Acupuncture for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial.

Importance: Current interventions for posttraumatic stress disorder (PTSD) are efficacious, yet effectiveness may be limited by adverse effects and high withdrawal rates. Acupuncture is an emerging intervention with positive preliminary data for PTSD. Objective: To compare verum acupuncture with sham acupuncture (minimal needling) on clinical and physiological outcomes. Design, Setting, and Participants: This was a 2-arm, parallel-group, prospective blinded randomized clinical trial hypothesizing superiority of verum to sham acupuncture. The study was conducted at a single outpatient-based site, the Tibor Rubin VA Medical Center in Long Beach, California, with recruitment from April 2018 to May 2022, followed by a 15-week treatment period. Following exclusion for characteristics that are known PTSD treatment confounds, might affect biological assessment, indicate past nonadherence or treatment resistance, or indicate risk of harm, 93 treatment-seeking combat veterans with PTSD aged 18 to 55 years were allocated to group by adaptive randomization and 71 participants completed the intervention protocols. Interventions: Verum and sham were provided as 1-hour sessions, twice weekly, and participants were given 15 weeks to complete up to 24 sessions. Main Outcomes and Measures: The primary outcome was pretreatment to posttreatment change in PTSD symptom severity on the Clinician-Administered PTSD Scale-5 (CAPS-5). The secondary outcome was pretreatment to posttreatment change in fear-conditioned extinction, assessed by fear-potentiated startle response. Outcomes were assessed at pretreatment, midtreatment, and posttreatment. General linear models comparing within- and between-group were analyzed in both intention-to-treat (ITT) and treatment-completed models. Results: A total of 85 male and 8 female veterans (mean [SD] age, 39.2 [8.5] years) were randomized. There was a large treatment effect of verum (Cohen d, 1.17), a moderate effect of sham (d, 0.67), and a moderate between-group effect favoring verum (mean [SD] Δ, 7.1 [11.8]; t90 = 2.87, d, 0.63; P = .005) in the intention-to-treat analysis. The effect pattern was similar in the treatment-completed analysis: verum d, 1.53; sham d, 0.86; between-group mean (SD) Δ, 7.4 (11.7); t69 = 2.64; d, 0.63; P = .01). There was a significant pretreatment to posttreatment reduction of fear-potentiated startle during extinction (ie, better fear extinction) in the verum but not the sham group and a significant correlation (r = 0.31) between symptom reduction and fear extinction. Withdrawal rates were low. Conclusions and Relevance: The acupuncture intervention used in this study was clinically efficacious and favorably affected the psychobiology of PTSD in combat veterans. These data build on extant literature and suggest that clinical implementation of acupuncture for PTSD, along with further research about comparative efficacy, durability, and mechanisms of effects, is warranted. Trial Registration: ClinicalTrials.gov Identifier: NCT02869646.

Improvement in Long-COVID Symptoms Using Acupuncture: A Case Study.

Background: The long-COVID syndrome (LCS), defined by residual symptoms from acute COVID-19 for <60 days, affects about one-third of all COVID survivors and is an emerging public health challenge. Empirical data about the range of symptoms or the utility of acupuncture alone for the LCS are very limited. Case: This observational case study of a 46-year-old male with LCS was conducted to preliminarily define the range of symptoms, a Traditional Chinese Medicine (TCM) diagnostic structure, and evaluate the potential utility of prescribed acupuncture for LCS. Results: The primary TCM diagnostic patterns from this patient's LCS presentation included Lung Qi and Yin Deficiency, Qi and Blood Stagnation, and Spleen Qi Deficiency with dampness. Acupuncture for this patient was associated with reduced symptoms and signs of LCS. Conclusion: A preliminary TCM diagnostic structure for LCS was defined. Acupuncture appears to have been helpful for a patient with LCS. Further research is needed to demonstrate the efficacy of acupuncture and/or other TCM modalities for LCS.

Conceptualizing a Traditional Chinese Medicine and Pathology of Arousal Diagnostic and Pathophysiological Framework for Postacute Sequelae of COVID-19.

