Consistent with our hypothesis, reported pain at baseline was a strong predictor of CAM use during the approximately six month period prior to first follow-up. Patients who experienced more pain were more likely to subsequently use at least one of the 16 CAM therapies studied; they were also more likely to use a larger number of these CAM therapies. In bivariate analyses, respondents who endorsed subsequent CAM use (except for manipulative/body-based methods and energy healing) reported significantly more pain at baseline than those who did not use CAM (see ). Multivariate analyses accordingly revealed that increased pain was associated with greater use of four of the five CAM domains specified by NCCAM (i.e., mind-body, biologically-based therapies, manipulative/body-based methods, and alternative medical systems). The only exception was energy healing, possibly due to the small number of patients (i.e., less than 5%) who endorsed using this therapy. In fact, pain was the only characteristic examined, with the exception of education that consistently predicted utilization across CAM domains. Regarding education, patients with less than a high school diploma were less likely to use all domains of CAM relative to college-educated patients. Notably, the relationships between pain and CAM use persisted even when controlling for objective indicators of disease progression including CD4 count and clinical stage, as well as other need characteristics such as energy, anxiety and depression.
On the other hand, changes in reported pain from baseline to follow-up were not associated with overall use of CAM. However, reductions in pain over time predicted a lower likelihood of use for biologically-based therapies. Examination of the individual therapies within this CAM domain revealed that this relationship was specific to use of underground/unlicensed drugs. Thus, patients whose pain had declined by follow-up were less likely to use these types of drugs. These findings are consistent with the notion that poorly controlled pain over time may lead HIV patients to seek out complementary, alternative, or untested drug treatments with possible adverse effects. Although the HCSUS did not specify which drugs were included in this category, use of various underground/unlicensed drugs such as oral interferon-α, disulfiram, and dinitrochlorobenzene have been documented in HIV patients (2
). Even though relatively few patients in the sample (i.e., 5%) endorsed using underground/unlicensed drugs, there is a potential for harm from such use. Several other characteristics were also independently associated with use of underground/unlicensed drugs. Men, younger persons, those who reported more pain at baseline and those who were classified as being drug dependent in the past year were more likely to use such drugs. Given that HIV+ individuals who reported more pain might be more inclined to pursue these unproven treatments, future studies should explore whether efforts targeted at alleviating pain in the HIV+ population would lead to a reduction in the use of potentially harmful underground/unlicensed drugs.
In our earlier work with the present sample, poorer health (i.e., CD4 count <50 cells/mm3
, and less vitality) independently predicted higher use of outpatient medical services, whereas in the present study, health status was not strongly linked with overall CAM use. Thus, clinical stage, CD4 count, vitality, presence of wasting syndrome, and early use of ART did not impact the likelihood of using at least one CAM therapy. Whereas we did find that less vitality predicted greater use of biologically-based therapies, it is notable that respondents with lower CD4 counts (i.e., 50-199 cells/mm3
) were actually less
likely to use manipulative/body-based methods compared to those with CD4 counts of 500 or more. Similarly, low CD4 counts were associated with less use of energy healing. Moreover, patients with CD4 counts below 500 were likely to use fewer
CAM therapies than those with CD4 counts of 500 or more. It is possible that HIV patients with low CD4 counts may be less inclined to seek unconventional treatments due to heightened concerns that such approaches may further compromise already-weakened immune systems. Disease progression in persons with low CD4 counts is more rapid than for persons with higher CD4 counts (38
) and opportunistic infections are more prevalent in persons with CD4 counts below 50 cells/mm3
Depression emerged as an important need characteristic that was independently associated with use of CAM. Patients who screened positive for depression at baseline were more likely to use at least one CAM therapy as well as more likely to use mind-body and biologically-based therapies. Depressed patients were also more likely to use a greater number of CAM therapies. These relationships were evident even after controlling for anxiety, suggesting depression, rather than global psychological distress, specifically influenced use of CAM. Our findings are consistent with previous work in this sample showing that the presence of depression is associated with increased visits to alternative therapists (12
). Prior research in a convenience sample indicated that HIV patients who use CAM to relieve stress and depression were more likely to make visits to CAM providers but were no more likely to use self-prescribed herbal, mineral, and vitamin supplements (14
). By contrast, in the current nationally representative sample, depression is associated with use of both CAM practitioners and self-care including biologically-based therapies which may interfere with medical treatment for HIV. London and colleagues (12
) suggested that HIV patients who are depressed may use CAM as part of a strategy to help manage depression. Thus, efforts aimed at identifying and treating depression should be considered in patients who use CAM, particularly in light of evidence supporting an association between depression and pain in HIV (36
When pain and other need characteristics are taken into account, relatively few other characteristics evidenced significant relationships with CAM use. The most salient factor, as mentioned above, was level of education. The less educated were less likely to use CAM therapies across all domains, and they were also more likely to use smaller number of such therapies–findings that are consistent with earlier work in HIV samples indicating that higher education predicts increased CAM use (15
). Overall use of CAM was not related to income level–lower income was primarily associated with less use of manipulative/body-based methods. Given that these therapies necessitate a visit to an alternative practitioner (i.e., massage therapist, chiropractor) for whose care patients pay greater out-of-pocket costs, this finding is not surprising. Insurance status also did not influence overall CAM use, which was also expected since health insurance often did not provide coverage for CAM during the sampled time period. For biologically-based therapies only, respondents with no insurance were more likely to use this CAM domain than respondents with Medicaid. It is conceivable that those without insurance are more likely to use self-care practices (e.g., use of supplements or lifestyle diets) due to lower costs and greater accessibility of these therapies.
