Howard Pope

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.

Internet-based health information consumer skills intervention for people living with HIV/AIDS.

Medical information can improve health, and there is an enormous amount of health information available on the Internet. A randomized clinical trial tested the effectiveness of an intervention based on social- cognitive theory to improve information use among people living with HIV/AIDS. Men and women (N = 448) were placed in either (a) an 8-session intervention that focused on Internet information consumer skills or (b) a time-matched support group and were followed to 9 months postintervention. The Internet skills group demonstrated greater Internet use for health, information coping, and social support compared with the control group. The authors conclude that people with HIV infection may benefit from increased access to health information on the Internet and that vulnerability to misinformation and fraud can be reduced through behavioral interventions.

Monitoring Medication Adherence by Unannounced Pill Counts Conducted by Telephone: Reliability and Criterion-Related Validity

Abstract Background: Although demonstrated valid for monitoring medication adherence, unannounced pill counts conducted in patients’ homes are costly and logistically challenging. Telephone-based unannounced pill counts offer a promising adaptation that resolves most of the limitations of home-based pill counting. Purpose: We tested the reliability and criterion-related validity of a telephone-based unannounced pill count assessment of antiretroviral adherence. Method: HIV-positive men and women (N = 89) in Atlanta, Georgia, completed a telephone-based unannounced pill count and provided contemporaneous blood specimens to obtain viral loads; 68 participants also received an immediate second pill count conducted during an unannounced home visit. Results: A high degree of concordance was observed between the number of pills counted on the telephone and in the home (intraclass correlation [ICC] = .981, p < .001) and percent of pills taken (ICC = .987, p < .001). Adherence obtained by the telephone count and home count reached 92% agreement (Kappa coefficient = .94). Adherence determined by telephone-based pill counts also corresponded with patient viral load, providing evidence for criterion-related validity. Conclusion: Unannounced telephone-based pill counts offer a feasible objective method for monitoring medication adherence.

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.

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.

Health information on the Internet and people living with HIV/AIDS: information evaluation and coping styles.

Individuals who seek information on the Internet to cope with chronic illness may be vulnerable to misinformation and unfounded claims. This study examined the association between health-related coping and the evaluation of health information. Men (n = 347) and women (n = 72) who were living with HIV/AIDS and reported currently using the Internet completed measures assessing their Internet use. Health Web sites downloaded from the Internet were also rated for quality of information. HIV-positive adults commonly used the Internet to find health information (66%) and to learn about clinical trials (25%); they also talked to their physicians about information found online (24%). In a multivariate analysis, assigning higher credibility to unfounded Internet information was predicted by lower incomes, less education, and avoidant coping styles. People who cope by avoiding health information may be vulnerable to misinformation and unfounded claims that are commonly encountered on the Internet.

Examining Factors Co-Existing with Interpersonal Violence in Lesbian Relationships

Interpersonal violence within lesbian relationships is a significant yet understudied problem. Women attending a gay pride festival in Atlanta, GA, were asked to complete a survey concerning same-sex interpersonal violence. Women who reported being in a current or previous same-sex partner relationship were included in the analyses (N = 226). Factors that occurred in the context of interpersonal violence were investigated: substance use, HIV/STI risk behaviors, barriers to reporting abuse, and attitudes inhibiting seeking of social support. In addition, the survey assessed relationship-related power dynamics. Results of multivariate analyses support the hypotheses that power imbalance and inequality when making sex-related decisions within women’s same-sex relationships are associated with interpersonal violence. Further findings suggested that a combination of factors must be considered when dealing with and reducing the risk for violence in same-sex relationships.

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.