Introduction: The postacute sequelae of COVID-19 (PASC) is a serious heterogeneous condition that affects a significant minority of those who endured COVID-19. PASC involves multiple body systems and an illness trajectory that has stages now being identified in medical research. Objective: Traditional Chinese Medicine (TCM) and acupuncture are well suited to conceptualize and treat PASC and other postviral conditions. No description of TCM theory and its relationship with modern medical theory about PASC and its illness trajectory currently exists. Conclusion: The authors provide an overview of the potential value of TCM for conceptualizing and treating PASC with a few examples and clarify directions for research.

Acupuncture for combat post-traumatic stress disorder: trial development and methodological approach for a randomized controlled clinical trial.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a significant public health problem, affecting approximately 7% of the general population and 13-18% of the combat Veteran population. The first study using acupuncture for PTSD in a civilian population showed large pre- to post-treatment effects for an empirically developed verum protocol, which was equivalent to group cognitive behavior therapy and superior to a wait-list control. The primary objective of this study is to determine both clinical and biological effects of verum acupuncture for combat-related PTSD in treatment-seeking US Veterans. METHODS: This is a two-arm, parallel-group, prospective randomized placebo-controlled clinical trial. The experimental condition is verum acupuncture and the placebo control is sham (minimal) acupuncture in 1-h sessions, twice a week for 12 weeks. Ninety subjects will provide adequate power and will be allocated to group by an adaptive randomization procedure. The primary outcome is change in PTSD symptom severity from pre- to post-treatment. The secondary biological outcome is change from pre- to post-treatment in psychophysiological response, startle by electromyographic (EMG) eyeblink. Assessments will be conducted at pre-, mid-, post-, and 1-month post-treatment, blind to group allocation. Intent-to-treat analyses will be conducted. DISCUSSION: The study results will be definitive because both clinical and biological outcomes will be assessed and correlated. Issues such as the number needed for recruitment and improvement, use of sham acupuncture, choice of biological measure, and future research need will be discussed. TRIAL REGISTRATION: ClinicalTrials.gov NCT02869646 . Registered on 17 August 2016.

Challenges of systematic reviewing integrative health care.

This article is based on an extensive review of integrative medicine (IM) and integrative health care (IHC). Since there is no general agreement of what constitutes IM/IHC, several major problems were identified that make the review of work in this field problematic. In applying the systematic review methodology, we found that many of those captured articles that used the term integrative medicine were in actuality referring to adjunctive, complementary, or supplemental medicine. The objective of this study was to apply a sensitivity analysis to demonstrate how the results of a systematic review of IM and IHC will differ according to what inclusion criteria is used based on the definition of IM/IHC. By analyzing 4 different scenarios, the authors show that, due to unclear usage of these terms, results vary dramatically, exposing an inconsistent literature base for this field.

A randomized controlled study to evaluate the efficacy of noninvasive limb cover for chronic phantom limb pain among veteran amputees.

OBJECTIVE: To assess the efficacy of a noninvasive limb cover for treating chronic phantom limb pain (PLP). DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Outpatient clinic. PARTICIPANTS: We randomly assigned 57 subjects to 2 groups: true noninvasive limb cover (n=30) and sham noninvasive limb cover (n=27). Inclusion criteria included age of 18 years or greater, upper or lower extremity amputation with healed residual limb, and 3 or more episodes of PLP during the previous 6 weeks. INTERVENTIONS: Subjects received 2 true or sham noninvasive limb covers to be worn over the prosthesis and residual limbs 24 hours a day for 12 weeks. MAIN OUTCOME MEASURES: Primary outcome measure was the numerical pain rating scale of PLP level (0-10). Secondary outcomes included overall pain level (0-10), PLP frequency per week, and the Veterans RAND 12-Item Health Survey (VR-12). We collected data at baseline and at 6- and 12-week follow-up visits. RESULTS: Demographic and clinical characteristics were not significantly different between groups. The true noninvasive limb cover group reported nonsignificant reductions in PLP from 5.9±1.9 at baseline to 3.9±1.7 at the 12-week follow-up. The sham noninvasive limb cover group also had nonsignificant reducations in PLP from 6.5±1.8 to 4.2±2.3. PLP did not differ significantly between the 2 groups at 6 weeks (mean difference, 0.8; 95% confidence interval [CI], -1.4 to 3) or at 12 weeks (mean difference, 0.2; 95% CI, -1.9 to 2.3). Similarly, overall pain level, PLP episodes per week, and VR-12 physical and mental health component scores did not differ between the 2 groups at 6 and 12 weeks. CONCLUSIONS: A true noninvasive limb cover did not significantly decrease PLP levels or the frequency of PLP episodes per week, overall bodily pain levels, or VR-12 physical and mental health component scores compared with a sham noninvasive limb cover in our veteran amputee sample.

