Fran Lowry

June 07, 2013

Brief counseling sessions improve adherence to antiretroviral therapy for people with HIV who have limited health literacy, but they do nothing for those with especially poor understanding.

Dr. Seth Kalichman

"Poor health literacy skills are a significant barrier to HIV medication adherence, and interventions are definitely needed to assist these folks," Seth Kalichman, PhD, from the University of Connecticut at Storrs told Medscape Medical News.

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information. "For those with the lowest literacy, our take-home message is that interventions are going to have to be pretty intensive and likely for a longer duration than what we tried," he said at the 8th International Conference on HIV Treatment and Prevention Adherence in Miami, Florida.

Dr. Kalichman and his group have been studying health literacy as a barrier to medication adherence for several years. They began to notice that the research participants who had the most difficulty completing questionnaires and understanding the informed consent process were the same participants who were having a difficult time adhering to their medications.

In the current study, the researchers sought to determine the efficacy of a special antiretroviral adherence counseling program for 446 men and women with HIV and limited literacy.

All participants were older than age 18 years, were receiving antiretroviral therapy, and scored below 90% correct on a test of functional health literacy. They were divided into marginal- and lower-literacy groups and then randomly assigned to receive the adherence counseling or to general health improvement counseling.

Stick-to-It Program

The Stick-to-It program consisted of two 60-minute sessions and one 30-minute booster session, and it used a pictographic flip chart and personalized feedback customized for each participant.

"This was a counseling approach that was tailored to these people. They all had lower literacy skills, although some were much worse than others," Dr. Kalichman explained. "We tried to make the counseling as easy as possible, using pictographs and illustrations, and to make the concepts for the educational and skills training parts as basic as we could."

The participants were followed for 9 months, and their adherence to antiretrovirals was measured by unannounced pill counts and by reviewing their medical records for their HIV viral load.

The researchers found that 75% of the moderate-literacy group who were randomly assigned to receive the special counseling had undetectable viral loads at follow-up, compared with 57% of those with moderate literacy who were assigned to general health education counseling.

For patients who had the lowest literacy status, 65% of those randomly assigned to the special counseling achieved undetectable viral load, compared with 76% of those who were assigned to general health education counseling.

The control condition participants actually did better, and we don't know why at this point. Dr. Seth Kalichman

"The control condition participants actually did better, and we don't know why at this point," Dr. Kalichman said.

About 30% of the moderate- and low-health-literacy participants actually had very high adherence rates at study entry. But by the end of the 9 months, 50% of moderate-literacy participants who had been randomly assigned to the specialized counseling had very high adherence, compared with 40% of the low-literacy patients who did not get the specialized counseling.

"Just a few sessions of counseling really helped some of these patients with marginal literary skills, but we found no benefit in patients with the lowest literary skills," Dr. Kalichman reiterated.

His research team is now working on finding more effective ways to help low-literacy individuals improve their adherence to antiretrovirals.

"We want to work on an approach that might involve less counseling and more strategic use of tools, such as cell phone counseling. Some of our other studies show that these folks may really benefit from this. You can do a weekly counseling session over the phone, and it takes much less time," Dr. Kalichman said.

Text messaging is another promising option for low-health-literacy people with HIV, he suggested.

"It may seem counterintuitive to use text messaging in people with low literacy, but it is important to realize that the vast majority of these participants can read. They just don't read well."

Medscape Medical News asked Benjamin Young, MD, vice president and chief medical officer of the International Association of Providers of AIDS Care in Washington, DC, to comment on the study.

"Studies such as these highlight the importance of adherence to medications in HIV medicine. Part of the reason why this study is important is because there isn't much literature on what specific interventions work best to improve adherence," Dr. Young said.

The finding that people with very low health literacy have a different set of needs from those who have moderate health literacy educates us to be aware that one size does not fit all when it comes to behavioral interventions, added Dr. Young, who was not part of the study.

"The research from Dr. Kalichman and his group reminds us that individuals in the community are just that, they are individuals and we need to be aware that even if a person comes from the same community, he or she might benefit from a slightly different or entirely different intervention."

This study was funded by the National Institute of Mental Health and National Institute of Nursing Research. Dr. Kalichman has disclosed no relevant financial relationships. Dr. Young is an employee of the International Association of Providers of AIDS Care and reports financial relationships with Bristol-Myers Squibb, GlaxoSmithKline, Merck & Co, and ViiV Healthcare.

8th International Conference on HIV Treatment and Prevention Adherence. Abstract 28. Presented June 3, 2013.


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