. In a study of HIV-positive clinical trial patients who used CAM, 98% reported that they were feeling

Gore-Felton et al. / Alternative Therapies

better, and 94% believed CAM therapies had improved their treatment outcome (Sparber et al., 2000). Moreover, 32% of the patients stated that CAM was equally or more effective than conventional treatment. This is consistent with other research among HIV-positive individuals in that most (70%) of the sample reported that the use of alternative therapies had improved their quality of life (Duggan et al., 2001). There are few studies that use a randomized clinical trial design to examine the effect of alternative therapies on the immune function of HIV-infected individuals. However, for those that have used randomized designs, the data are promising in that several studies have shown significant clinical improvement among HIV-positive individuals using alternative therapies. For example, a randomized trial to determine the effect of vitamin A supplements on pregnancy outcomes and CD4 counts among HIV-1 infected women living in Tanzania found that multivitamins decreased lowbirth-weight incidence, reduced risk of preterm delivery, and significantly increased CD4 counts and percentages as well as increased CD8 counts (Fawzi et al., 1998). In the United States, a nationwide study designed to determine the effectiveness of massage therapy and stress management techniques in a sample of HIV-positive men and women has provided some evidence in this regard. The study was a randomized, controlled trial of massage therapy and biofeedback stress management among a sample of 42 HIVinfected persons (40 males, 2 females) (Birk, McGrady, MacArthur, & Khuder, 2000). Immune measures and six dimensions of quality of life were assessed prior to randomization and then again at 12 weeks. The results indicated that there were no significant changes in any of the immune measures. However, follow-up assessment of the group that received massage therapy in combination with biofeedback stress management demonstrated significant improvement in participants’ health perceptions and decreases in health services utilization when compared to the group that received only massage therapy (Birk et al., 2000). Although there are CAM studies that indicate promising health outcomes for people living with HIV, it is important to note that a review of the effectiveness of CAM in managing HIV-related symptoms found

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that outcome studies examining the efficacy of CAM among HIV-positive populations are often conducted among small sample sizes with very little follow-up data or time points, and generalizability of many of the study findings is limited by participant attrition (Power, Gore-Felton, Vosvick, Israelski, & Spiegel, 2002). In addition, limited research has been conducted on the efficacy of CAM therapies for reducing HIV-related symptoms and delaying disease progression (Ozsoy & Ernst, 1999; Patrick, 2000; Swanson, Keithley, Zeller, & Cronin-Stubbs, 2000). However, due to the toxicity of ARVT, the use of antioxidant therapies in the treatment of HIV has become an increasingly popular area of research both in vitro and in vivo (Patrick, 2000). It has been demonstrated that some nutrients, specifically N-acetylcysteine, glutathione, and alpha-lipoic acid, can inhibit viral activation and CD4 cell death (Patrick, 2000). Chinese medicine, particularly herbal remedies and acupuncture, is one of the most commonly used CAM therapy categories in the treatment of HIV infection (Elion & Cohen, 1997). Baicalin, which is isolated from the Chinese herb Scutellaria baicalensis Georgi, has demonstrated an ability to inhibit HIV reverse transcriptase when examined in vitro (Wu et al., 2001). Moreover, a small study of the effectiveness of acupuncture in enhancing quality of sleep in HIV-positive individuals demonstrated improvements in both sleep activity and sleep quality after 5 weeks of acupuncture treatment (Phillips & Skelton, 2001). Although some HIV public health clinics have begun to offer alternative therapies such as massage, yoga, acupuncture, and Chinese herbs as an adjunct to conventional treatment, these services are costly and available only through private providers. Recent research reported only 26% of physicians discuss CAM during initial visits and only 5% at follow-up visits (Rose, O’Toole, Skeist, Pfeiffer, & Carlsen, 1998; Wynia, Eisenberg, & Wilson, 1999). This is disturbing in light of recent clinical studies that demonstrate that hypericum extracts (i.e., St. John’s wort) increase the metabolism of the HIV-1 protease inhibitor indinavir (Piscitelli, Burstein, Chaitt, Alfaro, & Falloon, 2000; Moore et al., 2000), which results in a large reduction in indinavir concentrations in blood samples that may lead to the development of drug resistance and treatment failure (Piscitelli et al., 2000).