Central and peripheral mechanisms underlying gastric distention inhibitory reflex responses in hypercapnic-acidotic rats.

We have observed that in chloralose-anesthetized animals, gastric distension (GD) typically increases blood pressure (BP) under normoxic normocapnic conditions. However, we recently noted repeatable decreases in BP and heart rate (HR) in hypercapnic-acidotic rats in response to GD. The neural pathways, central processing, and autonomic effector mechanisms involved in this cardiovascular reflex response are unknown. We hypothesized that GD-induced decrease in BP and HR reflex responses are mediated during both withdrawal of sympathetic tone and increased parasympathetic activity, involving the rostral (rVLM) and caudal ventrolateral medulla (cVLM) and the nucleus ambiguus (NA). Rats anesthetized with ketamine and xylazine or α-chloralose were ventilated and monitored for HR and BP changes. The extent of cardiovascular inhibition was related to the extent of hypercapnia and acidosis. Repeated GD with both anesthetics induced consistent falls in BP and HR. The hemodynamic inhibitory response was reduced after blockade of the celiac ganglia or the intraabdominal vagal nerves with lidocaine, suggesting that the decreased BP and HR responses were mediated by both sympathetic and parasympathetic afferents. Blockade of the NA decreased the bradycardia response. Microinjection of kainic acid into the cVLM reduced the inhibitory BP response, whereas depolarization blockade of the rVLM decreased both BP and HR inhibitory responses. Blockade of GABA(A) receptors in the rVLM also reduced the BP and HR reflex responses. Atropine methyl bromide completely blocked the reflex bradycardia, and atenolol blocked the negative chronotropic response. Finally, α(1)-adrenergic blockade with prazosin reversed the depressor. Thus, in the setting of hypercapnic-acidosis, a sympathoinhibitory cardiovascular response is mediated, in part, by splanchnic nerves and is processed through the rVLM and cVLM. Additionally, a vagal excitatory reflex, which involves the NA, facilitates the GD-induced decreases in BP and HR responses. Efferent chronotropic responses involve both increased parasympathetic and reduced sympathetic activity, whereas the decrease in BP is mediated by reduced α-adrenergic tone.

Systematic review of integrative health care research: randomized control trials, clinical controlled trials, and meta-analysis.

A systematic review was conducted to assess the level of evidence for integrative health care research. We searched PubMed, Allied and Complementary Medicine (AMED), BIOSIS Previews, EMBASE, the entire Cochrane Library, MANTIS, Social SciSearch, SciSearch Cited Ref Sci, PsychInfo, CINAHL, and NCCAM grantee publications listings, from database inception to May 2009, as well as searches of the "gray literature." Available studies published in English language were included. Three independent reviewers rated each article and assessed the methodological quality of studies using the Scottish Intercollegiate Guidelines Network (SIGN 50). Our search yielded 11,891 total citations but 6 clinical studies, including 4 randomized, met our inclusion criteria. There are no available systematic reviews/meta-analyses published that met our inclusion criteria. The methodological quality of the included studies was assessed independently using quality checklists of the SIGN 50. Only a small number of RCTs and CCTs with a limited number of patients and lack of adequate control groups assessing integrative health care research are available. These studies provide limited evidence of effective integrative health care on some modalities. However, integrative health care regimen appears to be generally safe.

Integrative health care under review: an emerging field.