Age, racial/ethnic and regional variations in CAM use persisted even when controlling for pain and other need characteristics. Older persons were less likely to use at least one CAM therapy as well as biologically-based and manipulative/body-based methods. Relative to whites, Hispanics were less likely to use any CAM as well as mind-body, whereas African-Americans were less likely to use manipulative/body-based methods. Hispanics were also more likely to use fewer CAM therapies compared to whites. These findings may reflect cultural preferences for certain types of CAM, but further study is necessary. Geographic variations in use may be possibly due in part to less availability of CAM providers in certain regions.
Notably, persons exposed to HIV via IV-drug use were more likely to use any CAM and to use a greater number of such therapies, compared to MSMs. These findings are somewhat surprising given that higher education level has been consistently shown to be one of the strongest predictors of CAM use(4
) and IV-drug users generally have a lower level of education than the general public (44
). However, even after we controlled for education, our findings indicated that a history of IV-drug use predicts increased use of CAM. Prior research in convenience samples has revealed mixed findings with one study reporting that IV-drug users with HIV had lower rates of CAM use than MSMs (45
), one study indicating the opposite pattern with MSMs reporting lower rates of CAM use than IV-drug users,(46
) and one study showing no differences in CAM use (47
). These disparate findings may be due to variations in survey methodology and/or definitions of CAM. As discussed by Manheimer and colleagues (44
), CAM may be particularly appealing to IV-drug users either because of mistrust of the conventional medical system or due to perceptions of being stigmatized in past interactions with conventional medicine. Social isolation of IV-drug users may influence them toward using self-care or alternative therapies for health care, either by choice or out of economic necessity (44
). The present study controlled for income so economic necessity is less likely to explain our finding. We previously reported greater pain at baseline in IV-drug using women in the HCSUS sample (9
), highlighting the need for further research on CAM use in this subgroup of HIV patients.
Limitations to our findings should be mentioned. We used the bodily pain subscale of the SF-36 to measure pain and this subscale consisted of only two items. Therefore, important aspects of pain (e.g., pain location; sensory quality of HIV-related pain) were not assessed. Moreover, the subscale assessed pain in the previous 4 weeks and thus, the presence of pain prior to or persisting beyond this time frame was not evaluated. The CAM therapies examined in the HCSUS were derived from prior research by Eisenberg and colleagues (1
); however, the list of therapies studied was not exhaustive and the survey did not include items that assessed whether respondents used CAM therapies not specifically listed. Relatedly, the item asking about underground/unlicensed drugs was developed for the purposes of the HCSUS and this item did not specify which drugs were referred to in this category. Thus, it is not possible to discern which underground/unlicensed drugs were used by respondents. The HSCUS was conducted between 1996 and 1997 and it is likely that the popularity of certain therapies may have changed since that time. For example, only one therapy (i.e., energy healing) was included in the category for energy therapies even though there are several different types of such therapies. The HCSUS did not ask about use of conventional pain treatments and so such information, which might have influenced change in pain over time, could not be included in the present analyses. Another important limitation is that the HCSUS only included persons with HIV who were receiving medical care for their HIV. Therefore, those with very poor access to medical care, those who are less compliant, and those who are relatively healthy are likely underrepresented (32
). Often, persons in the early stages of the disease are not receiving care for HIV (32
). Thus, the relationship between pain and CAM use for these persons may be different from that found in this study although even persons in the early stages of HIV may experience pain (48
In sum, our findings suggest that pain is an important predictor of use of CAM in persons living with HIV, including both self-care and visits to CAM practitioners. Moreover, patients whose pain declined over time were less likely to have used underground/unlicensed drugs—findings that are consistent with the notion that poorly controlled pain over time may lead HIV patients to seek out untested drug treatments with the potential for adverse effects. Depression was also associated with the use of underground/unlicensed drugs. Thus, greater efforts at alleviating pain and symptoms of depression may be directed at HIV populations with a view to reducing use of underground or unproven drug therapies. The present results are consistent with our earlier work in this sample demonstrating that pain is a significant predictor of outpatient services utilization. Previously, we found that patients who reported more pain and those who developed more pain over time used more outpatient services, after controlling for clinical indicators and sociodemographic factors (9
). Taken together, the prior findings and the results of the current study suggest that pain is a significant need characteristic that influences use of conventional health services as well as use complementary and alternative care, irrespective of clinical health indicators. Since pain is a significant factor associated with use of CAM, further research on the safety and efficacy of CAM approaches for pain in HIV is warranted.