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Similarly, a study conducted to determine the effect of garlic on the pharmacokinetics of the protease inhibitor saquinavir found a 51% reduction of saquinavir in blood samples, suggesting that patients and providers should use caution when combining garlic supplements solely with saquinavir (Piscitelli, Burstein, Welden, Gallicano, & Falloon, 2002). Understanding characteristics that are associated with health practices, including the use of alternative medicine practices, is an important first step in designing health care systems and practices that minimize access-to-care issues. Although limited research has focused on the determinants of CAM use among HIVpositive persons, a burgeoning body of literature describes demographic and medical correlates of CAM use among HIV-positive adults. For example, in a study among 191 HIV-positive outpatients, having an annual income greater than $15,000 was one of the best predictors of alternative medicine use (Duggan et al., 2001). Other research has found that higher education levels and lower T-cell counts were significantly associated with greater CAM use (Fairfield et al., 1998). Moreover, psychological factors have also been associated with CAM use such that among 70 HIV-positive gay men, those who used an active coping style to deal with HIV symptoms and who were able to express their feelings about their HIV disease were more likely to use CAM (Knippels & Weiss, 2000). Also in this study, men who were symptomatic and reported little or no pain were more likely to use CAM (Knippels & Weiss, 2000). However, the findings have been mixed. Other research has not found significant relationships between CAM use and demographic factors (age, gender), medical factors (duration of HIV disease), or behavior (HIV risk behavior) (Manfredi & Chiodo, 2000). The inconsistency in findings and lack of diverse population samples warrant further research on characteristics associated with CAM among persons living with HIV and AIDS. The primary objective of this research study was to assess the prevalence of using HIV-related drugs, alternative supplements, and alternative therapies among a sample of HIV-positive persons whose diversity is reflective of the population living with HIV and AIDS. In addition, because of the high prevalence of CAM utilization previously found among patients

who want to reduce symptoms of stress and depression, we explored a model that examined the association between psychosocial factors and CAM use in an ethnically diverse, gender-balanced, and predominantly low-income sample of HIV-positive persons.

Method Participants This study was approved by the appropriate institutional review board, and informed consent was obtained from each participant. The present study is part of a larger, ongoing, randomized clinical trial designed to examine the effects of supportive expressive group psychotherapy (Spiegel, Bloom, Kraemer, & Gottheil, 1989) on quality of life and health behavior in 179 HIV-positive men and women. Baseline data were collected prior to randomization. In this present study, we report data on a subsample of 158 participants (73 women and 85 men) who had complete baseline data on all measures of interest. Men and women with HIV infection were recruited from the San Francisco Bay area and Sacramento through newspaper advertisements and at four major county hospitals, a university hospital, and community medical clinics. To meet criteria for being included in this study, participants had to meet all of the following criteria: provide access to or a copy of test results confirming that the person has serologically tested positive for HIV-1 antibodies by standard methods, be age 18 years of age or older, and be English speaking. Participants were excluded if they were at risk to harm self or others, were members of support/therapy groups for HIV, or demonstrated psychiatric symptoms that impaired their ability to participate in a small group intervention (e.g., actively psychotic, intoxicated). Forty-six percent of the participants were women. The average age was 40.2 years (SD = 7.6). The education that participants had completed ranged from 3 to 21 years, with a mean of 13.7 years (SD = 3.0). Although most of the participants (61%) reported incomes less than $20,000, 39% reported incomes greater than $20,000 with almost a quarter (21.3%) of the sample reporting annual incomes greater than or

Gore-Felton et al. / Alternative Therapies Table 1.

