摘要：Objectives. This study examined the influence of sociodemographic, clinical, and attitudinal variables on the use of alternative therapists by people in care for HIV. Methods. Bivariate and multivariate analyses of baseline data from the nationally representative HIV Cost and Services Utilization Study were conducted. Results. Overall, 15.4% had used an alternative therapist, and among users, 53.9% had fewer than 5 visits in the past 6 months. Use was higher for people who were gay/lesbian, had incomes above $40 000, lived in the Northeast and West, were depressed, and wanted more information about and more decisionmaking involvement in their care. Among users, number of visits was associated with age, education, sexual orientation, insurance status, and CD4 count. Conclusions. Among people receiving medical care for HIV, use of complementary care provided by alternative therapists is associated with several sociodemographic, clinical, and attitudinal variables. Evaluation of the coordination of provider-based alternative and standard medical care is needed. Complementary and alternative medicine (CAM) is widely used in the United States by people with various chronic illnesses and for preventive purposes. 1, 2 Numerous studies have investigated CAM use among people infected with HIV. 3– 18 Despite this research effort, questions remain. The prevalence of CAM use in this population remains somewhat uncertain, evidence regarding the correlates of CAM use is limited and conflicting, and relatively little empirical evaluation has been done of how attitudinal factors influence CAM use among people infected with HIV. Previous estimates of CAM use (self-care and alternative therapist use combined) among people infected with HIV have ranged from 29% 10 to 76%, 9 with some researchers suggesting that people infected with HIV use CAM at substantially higher rates than people with other serious illnesses. 3, 11 Evidence from industrialized countries other than the United States (Italy, Great Britain, Canada, and Australia) has revealed similarly high levels of CAM use among people infected with HIV. 19– 22 Although overall levels of CAM use appear to be moderate to high among people with HIV infection generally, the available evidence suggests that CAM use among people with HIV infection is disproportionately high among Whites, males, homosexuals, people educated beyond high school, and those who have higher incomes. 3– 5, 7, 10, 14, 16 Beyond this basic demographic profile, existing studies have yielded limited evidence regarding other correlates of CAM use among people infected with HIV. Some studies have found that HIV-related clinical indicators, such as having received an AIDS diagnosis, having a lower CD4 count, experiencing opportunistic infections, and having been seropositive for more than 2 years, are associated with use of CAM, whereas others have not. 3, 8– 10, 12, 13, 15, 16 Few studies of people infected with HIV have examined substance use and mental health problems in relation to CAM use, although many studies have concluded that people infected with HIV use CAM to promote emotional well-being. Available evidence suggests no association between depressive symptoms and CAM use among people infected with HIV 16, 21 ; however, in 1 study, users of CAM providers (as opposed to users of self-prescribed herbal, mineral, and vitamin supplements) were particularly likely to say that they used CAM to relieve stress and depression. 9 The available evidence on the prevalence and correlates of CAM use among people infected with HIV is somewhat mixed and uncertain, at least in part because most studies have used small convenience samples selected from clinics, and samples often lack representation and variation in key domains. Frequently, no distinction is drawn between alternative therapies administered as part of a self-care regimen and CAM provided by an alternative therapist. This distinction is important, because the correlates of CAM use as part of a self-care regimen may be different from the correlates of alternative therapist use, and evaluation of variation in the amount of CAM use may be complicated when self-care and alternative therapist use are conflated. Little empirical evaluation of the influence of attitudinal factors is found in the existing literature on CAM use among people infected with HIV. Three potentially complementary theories that focus on attitudinal factors have been developed in studies of CAM use in the general population and in qualitative studies of CAM use by people infected with HIV. 23– 31 These theories suggest that use of alternative medicine may be motivated by various factors that either push or pull the person toward CAM use, such as dissatisfaction with conventional medicine, the need for ideological congruence, and the need for personal control. People may be driven to using alternative medicine because of the failure of conventional medicine to help; because of distrust or lack of confidence in the efficacy of conventional medicine; or because of past negative medical experiences. Similarly, some people may be attracted to alternative medicine because of their belief in alternative health care and its efficacy, or because they hold a distinct set of health beliefs legitimating nontraditional medical practices. For these people, CAM may offer treatments and explanations for disease that are more compatible with the individual’s worldview regarding health and illness. Additionally, for individuals disposed toward asserting control over their illness (i.e., those who seek to “become their own doctors” 25, 26 ), self-care may promote feelings of personal control, and nontraditional health care providers may allow individuals to play a more active role in the management of their illnesses. In this study, we used data from the HIV Cost and Service Utilization Study (HCSUS), a nationally representative study of people receiving conventional medical care for HIV, to address some of the limitations and gaps in the existing literature on CAM use among people infected with HIV. Using this population-based sample, we focused on the use of alternative therapists (as opposed to CAM use more generally). We estimated the prevalence of alternative therapist use in the past 6 months and the number of visits among those having made at least 1 visit. We also examined sociodemographic, clinical, and attitudinal correlates of alternative therapist use among people receiving conventional medical care for HIV and the amount of use among those with at least 1 visit to an alternative therapist. Drawing on available theories and empirical evidence, we hypothesized that use of alternative therapists would be higher among Whites, men, homosexuals, the better educated, and those with higher incomes. Although available evidence is mixed, we also examined the associations between use of alternative therapists and several indicators of HIV clinical status, substance use, and depression. Finally, focusing on attitudinal factors, we hypothesized that use of alternative therapists would be more likely among people who have greater uncertainty about the efficacy of conventional HIV treatments, have experienced discrimination because of their HIV status, are better informed about HIV, have high interest in the personal management of their care and treatment, and have less trust in conventional medical providers.