OBJECTIVE: The purpose of this study was to review the research literature for the emerging field of Integrative Medicine/Integrative Health Care (IM) using the methods of systematic review. METHODS: We conducted an electronic literature search using PubMed, Allied and Complementary Medicine, BIOSIS Previews, EMBASE, the entire Cochrane Library, MANTIS, Social SciSearch, SciSearch Cited Ref Sci, PsychInfo, CINAHL, and NCCAM grantee publications listings from database inception to May 2009, as well as searches of the gray literature. Available studies published in English language were included. Three independent reviewers rated each article and assessed the methodological quality of studies using the Scottish Intercollegiate Guidelines Network. RESULTS: Our initial search yielded 11 591 citations. Of these, only 660 were judged to be relevant to the purpose of our search. Most articles deal with implementing and implemented programs. They focus on practice models, strategies for integrative health, the business case, and descriptive studies. This is followed in terms of numbers by conceptual/philosophical writings. These in turn are followed by research articles including randomized controlled trials, program evaluations, and cost-effectiveness studies. The literature reflects an emerging field in that it is focused more on how to create IM than on researching outcomes. However, the lack of definition and clarity about the term integrative medicine (also known as integrative health care) and the absence of taxonomy for models of IM make it very difficult to efficiently conduct systematic reviews of this field at the moment. CONCLUSION: Our review revealed that most articles focused on describing practice models and conceptual/philosophical models, whereas there are fewer randomized controlled trials and observation studies. The lack of consensus on a clear definition and taxonomy for integrative health care represents a major methodological barrier on conducting systematic literature reviews and meta-analysis in this emerging field.

Role of religiosity and spirituality in complementary and alternative medicine use among cancer survivors in California.

OBJECTIVES: Cancer survivors often turn to religion, spirituality, and complementary and alternative medicine (CAM) because they perceive these areas as being more holistic and patient-centered than conventional medicine. Because increased religiosity and spirituality have been found to be associated with higher CAM use in the general population, it was hypothesized that these factors would be important predictors of CAM use in cancer survivors. DESIGN AND SUBJECTS: The study included a subsample of 1844 people with cancer or a history of cancer from the 2003 California Health Interview Survey of CAM, a cross-sectional survey of a population-based sample of adults in California. Prevalence and predictors of religious/spiritual forms of CAM (R/S CAM) and nonreligious/nonspiritual forms of CAM (non-R/S CAM) were compared. Multivariate logistic regression was used to identify the predictors of R/S CAM and non-R/S CAM. RESULTS: Nearly two thirds of participants reported using at least 1 type of R/S CAM, and 85% reported ever using non-R/S CAM. The majority of cancer survivors reported that they were very/moderately religious or spiritual. Both religiosity and spirituality were strongly related to non-R/S CAM use, but in opposite directions. Very or moderately religious cancer survivors were less likely (odds ratio=0.30; 95% confidence interval, 0.12-0.40) than nonreligious cancer survivors to use non-R/S CAM. In contrast, very or moderately spiritual cancer survivors were more likely (odds ratio=2.42; 95% confidence interval, 1.16-6.02) than nonspiritual cancer survivors to use non-R/S CAM. CONCLUSIONS: The use of R/S CAM and non-R/S CAM is very high in cancer survivors. It may be helpful for clinicians to ascertain their patients' use of these types of CAM to integrate all forms of care used to managing their cancer.

Religious and spiritual practices and identification among individuals living with cancer and other chronic disease.

Religion and spirituality in the context of health care are poorly understood, particularly for individuals with chronic illness. Using data from the 2003 Complementary and Alternative Medicine supplement to the 2001 California Health Interview Survey, we examined whether cancer survivors (n = 1,777) and individuals with other chronic illnesses (n = 4,784) were either more likely to identify themselves as religious and spiritual or more likely to use religious and spiritual practices for health purposes than individuals with no disease (n = 2,342). We observed that cancer survivors and individuals with chronic illnesses were more likely than those with no disease to use religious and spiritual prayer and healing practices. Individuals with chronic diseases were not inherently more likely to identify themselves as religious than were healthy individuals and were only slightly more likely to identify themselves as spiritual. These findings indicate that individuals with cancer and other chronic illnesses may be using religious and spiritual practices as a way to cope with their illness. Future research should continue to examine whether and how religious and spiritual practices are used as complementary or alternative medicine, and health care professionals should ask their patients about such use.

Suboptimal control of atherosclerotic disease risk factors after cardiac and cerebrovascular procedures.