Sample Characteristics (N = 85 men and 73 women)

Variable

M (SD)

Ethnic background Caucasian African American Other Total household income Less than $20,000 Employment status Unemployed Part-time Full-time Sexual orientation Gay/lesbian Heterosexual Bisexual Medical status AIDS diagnosis CD4 count 389 (431) AIDS-related symptoms in the past 3 months Taking HIV-related medications Center for Epidemiological Studies Depression Scale (CES-D) scores 17.2 (12.0)

%

Range

56 32 12 61 64 14 22 50 44 6 44.8 6-4,820 80.0 78.0

0-48

equal to $40,000. Additional demographic and medical characteristics of the participants are summarized in Table 1. Measures Demographic characteristics. The Background Information Questionnaire, a brief self-report measure, was used to assess demographic characteristics. These included participant’s age, marital status, ethnicity, sexual orientation, education, employment, and family income. Verification of serostatus. Prior to enrolling a patient into the study, we asked for her or his physician to verify the patient’s HIV serostatus. Also, we examined patients’ medical records at baseline to determine their most recent CD4 T-cell count and to assess whether each patient met diagnostic criteria for AIDS (T-cell count less than 200 cells/microliter). Mood. The Center for Epidemiological Studies Depression Scale (CES-D) (Radloff, 1977), a 20-item

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inventory, was used to measure depressive symptoms over the previous week. This screening scale has been extensively used to examine depression among persons living with HIV (Griffin, Rabkin, Remien, & Williams, 1998). The CES-D items were each scored on a 4-point (0-3) Likert-type scale indicating the frequency of symptoms, so scores could range from 0 to 60. The mean score for the general population has been found to be approximately 8, with scores of 15 or below indicating low depressive symptoms, scores between 16 and 22 indicating probable depression, and scores of 23 or higher indicating significant depression (Radloff & Locke, 1986). Use of HIV-related medications. We asked participants about their current use of HIV-related medications in the following drug classifications: nucleoside analog reverse transcriptase inhibitors (e.g., zidovudine, didanosine, and lamivudine), non-nucleoside analog reverse transcriptase inhibitors (e.g., nevirapine), protease inhibitors (e.g., saquinavir and ritonavir), and medications used for prophylaxis and treatment of opportunistic infections related to HIV infection (e.g., Dapsone and Bactrim). For each drug, participants indicated whether they were taking it, the date they started using it, and the dosage per day that they were prescribed. Use of alternative supplements. We asked participants about their current use of alternative supplements. These were assessed across six categories: (a) nutritional supplements (e.g., vitamins), (b) foreign pharmaceuticals (e.g., ribavirin), (c) prescription pharmaceuticals (e.g., oral alpha interferon), (d) miscellaneous adjuvants (e.g., bitter melon extract and dextran sulfate), (e) Chinese herbs, and (f) botanicals (e.g., echinacea and shiitake mushrooms). For each supplement, participants indicated whether they were taking it, the date they started using it, and the dosage per day. Use of alternative therapies. We asked participants to indicate whether they were engaging in alternative therapies. The following treatments were assessed: acupuncture, massage, yoga, chiropractic treatment, mental imagery, meditation, Qigong (an approach using breathing and meditation), therapeutic touch,

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and Reiki (a particular approach to therapeutic touch using light touch/massage). For each type of alternative therapy, participants who reported using it were asked to indicate when the therapy began and the frequency of using it. Data Analysis We computed descriptive statistics, examined mean differences, and conducted correlational analyses. Logistic regression analysis was conducted to examine factors associated with alternative therapy use. Alternative therapy was defined as any supplement or therapeutic intervention (e.g., massage, acupuncture) that at the time of this study was not prescribed as part of conventional medical practices for the treatment of HIV or AIDS, as described above in our measures of alternative supplements and therapies. We used the logistic regression analysis to simultaneously examine the relationships of demographic variables, medical variables, and a psychological variable (i.e., depression) with whether participants used alternative therapies.

