Denise White

Association Between Health Literacy and HIV Treatment Adherence: Further Evidence from Objectively Measured Medication Adherence

Background. People with lower-health literacy are vulnerable to health problems. Studies that have examined the association between literacy and medication adherence have relied on self-reported adherence, which is subject to memory errors, perhaps even more so in people with poor literacy. Purpose. To examine the association between health literacy and objectively assessed HIV treatment adherence. Methods. Men and women (N = 145) receiving antiretroviral therapy completed a test of health literacy and measures of common adherence markers. Medication adherence was monitored by unannounced pill counts. Results. Median adherence was 71%; participants with lower-health literacy also demonstrated poorer adherence compared to participants with higher literacy. Hierarchical regression showed literacy predicted adherence over and above all other factors. Sensitivity tests showed the same results for 80% and 90% adherence. Conclusions. The association between literacy and adherence appears robust and was confirmed using an objective measure of medication adherence.

Adherence to antiretroviral therapy assessed by unannounced pill counts conducted by telephone.

BACKGROUNDUnannounced pill counts conducted in patients’ homes is a valid objective method for monitoring medication adherence that is unfortunately costly and often impractical. Conducting unannounced pill counts by telephone may be a viable alternative for objectively assessing medication adherence.PURPOSETo test an unannounced pill count assessment of adherence conducted by telephone.METHODSHIV-positive men and women (N = 77) in Atlanta GA completed an unannounced telephone-based pill count immediately followed by a pill count conducted in an unannounced home visit.RESULTSA high degree of concordance was observed between phone and home-based number of pills counted (Intraclass correlation, ICC = .997, 95% CI .995–.998, P < .001) and percent of pills taken (ICC = .990, 95% CI .986–.992, P < .001). Concordance between adherence above/below 90% and phone/home counts was 95%, Kappa coefficient = .995. Concordance between pill counts was not influenced by participant education or health literacy and was maintained when the data were censored to remove higher levels of adherence. Analyses of discordant pill counts found the most common source of error resulted from overcounted doses in pillboxes on the telephone.CONCLUSIONSUnannounced phone-based pill counts offer an economically and logistically feasible objective method for monitoring medication adherence.

Health and Treatment Implications of Food Insufficiency among People Living with HIV/AIDS, Atlanta, Georgia

HIV/AIDS is concentrated among the inner-city poor and poverty may directly interfere with HIV treatment. This study examined food insufficiency in relation to HIV-related health and treatment. A sample of 344 men and women living with HIV/AIDS in Atlanta, Georgia completed measures of food security, health, and HIV disease progression and treatment. HIV treatment adherence was monitored using unannounced pill counts. Results showed that half of people living with HIV/AIDS in this study lacked sufficient food, and food insufficiency was associated with multiple indicators of poor health, including higher HIV viral loads, lower CD4 cell counts, and poorer treatment adherence. Adjusted analyses showed that food insufficiency predicted HIV treatment non-adherence over and above years of education, employment status, income, housing, depression, social support, and non-alcohol substance use. Hunger and food insecurity are prevalent among people living with HIV/AIDS, and food insufficiency is closely related to multiple HIV-related health indicators, particularly medication adherence. Interventions that provide consistent and sustained meals to people living with HIV/AIDS are urgently needed.

The Role of Stigma and Medical Mistrust in the Routine Health Care Engagement of Black Men Who Have Sex With Men

UNLABELLED Objectives: We assessed how health care-related stigma, global medical mistrust, and personal trust in ones health care provider relate to engaging in medical care among Black men who have sex with men (MSM). METHODS In 2012, we surveyed 544 Black MSM attending a community event. We completed generalized linear modeling and mediation analyses in 2013. RESULTS Twenty-nine percent of participants reported experiencing racial and sexual orientation stigma from heath care providers and 48% reported mistrust of medical establishments. We found that, among HIV-negative Black MSM, those who experienced greater stigma and global medical mistrust had longer gaps in time since their last medical exam. Furthermore, global medical mistrust mediated the relationship between stigma and engagement in care. Among HIV-positive Black MSM, experiencing stigma from health care providers was associated with longer gaps in time since last HIV care appointment. CONCLUSIONS Interventions focusing on health care settings that support the development of greater awareness of stigma and mistrust are urgently needed. Failure to address psychosocial deterrents will stymie progress in biomedical prevention and cripple the ability to implement effective prevention and treatment strategies.

Integrated Behavioral Intervention to Improve HIV/AIDS Treatment Adherence and Reduce HIV Transmission

OBJECTIVES We conducted a randomized clinical trial to test an integrated behavioral intervention designed to enhance using HIV treatment as prevention by improving medication adherence, reducing risks for other sexually transmitted infections, and minimizing risk compensation beliefs. METHODS Individuals living with HIV/AIDS (n = 436) participated in a randomized clinical trial testing an intensive behavioral intervention aimed at reducing HIV transmission risks compared with an attention control condition. We used unannounced pill counts to monitor antiretroviral therapy adherence and computerized interviews to measure risk behaviors. RESULTS The integrated transmission risk reduction intervention demonstrated increased antiretroviral therapy adherence and less unprotected intercourse with nonseroconcordant partners at 3- and 6-month follow-ups as well as fewer new sexually transmitted infections diagnosed over the 9-month follow-up period (adjusted odds ratio = 3.0; P < .05; 95% confidence interval = 1.01, 9.04). The integrated intervention also reduced behavioral risk compensation beliefs. CONCLUSIONS A theory-based integrated behavioral intervention can improve HIV treatment adherence and reduce HIV transmission risks. HIV treatment as prevention should be bundled with behavioral interventions to maximize effectiveness.

Brief behavioral self-regulation counseling for HIV treatment adherence delivered by cell phone: an initial test of concept trial.