BACKGROUND AND PURPOSE: Undergoing a carotid endarterectomy, a coronary artery bypass graft, or a percutaneous coronary intervention provides an opportunity to optimize control of blood pressure and low-density lipoprotein. METHODS: Using Veterans Administration databases, we determined whether patients who underwent a carotid endarterectomy (n=252), coronary artery bypass graft (n=486), or percutaneous coronary intervention (n=720) in 2002 to 2003 at 5 Veterans Administration Healthcare Systems had guideline-recommended control of blood pressure and low-density lipoprotein in 12-month periods before and after a vascular procedure. Postprocedure control of risk factors across procedure groups was compared using chi(2) tests and multivariate logistic regression. RESULTS: The proportion of patients undergoing carotid endarterectomy who had optimal control of both blood pressure and low-density lipoprotein increased from 23% before the procedure to 33% after the procedure (P=0.05) compared with increases from 32% to 43% for coronary artery bypass graft (P=0.001) and from 29% to 45% for percutaneous coronary intervention (P=0.002). Compared with the carotid endarterectomy group, the percutaneous coronary intervention group was more likely to achieve optimal control of blood pressure (OR: 1.92, 95% CI: 1.42 to 2.59) or low-density lipoprotein (OR: 1.51, 95% CI: 1.01 to 2.26) and the coronary artery bypass graft group was more likely to achieve optimal control of blood pressure (OR: 1.53, 95% CI: 1.42 to 2.59). Postprocedure cardiology visits, increase in medication intensity, and greater frequency of outpatient visits were also associated with optimal postprocedure risk factor control. CONCLUSIONS: Although modest improvements in risk factor control were detected, a majority of patients in each vascular procedure group did not achieve optimal risk factor control. More effective risk factor control programs are needed among most vascular procedure patients.

Variation in complementary and alternative medicine (CAM) use across racial/ethnic groups and the development of ethnic-specific measures of CAM use.

OBJECTIVES: The use of complementary and alternative medicine (CAM) is likely to vary among racial/ethnic groups because its use is related to cultural and health beliefs. Understanding patterns of CAM use among ethnic groups could inform clinical practice and the study of CAM use in a diverse population. The authors compared CAM use among Asian-Americans, American Indians, African Americans, Latinos, whites, and other racial/ethnic groups in order to develop ethnic-specific measures of CAM use and explore factors associated with such CAM use across ethnic groups. DESIGN: A cross-sectional survey of a sample of 9187 adults representative of the California population was performed. OUTCOME MEASURES: Ethnic-specific constructs for Asian-Americans, American Indians, African Americans, Latinos, and whites were devised. RESULTS: The authors identified ethnic-specific CAM modalities for each ethnic group. Demographic and clinical factors associated with use of ethnic-specific CAM differed from the predictors of overall CAM use in the general population and varied by ethnicity. CONCLUSIONS: Patterns of CAM use and ethnic-specific CAM use vary across racial/ethnic groups. Evaluation of CAM use in ethnically diverse populations should recognize ethnic-specific modalities and variation across ethnicity.

Variations in provider conceptions of integrative medicine.

Consumers often turn to complementary and alternative medicine (CAM) and use it concurrently with conventional medicine to treat illnesses and promote wellness. However, prior studies demonstrate that these two paradigms are often not combined effectively. Consumers often do not tell physicians about CAM treatments or CAM practitioners about conventional treatments that they are using. This can lead to inefficient care and/or adverse interactions. There is also a lack of consensus about the structure and practice of integrative medicine among the various types of practitioners. This qualitative study aimed to identify key domains and develop a conceptual model of integrative medicine at the provider level, using a grounded theory approach. Purposive sampling was used to select 50 practitioners, including acupuncturists, chiropractors, internists/family practitioners, and physician acupuncturists in private practice and at academic medical centers in Los Angeles. We conducted semi-structured, in-depth interviews with practitioners and then identified core statements that describe practitioners' attitudes and behaviors toward integrative medicine. Core statements were free pile sorted to ascertain key domains of integrative medicine. Four key domains of integrative medicine were identified at the provider level: attitudes, knowledge, referral, and practice. Provider age, training, and practice setting also emerged as important factors in determining clinicians' "orientation" toward integrative medicine. "Dual-trained" practitioners, such as physician acupuncturists, exemplified clinicians with a greater orientation toward integrative medicine. They advocated an open-minded perspective about other healing traditions, promoting co-management with and making referrals to practitioners of other paradigms, and treating patients with both CAM and conventional healing modalities.

Complementary and alternative medicine use among Asian-American subgroups: prevalence, predictors, and lack of relationship to acculturation and access to conventional health care.