Results Use of HIV-Related Medications Most of the participants were taking HIV-related medication (78%). Most of the participants reported taking a nucleoside analog reverse transcriptase inhibitor (73%), 40% were taking a protease inhibitor, only 8% were taking a non-nucleoside analog reverse transcriptase inhibitor, and 49% reported taking other HIV-related medications. In addition to taking HIVrelated medications, which included ARVT, 65% reported taking prescription medication that was not related to their HIV infection. There were ethnic differences in the use of HIV-related medications such that Caucasians were significantly more likely than others to report taking medications used for prophylaxis and treatment of opportunistic infections related to HIV infection (t = 3.30, p < .01) such as fluconazole and Dapsone, even though no significant ethnic differences were found in AIDS diagnoses or AIDS-related symptoms. We found only one significant gender

Table 2.

Prevalence of Alternative Therapy Use %

Alternative supplements N-acetyl cysteine L-lysine Garlic Other Mineral supplement Foreign pharmaceuticals Chinese herbs Botanicals Multivitamins Alternative therapies Acupuncture Massage Meditation Yoga Chiropractic therapy Therapeutic touch Qigong Reiki

4.4 3.8 7.0 23.4 16.5 0.6 12.0 12.0 50.0 31.0 23.4 27.8 5.1 8.9 3.8 3.8 4.4

difference in protease inhibitor use such that men were more likely than women to take protease inhibitors (t = 2.69, p < .01), despite finding no significant gender differences in AIDS diagnosis, time since diagnosis, or CD4 count obtained from medical charts. Use of Alternative Supplements Table 2 shows the most frequently used supplements. More than two thirds (67%) of the participants who were taking HIV-related medications were also taking an alternative supplement. In addition, 51% of those taking an HIV-related medication reported taking a nutritional supplement, which included minerals and vitamins. Half of the sample (50%) reported that they took a multivitamin, 14% took vitamin E, 24% took vitamin C, and 7% took vitamin A. Vitamin use was not found to significantly differ by gender, disease status (i.e., AIDS diagnosis), or CD4 count. Twentythree percent reported “other alternative supplement” use, 17% used mineral supplements, 12% reported using Chinese herbs, and 12% used botanicals. More than half of the sample (52%) reported taking HIVrelated medications and alternative supplements.

Gore-Felton et al. / Alternative Therapies

Use of Alternative Therapies Alternative therapies were used by a substantial proportion of our sample (see Table 2). Almost one third of the sample received acupuncture (31%), and 23% reported receiving massage specifically to treat HIV-related symptoms. Meditation practice was reported by 28%. We found a small positive relationship between using alternative supplements and engaging in alternative therapies (r = .19, p < .02). Mood There was a range of depressive symptoms (0-48) reported on the CES-D. The average for this sample of HIV-positive persons (M = 17.2, SD = 12) is more than twice the mean depression scores found among the general population. Depression was not significantly associated with gender, ethnicity, AIDS diagnosis, or CD4 count, so it could be examined independently of other factors examined in this study in relation to alternative medicine use. Factors Associated With Alternative Therapy Use The results of the multiple regression analysis are shown in Table 3. Gender was found to be significantly related to alternative medicine use such that women were four times more likely to use alternative therapies (odds ratio [OR] = 4.1, p < .01). Also, an ethnic difference was found, with Caucasians nearly four times more likely to use alternative treatments compared to other ethnic groups (OR = 3.9, p < .01). Furthermore, individuals with lower depression scores were more likely to use alternative therapies (OR = .96, p < .02). HIV-related symptoms and CD4 counts were not found to be significantly associated with alternative therapy use.

Discussion Consistent with previous research (Knippels & Weiss, 2000; Sparber et al., 2000; Standish et al., 2001), most of the participants in this study were taking HIV medications along with an alternative supplement. This is important because there have been very

Table 3.

