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Physicians need to be knowledgeable, open-minded
It was clear to Donald Abrams, MD, that a patient he was treating at an AIDS clinic was reacting to something he was taking, but the man’s medical records indicated he was not on prescription medication. Abrams asked if he was taking any vitamins. Yes, the patient was taking five or six different vitamins. Herbs? Yes, he was taking a half-dozen herbs, as well. Abrams asked why he had never told any other doctor about it. The patient replied that no other doctor had ever asked him before.
The use of alternative medicine in the general U.S. population has increased from 33.8% in 1990 to 42.1% in 1997.1 Although significant numbers of people are turning to various forms of alternative therapies, researchers suggest that the reasons are poorly understood.2
Not so for HIV/AIDS patients, say the clinicians interviewed for this article.
"In spite of the fact that we have good control of the virus now with antivirals, there are areas where we still don’t have good available treatments," says Abrams, an oncologist and assistant director of the AIDS Program at San Francisco General Hospital. "In those areas — such as the new body alterations [fat accumulations in the abdomen and on the back of the neck from protease inhibitors, or loss of total body fat] that we’re seeing in HIV patients, or with building back immune systems — people are turning to alternative interventions."
Patients with chronic illnesses for which there are few or no conventional curative treatments are the groups most likely to use alternative therapies, says Abrams, who estimates that from 40% to 70% of HIV/AIDS patients seek some kind of complementary or alternative intervention.3
The widespread use of alternative HIV/AIDS treatments presents a couple of concerns.
"Physicians need to learn how to ask their patients whether or not they’re using them," Abrams says. "The major problem is that they don’t know how to ask. Physicians need to be not only open-minded and nonjudgmental, but they also have to know how to ask the questions."
Learning about commonly used alternatives such as herbs and understanding their actions through research on the Internet and other sources can help doctors communicate with their patients.
Abrams also warns that most of the herbs and supplements patients are taking have not undergone testing similar to prescription drugs.
"We don’t know if there are interactions with prescribed drugs," he says. "People should be careful, but if they have a condition they feel they is being benefited by one of these interventions, I’d like to further test it. My belief has always been, if it’s out there and may have some benefits, let’s test it. If it’s out there and it may do some harm, we’d better know that as well."
However, testing alternative therapies is no easy matter. Abrams has been investigating alternative treatments for nearly 20 years and collaborated with an Asian medicine practitioner in publishing the first placebo-controlled clinical trial of Chinese herbs in patients with symptomatic HIV disease. The study showed some reduced symptoms in subjects taking herbs, but concluded that larger trials of longer duration were needed.4
With keen competition for scarce federal dollars, obtaining funds for further research of alternatives such as herb therapy has been problematic. In addition, those studies can be difficult to conduct. For example, Abrams says he learned that the Chinese herbs study really didn’t resemble an actual Chinese medicine intervention, in which each patient would be given an individualized treatment based on a traditional Chinese medicine diagnosis that differs greatly form the Western medical model. (See related story, p. 22.) Also, an authentic Chinese medicine treatment would include acupuncture, and the herbs would have been consumed as a tea, not in pill form.
Investigators at the AIDS Research Center of Bastyr University, a naturopathic college in Kenmore, WA, also are seeking federal funds for research into alternatives. Carlo Calabrese, ND, MPH, the center’s co-director, says recent research has shown that the number of therapies being used by HIV-positive people is "unexpectedly large."5
Another Bastyr study aims to determine whether patients who use both conventional and alternative medicine have different outcomes from patients who use only conventional medicine. Researchers are collecting data every six months from 1,500 HIV-positive men and women who are using alternatives.6
About half the participants use acupuncture. Initial results focusing mainly on acupuncture and the use of Chinese herbs could be published this year, and Calabrese says only that some outcome parameters show positive results while others do not.
"I am not looking at an AIDS cure, but I am seeing some significantly positive results, and I’m also seeing some [conditions] which acupuncture does not help," he states.
Research is necessary to "separate the wheat from the chaff," Calabrese says. "We want to know if there are therapies that are beneficial, and at the same time if certain [therapies] are harmful, we ought to caution the public. We also advocate medical doctors keeping an open mind about what their patients are doing."
Although advances in drug treatment for HIV/AIDS seem promising, many patients are attracted to alternative or complementary therapies based on a need for "empowerment, . . . a sense of connectedness between their thoughts, diet, and medical regimen on the one hand, and their view of HIV on the other," reports a recent study of complementary medi cine and HIV infection.7
Author Richard A. Elion, MD, a Washington, DC, family practitioner specializing in HIV/ AIDS, combines both conventional and alternative medicine for about 70% of his patients.
Elion tells AIDS Alert it’s important for physicians to know what their patients are taking because of any potential interactions, but it’s also important for physicians to be able to offer patients alternative therapies that work. He advocates using "integrative therapies" such as acupuncture, Chinese herbs, vitamin supplements, antioxidants, and amino acids.
While drug treatment can help suppress viral loads, alternative medicine better addresses restoration and maintenance of immune function, he says. It is not surprising, then, that HIV-infected patients often seek both types of treatments.
In fact, "this trend may very well establish HIV infection as the model condition for a natural integration of allopathic medicine with the emerging sciences of energy medicine, meditation, nutrition, and herbal therapies," Elion’s report states.
Nevertheless, patients’ use of alternative therapies should be coordinated by physicians, "but sometimes physicians are not competent to supervise that," he notes. "They should have a dialogue with the alternative practitioner so there can be a team approach and so the patient isn’t in a position of trying to manage it themselves."
1. Eisenberg DM, Davis RB, Ettner SL. Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey. JAMA 1998; 280:1,569-1,575.
2. Astin JA. Why patients use alternative medicine: Results of a national study. JAMA 1998; 279:1,548-1,553.
3. Abrams DI. "Alternative Therapies for HIV." In: Sande MA, Volberding PA, eds. The Medical Management of AIDS. 5th ed. Philadelphia: WB Saunders; 1996, pp. 143-158.
4. Burack JH, Cohen MR, Hahn JA, et al. Pilot randomized controlled trial of Chinese herbal treatment for HIV-associated symptoms. J Acquir Immune Defic Syndr Hum Retrovirol 1996; 12:386-393.
5. Calabrese C, Wenner CA, Reeves C, et al. Treatment of human immunodeficiency virus-positive patients with complementary and alternative medicine: A survey of practitioners. J Alt Comp Med 1998; 4:281-287.
6. Standish LJ, Calabrese C, Reeves C, et al. A scientific plan for the evaluation of alternative medicine in the treatment of HIV/AIDS. Altern Ther Health Med 1997; 3:58-67.
7. Elion RA, Cohen C. Complementary medicine and HIV infection. Primary Care 1997; 24:905-919.