OBJECTIVES: Acculturation and access to conventional health care have been found to be predictors of complementary and alternative medicine (CAM) use in the general population. We hypothesized that these factors would be predictors of CAM use in Asian-American subgroups. Because of differences in health and cultural beliefs, we also hypothesized that patterns and predictors of CAM use would vary among Asian-American subgroups. METHODS: Cross-sectional survey of a sample of 9187 adults representative of the California population. RESULTS: Nearly three quarters of Asian-Americans used at least one type of CAM in the past 12 months, which was significantly higher than the national prevalence rate. Chinese Americans had the highest prevalence of any CAM use, whereas South Asians had the lowest prevalence (86% vs. 67%, respectively). Acculturation and access to conventional medical care was unrelated to any CAM use for most Asian-American subgroups. Spirituality was the strongest predictor of any CAM use for most Asian-American subgroups. CONCLUSIONS: CAM use varies across Asian-American subgroups. Acculturation and access to conventional medical care is unrelated to any CAM use for most Asian-American subgroups.

A Self-Report Measure of Clinicians' Orientation toward Integrative Medicine.

OBJECTIVE: Patients in the U.S. often turn to complementary and alternative medicine (CAM) and may use it concurrently with conventional medicine to treat illness and promote wellness. However, clinicians vary in their openness to the merging of treatment paradigms. Because integration of CAM with conventional medicine can have important implications for health care, we developed a survey instrument to assess clinicians' orientation toward integrative medicine. STUDY SETTING: A convenience sample of 294 acupuncturists, chiropractors, primary care physicians, and physician acupuncturists in academic and community settings in California. DATA COLLECTION METHODS: We used a qualitative analysis of structured interviews to develop a conceptual model of integrative medicine at the provider level. Based on this conceptual model, we developed a 30-item survey (IM-30) to assess five domains of clinicians' orientation toward integrative medicine: openness, readiness to refer, learning from alternate paradigms, patient-centered care, and safety of integration. PRINCIPAL FINDINGS: Two hundred and two clinicians (69 percent response rate) returned the survey. The internal consistency reliability for the 30-item total scale and the five subscales ranged from 0.71 to 0.90. Item-scale correlations for the five subscales were higher for the hypothesized subscale than other subscales 75 percent or more of the time. Construct validity was supported by the association of the IM-30 total scale score (0-100 possible range, with a higher score indicative of greater orientation toward integrative medicine) with hypothesized constructs: physician acupuncturists scored higher than physicians (71 versus 50, p<.001), dual-trained practitioners scored higher than single-trained practitioners (71 versus 62, p<.001), and practitioners' self-perceived "integrativeness" was significantly correlated (r=0.60, p<.001) with the IM-30 total score. CONCLUSION: This study provides support for the reliability and validity of the IM-30 as a measure of clinicians' orientation toward integrative medicine. The IM-30 survey, which we estimate as requiring 5 minutes to complete, can be administered to both conventional and CAM clinicians.

Complementary and alternative medicine use and substitution for conventional therapy by HIV-infected patients.

BACKGROUND: HIV-infected patients commonly use complementary and alternative medicine (CAM), but it is not known how often CAM is used as a complement or as a substitute for conventional HIV therapy. OBJECTIVES: To evaluate the prevalence and factors associated with CAM use with potential for adverse effects and CAM substitution for conventional HIV medication. DESIGN AND PARTICIPANTS: Cross-sectional survey of U.S. national probability sample of HIV-infected patients (2,466 adults) in care from December 1996 to July 1997. MAIN OUTCOME VARIABLES: Any CAM use, CAM use with potential for adverse effects, and use of CAM as a substitute for conventional HIV therapy. Substitution was defined as replacement of some or all conventional HIV medications with CAM. RESULTS: Fifty-three percent of patients had recently used at least one type of CAM. One quarter of patients used CAM with the potential for adverse effects, and one-third had not discussed such use with their health care provider. Patients with a greater desire for medical information and involvement in medical decision making and with a negative attitude toward antiretrovirals were more likely to use CAM. Three percent of patients substituted CAM for conventional HIV therapy. They were more likely to desire involvement in medical decision-making (odds ratio, 1.8; 95% confidence interval, 1.0-3.2) and to have a negative attitude toward antiretrovirals (odds ratio, 7.8; 95% confidence interval, 3.0-19.0). CONCLUSIONS: Physicians should openly ask HIV-infected patients about CAM use to prevent adverse effects and to identify CAM substitution for conventional HIV therapy.