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Summary of Logistic Regression Analysis Examining Variables Associated With the Use of Alternative Therapies

Independent Variable

Beta

Female gender 1.41 Age 0.01 Household income –0.97 Caucasian ethnicity 1.37 African American ethnicity –0.45 AIDS-related symptoms 0.09 CD4 T-cell count –0.00 Center for Epidemiological Studies Depression Scale (CES-D) total score –0.04

SE B

OR

95% CI

.51 .02 .33 .56

4.11* ns ns 3.95**

1.52-11.10

.63 .08 .00

ns ns ns

.02

0.96**

1.31-11.93

0.92-0.99

NOTE: OR = odds ratio; CI = confidence interval. Nagelkerke R2 = .22; model chi-square (χ2) = 25.81, df = 8, p < .01. *p < .01. **p < .02. ns = not significant.

few empirical studies examining the influence of these supplements on HIV medications. Moreover, what little research has been done has shown that interaction effects between alternative supplements (i.e., St. John’s wort and garlic) and HIV medication may have deleterious health outcomes for patients (Moore et al., 2000; Piscitelli et al., 2000, 2002). The high prevalence of alternative supplement use in conjunction with HIV medication in our study highlights the urgent need to understand the health benefits as well as the health risks of alternative supplement use among patients with HIV and AIDS. The use of alternative therapies was not related to HIV-related symptomatology or disease progression (i.e., CD4 count). Indeed, it was nonmedical factors that were associated with alternative therapy use, namely, female gender, Caucasian ethnicity, and lower depression. These findings therefore parallel those found in a national sample of adults that was not limited to HIV-infected persons, in which the use of unconventional therapy was not significantly associated with the medical factors that were investigated (Eisenberg et al., 1993). Contrary to previous research (Manfredi & Chiodo, 2000), we found that gender was significantly related to using alternative therapies, with women more likely than men to report engaging in such treatment. In general, women in the United States demonstrate higher health care utilization compared to men (Bertakis,

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Azari, Helms, Callahan, & Robbins, 2000), and women are more likely to seek care for themselves compared to men. In exploring gender differences in disease status, HIV-related symptoms, time since diagnosis, and HIV-related medicine use, only protease inhibitor use was found to significantly differ, with men more likely than women to use protease inhibitors. Although causal determinations of why women use CAM more than men or why men are more likely to take protease inhibitors are beyond the scope of this study, we believe our findings strongly highlight the need for clinical studies to examine gender differences in the medical management and medical outcomes of persons living with HIV and AIDS. In addition, ethnicity was significantly associated with the use of alternative therapies. Consistent with previous research, Caucasians were more likely to use alternative treatments compared to other ethnic groups (Smith, Boyd, & Kirking, 1999). No ethnic differences in disease status or depressed mood were found that could account for this difference. However, a previous study examining adherence and medical utilization among HIV-positive adults found that social networks and medical professionals were the most important information sources (Stone et al., 1998). Thus, one explanation for this ethnic difference is that information about the availability and utility of various alternative therapies may not be as widespread and commonplace in ethnic minority communities affected by HIV and AIDS compared to communities that are primarily Caucasian. An alternative explanation may be that there are cultural differences related to health beliefs that are associated with using CAM. However, these explanations are speculative and thus highlight the need for more research to delineate factors associated with ethnic differences in CAM use, particularly with regard to health outcomes. Contrary to previous research (Cassidy, 1998; Duggan et al., 2001), this study did not find a significant relationship between income level and use of alternative therapy. Perhaps because this sample was recruited largely from the San Francisco Bay area in California, differences in alternative therapy use may be attributed more to variation in behavior, which is influenced more by local culture compared to income. Moreover, this sample was largely low income, and therefore we did not have a sufficient distribution across the range of income levels, which reduced our