Affordable and effective antiretroviral therapy (ART) adherence interventions are needed for many patients to promote positive treatment outcomes and prevent viral resistance. We conducted a two-arm randomized trial (n = 40 men and women receiving and less than 95% adherent to ART) to test a single office session followed by four biweekly cell phone counseling sessions that were grounded in behavioral self-management model of medication adherence using data from phone-based unannounced pill counts to provide feedback-guided adherence strategies. The control condition received usual care and matched office and cell phone/pill count contacts. Participants were baseline assessed and followed with biweekly unannounced pill counts and 4-month from baseline computerized interviews (39/40 retained). Results showed that the self-regulation counseling delivered by cell phone demonstrated significant improvements in adherence compared to the control condition; adherence improved from 87% of pills taken at baseline to 94% adherence 4 months after baseline, p < 0.01. The observed effect sizes ranged from moderate (d = 0.45) to large (d = 0.80). Gains in adherence were paralleled with increased self-efficacy (p < 0.05) and use of behavioral strategies for ART adherence (p < 0.05). We conclude that the outcomes from this test of concept trial warrant further research on cell phone-delivered self-regulation counseling in a larger and more rigorous trial.

Prevalence and clinical implications of interactive toxicity beliefs regarding mixing alcohol and antiretroviral therapies among people living with HIV/AIDS.

Alcohol use is a barrier to medication adherence. Beyond the cognitive effects of intoxication, people living with HIV/AIDS who believe that alcohol should not be mixed with their medications may temporarily stop taking medications when drinking. To examine the effects of alcohol-treatment beliefs on HIV treatment adherence. People living with HIV/AIDS who were receiving treatment (n = 145) were recruited from community and clinical services during the period between January 2006 and May 2008 to complete measures of substance use and alcohol-antiretroviral (ARV) interactive toxicity beliefs (e.g., alcohol breaks down HIV medications so they will not work). Medication adherence was monitored using unannounced telephone-based pill counts. Forty percent of participants were currently using alcohol and nearly one in four drinkers reported stopping their medications when drinking. Beliefs that mixing alcohol and medications is toxic were common among drinkers and nondrinkers, with most beliefs endorsed more frequently by non-drinkers. Hierarchical regression analysis showed that stopping ARVs when drinking was associated with treatment nonadherence over and above quantity/frequency of alcohol use and problem drinking. Beliefs that alcohol and ARVs should not be mixed and that treatments should be interrupted when drinking are common among people living with HIV/AIDS. Clinicians should educate patients about the necessity of continuing to take ARV medications without interruption even if they are drinking alcohol.

Alcohol and adherence to antiretroviral medications: interactive toxicity beliefs among people living with HIV.

&NA; When taken without interruption, antiretroviral therapies (ART) effectively treat HIV infection. Alcohol is a well‐known direct and indirect influence on ART adherence. Believing that drinking is harmful while taking ART (interactive toxicity beliefs) is also associated with poor adherence. The current study included 333 people living with HIV who were taking ART and actively using alcohol. Participants were recruited from health care providers and social services in a major southern U.S. city. Results showed that 52% of persons found non‐adherent to ART stated that they stopped taking their medications when they were drinking. Multivariate analyses showed that interrupting treatment when drinking was related to current non‐adherence, over and above several common correlates of non‐adherence including frequency of alcohol use itself. These results confirm and extend past research, indicating an urgent need for medication adherence interventions designed for people living with HIV who drink.

Beliefs About Treatments for HIV/AIDS and Sexual Risk Behaviors Among Men Who have Sex with Men, 1997–2006

Beliefs that HIV treatments reduce HIV transmission risks are related to increases in sexual risk behaviors, particularly unprotected anal intercourse among men who have sex with men (MSM). Changes in unprotected anal intercourse and prevention-related treatment beliefs were recently reported for surveys of mostly white gay men collected in 1997 and 2005. The current study extends this previous research by replicating the observed changes in behaviors and beliefs in anonymous community surveys collected in 2006. Results indicated clear and consistent increases in beliefs that HIV treatments reduce HIV transmission risks and increases in unprotected anal intercourse. These changes were observed for both HIV positive and non-HIV positive men. African American men endorsed the belief that HIV treatments protect against HIV transmission to a greater degree than White men. Results show that HIV prevention messages need to be updated to educate MSM about the realities of HIV viral concentrations and HIV transmission risks.

Psychosocial factors related to willingness to use pre-exposure prophylaxis for HIV prevention among Black men who have sex with men attending a community event

UNLABELLED Objectives In the US, Black men who have sex with men (BMSM) are disproportionately affected by HIV/AIDS. Pre-exposure prophylaxis (PrEP) holds tremendous promise for curbing the HIV/AIDS epidemic among these men. However, many psychosocial components must be addressed in order to implement this prevention tool effectively among BMSM. METHODS We assessed PrEP knowledge and use, health care access experiences, race-based medical mistrust, sexual partners and behaviours, and drug and alcohol use among 699 men attending a community event in the south-eastern United States. We used generalised linear modelling to assess factors associated with their willingness to use PrEP. RESULTS Three hundred and ninety-eight men reported being BMSM and having HIV-negative status. Among these men, 60% reported being willing to use PrEP. Lack of being comfortable with talking to a health care provider about having sex with men, not having discussed having sex with a man with a health care provider, race-based medical mistrust, and alcohol consumption and substance use were all identified as barriers to willingness to use PrEP. Sexual risk-taking, number of sex partners and STI diagnosis were not associated with willingness to use PrEP. CONCLUSIONS Findings from the current paper demonstrate the importance of acknowledging the role of various psychosocial factors in the uptake of PrEP. It is imperative that we prioritise research into understanding these barriers better, as the failure to do so will impede the tremendous potential of this prevention technology.