Randomized Clinical Trial of HIV Treatment Adherence Counseling Interventions for People Living With HIV and Limited Health Literacy

Abstract

Background Limited health literacy is a known barrier to medication adherence among people living with HIV. Adherence improvement interventions are urgently needed for this vulnerable population. Purpose This study tested the efficacy of a pictograph-guided adherence skills building counseling intervention for limited literacy adults living with HIV. Methods Men and women living with HIV and receiving antiretroviral therapy (ART, N=446) who scored below 90% correct on a test of functional health literacy were partitioned into marginal and lower literacy groups and randomly allocated to one of three adherence-counseling conditions: (a) pictograph-guided adherence counseling, (b) standard adherence counseling, or (c) general health improvement counseling. Participants were followed for 9-months post-intervention with unannounced pill count adherence and blood plasma viral load as primary endpoints. Results Preliminary analyses demonstrated the integrity of the trial and more than 90% of participants were retained. Generalized estimating equations showed significant interactions between counseling conditions and levels of participant health literacy across outcomes. Participants with marginal health literacy in the pictograph-guided and standard-counseling conditions demonstrated greater adherence and undetectable HIV viral loads compared to general health counseling. In contrast and contrary to hypotheses, participants with lower health literacy skills in the general health improvement counseling demonstrated greater adherence compared to the two adherence counseling conditions. Conclusions Patients with marginal literacy skills benefit from adherence counseling regardless of pictographic tailoring and patients with lower literacy skills may require more intensive or provider directed interventions.

Discussing the Effects of Poor Health Literacy on Patients Facing HIV: A Narrative Literature Review

“…93,94 Since healthcare professionals are usually perceived by patients with limited health literacy as the most trusted and reliable source of health information, provider-directed interventions are considered to be especially effective. 66 The same is true with regard to HIV-related illnesses, such as cervical cancer. 95 Therefore, the enhancement of health literacy is understood as a crucial strategy to improve the health, social, and economic outcomes of interventions aimed at addressing long-term conditions, including HIV.…”

“…Indeed, in a recent study aimed at examining the antiretroviral medication adherence of poor health literate individuals living with HIV, limited health literacy was found to be associated with greater illness severity and weak health conditions. 66 Kalichman and Rompa 67 formerly supported that health literacy performs as a significant predictor of well-being among people living with HIV. In fact, poor health literate patients affected by HIV infection are likely to demonstrate difficulty comprehending simple medical instructions and to access healthcare services.…”

“…In fact, poor health literate patients affected by HIV infection are likely to demonstrate difficulty comprehending simple medical instructions and to access healthcare services. Besides, they have been recently found to show deficient knowledge of their HIV-related health status, 68 low compliance with clinical prescription, 66 inadequate treatment awareness, 69 and poor medication adherence. 70 From this point of view, it is argued that people living with HIV and limited health literacy skills are expected to report lower health conditions as well as greater number of hospitalizations compared to their health literate counterparts.…”

“…81 On the other hand, patients with the lowest levels of health literacy are more likely to need informational assistance and external support to improve their adherence strategies. 66 From this point of view, adherence enhancement programs targeted to the specific characteristics of the least literate groups of people living with HIV are imperative to improve both medication adherence and health outcomes. 93,94 Since healthcare professionals are usually perceived by patients with limited health literacy as the most trusted and reliable source of health information, provider-directed interventions are considered to be especially effective.…”

Optimizing ART Adherence: Update for HIV Treatment and Prevention

“…We also included two recent studies from our group. The interventions reviewed ranged from individual counseling to text messaging to computerized self-administered approaches among various populations, such as youth [32, 33], newly released inmates [34], transgender women [35], and adults with low health literacy [36]. Among those interventions for adults, some had samples that were predominantly African American [32], except for two that were specifically developed for Hispanic and Latino individuals [37, 38].…”