ability to detect a significant relationship between income and alternative therapy use. In addition to gender and ethnicity, we found that mood was associated with CAM use such that participants who reported less depression were more likely to use alternative therapies. It is important to note that because of the cross-sectional design of our study, we have no way of asserting causality. Thus, it may be that using alternative therapies leads to a decrease in depression or it may be that depression causes greater CAM use. The empirical evidence is mixed in that our finding is consistent with research that has reported a reduction in depressive symptoms post CAM use (Ozsoy & Ernst, 1999; Power et al., 2002; Swanson et al., 2000) but is inconsistent with research among other populations, which has found that use of alternative medicines is associated with greater depression (Astin, Pelletier, Marie, & Haskell, 2000; Unuetzer et al., 2000). Consistent with previous research (Duggan et al., 2001; Stringer, Berezovskaya, O’Brien, Beck, & Casaburi, 1998), we did not find a significant relationship between CAM use and disease progression as measured by HIV-related symptoms and CD4 count. It is important to note that research in this area is mixed such that other studies report that greater CAM use is associated with slower disease progression (i.e., a rise or stabilization of CD4 count) among persons living with HIV and AIDS (Fawzi et al., 1998; LaPerriere et al., 1997; Perna et al., 1999). Future research on psychosocial factors and health beliefs that may be associated with decisions to use CAM particularly among HIV-positive populations is needed. For example, beliefs may differ among particular subpopulations about the value of CAM, which may affect whether individuals decide to pursue CAM. In addition, future studies need to assess when various CAM practices yield the most benefit and for whom. For example, it may be that particular CAM practices facilitate better long-term outcomes when used as an early intervention strategy, whereas other CAM practices may be better suited for use during more advanced disease after conventional therapies have failed or are not as effective. We found a high prevalence (i.e., half of the participants) of vitamin use, which is consistent with previous research that indicates that mega dosing of vitamins is not uncommon among HIV-positive patients

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(Duggan et al., 2001; Sparber et al., 2000). The efficacy and risks of such a practice among this population are unknown. Given the frequency of reported vitamin use among HIV-positive men and women, future research that uses randomized clinical trials among diverse sample populations is needed to assess the safety as well as the efficacy of vitamin use, particularly the practice of mega dosing when used in conjunction with ARVTs. Interpretations of the results of this study are limited by its cross-sectional design. The design does not permit us to determine the direction of causality in the significant relationships found between psychosocial factors and CAM use. For example, it is possible that having less depression enables individuals to seek and use CAM. Alternatively, CAM use may help to alleviate depression. Another interpretation is that the relationship between CAM use and depression may be due to a third, unknown variable that is related to both variables. Future studies are needed that investigate CAM and its use by HIV-positive men and women using a longitudinal research design to help to better identify possible causal relationships between psychosocial factors and the benefit of alternative treatments. An additional limitation is due to our sampling approach in which study participants were drawn from a convenience sample. Thus, we caution against generalizing these findings to all people living with HIV and AIDS. However, even with these limitations, we believe that the prevalence of CAM use found in this study provides further evidence indicating that clinical studies are needed to determine the long-term efficacy of these health practices. Certainly, the lack of empirical evidence using randomized clinical trial designs to examine the efficacy of alternative treatments for HIV may contribute to a lack of communication found between patients and their primary care providers about CAM (Rose et al., 1998; Wynia et al., 1999). However, the recent findings regarding the contraindication of taking St. John’s wort with indinavir (Moore et al., 2000; Piscitelli et al., 2000) and garlic with saquinavir (Piscitelli et al., 2002) is indicative of the need for primary care providers who treat HIV-positive patients to be aware of any supplements their patients are taking. Without this information, primary care providers’ ability to medically manage patients’ HIV disease may be compromised. We believe that the prevalence of CAM use

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among patients coupled with research suggesting that nutritional supplements positively affect survival and immune functioning warrant the assessment of CAM, including vitamin use, by health care professionals who are treating HIV-positive patients as part of standard care.

Acknowledgments This research was funded by National Institute of Mental Health (NIMH) Grant MH54930 (David Spiegel, MD, principal investigator), and manuscript preparation was supported by NIMH Center Grant P30-MH52776 and National Research Service Award Postdoctoral Training Grant T32-MH19985. The authors would like to thank the following people for their support: Luther Brock, Xin-Hua Chen, Margaret Chesney, Catherine Classen, Sue Dimiceli, Ron Durán, Jan Porter, Peea Kim, Michael Edell, Jason Flamm, Michele Gill, Mark Holodniy, Peea Kim, David Lewis, José Maldonado, Kristen O’Shea, and the men and women who served as participants in this research.

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