Monitoring medication adherence by unannounced pill counts conducted by telephone: reliability and criterion-related validity

Optimal Treatment Adherence Counseling Outcomes for People Living with HIV and Limited Health Literacy

Limited health literacy has been shown to contribute to poor adherence to antiretroviral therapy (ART) in people living with HIV/AIDS. Given the mixed results of previous interventions for people with HIV and low health literacy, investigating possible targets for improved adherence is warranted. The present study aims to identify the correlates of optimal and suboptimal outcomes among participants of a recent skills-based medication adherence intervention. This secondary analysis included 188 men and women living with HIV who had low health literacy and who had complete viral load data. Adherence was assessed by unannounced pill count and follow-up viral loads were assessed by blood draw. Results showed that higher levels of health literacy and lower levels of alcohol use were the strongest predictors of achieving HIV viral load optimal outcomes. The interplay between lower health literacy and alcohol use on adherence should be the focus of future research.

Medication beliefs and structural barriers to treatment adherence among people living with HIV infection

BACKGROUND

People living in poverty face multiple structural challenges to medication adherence including lack of transportation, inadequate housing and food insecurity. The degree to which individuals' motivations to remain adherent may overcome structural barriers has received limited attention.

PURPOSE

To examine whether medication necessity and concerns beliefs predict antiretroviral therapy (ART) adherence over and above structural adherence barriers associated with poverty.

METHODS

People living with HIV in a southern US city (N = 942) completed computerised interviews, an objective measure of adherence and HIV viral suppression obtained from medical records. Hierarchical logistic regression models were constructed to examine demographic and illness characteristics, structural barriers, mental health, substance use and medication necessity and concerns beliefs as predictors of ART adherence.

RESULTS

In multivariable models, current drug use and medication necessity and concerns beliefs predicted treatment adherence over and above demographic, health, mental health and structural factors.

CONCLUSIONS

Medication beliefs are proximal and powerful motivating factors that predict adherence. Adherence interventions should directly address medication beliefs in developing strategies to manage barriers facing people with HIV living in poverty.

Impact of combination antiretroviral therapy initiation on adherence to antituberculosis treatment

Background

Healthcare workers are often reluctant to start combination antiretroviral therapy (ART) in patients receiving tuberculosis (TB) treatment because of the fear of high pill burden, immune reconstitution inflammatory syndrome, and side-effects.

Object

To quantify changes in adherence to tuberculosis treatment following ART initiation.

Design

A prospective observational cohort study of ART-naïve individuals with baseline CD4 count between 50 cells/mm³ and 350 cells/mm³ at start of TB treatment at a primary care clinic in Johannesburg, South Africa. Adherence to TB treatment was measured by pill count, self-report, and electronic Medication Event Monitoring System (eMEMS) before and after initiation of ART.

Results

ART tended to negatively affect adherence to TB treatment, with an 8% - 10% decrease in the proportion of patients adherent according to pill count and an 18% - 22% decrease in the proportion of patients adherent according to eMEMS in the first month following ART initiation, independent of the cut-off used to define adherence (90%, 95% or 100%). Reasons for non-adherence were multifactorial, and employment was the only predictor for optimal adherence (adjusted odds ratio 4.11, 95% confidence interval 1.06-16.0).

Conclusion

Adherence support in the period immediately following ART initiation could optimise treatment outcomes for people living with TB and HIV.

The Promises and Challenges of Ecological Momentary Assessment in Schizophrenia: Development of an Initial Experimental Protocol

Severe mental illnesses, including schizophrenia and other psychotic-spectrum disorders, are a major cause of disability worldwide. Although efficacious pharmacological and psychosocial interventions have been developed for treating patients with schizophrenia, relapse rates are high and long-term recovery remains elusive for many individuals. Furthermore, little is still known about the underlying mechanisms of these illnesses. Thus, there is an urgent need to better understand the contextual factors that contribute to psychosis so that they can be better targeted in future interventions. Ecological Momentary Assessment (EMA) is a dynamic procedure that permits the measurement of variables in natural settings in real-time through the use of brief assessments delivered via mobile electronic devices (i.e., smart phones). One advantage of EMA is that it is less subject to retrospective memory biases and highly sensitive to fluctuating environmental factors. In the current article, we describe the research-to-date using EMA to better understand fluctuating symptoms and functioning in patients with schizophrenia and other psychotic disorders and potential applications to treatment. In addition, we describe a novel EMA protocol that we have been employing to study the outcomes of patients with schizophrenia following a hospital discharge. We also report the lessons we have learned thus far using EMA methods in this challenging clinical population.

HIV sexual transmission risks in the context of clinical care: a prospective study of behavioural correlates of HIV suppression in a community sample, Atlanta, GA, USA

Introduction

Antiretroviral therapy (ART) improves the health of people living with HIV and has the potential to reduce HIV infectiousness, thereby preventing HIV transmission. However, the success of ART for HIV prevention hinges on sustained ART adherence and avoiding sexually transmitted infections (STI).

Objectives

To determine the sexual behaviours and HIV transmission risks of individuals with suppressed and unsuppressed HIV replication (i.e., viral load).

Methods

Assessed HIV sexual transmission risks among individuals with clinically determined suppressed and unsuppressed HIV. Participants were 760 men and 280 women living with HIV in Atlanta, GA, USA, who completed behavioural assessments, 28-daily prospective sexual behaviour diaries, one-month prospective unannounced pill counts for ART adherence, urine screening for illicit drug use and medical record chart abstraction for HIV viral load.

Results

Individuals with unsuppressed HIV demonstrated a constellation of behavioural risks for transmitting HIV to uninfected sex partners that included symptoms of STI and substance use. In addition, 15% of participants with suppressed HIV had recent STI symptoms/diagnoses, indicating significant risks for sexual infectiousness despite their HIV suppression in blood plasma. Overall, 38% of participants were at risk for elevated sexual infectiousness and just as many engaged in unprotected sexual intercourse with non-HIV-infected partners.

Conclusions

Implementation strategies for using HIV treatments as HIV prevention requires enhanced behavioural interventions that extend beyond ART to address substance use and sexual health that will otherwise undermine the potential preventive impact of early ART.

Food insecurity and antiretroviral adherence among HIV positive adults who drink alcohol

Food insecurity is associated with HIV treatment non-adherence and poor health outcomes for people living with HIV/AIDS. Given the poor nutritional status common to people who drink alcohol, food insecurity may be particularly problematic for HIV positive individuals who drink alcohol. To examine food insecurity among HIV positive men and women who drink alcohol and its association with antiretroviral therapy (ART) adherence, health outcomes and health service utilization. Adults living with HIV (N = 183) in Atlanta, Georgia who reported alcohol use in the previous week and were receiving ART participated in a 12-month cohort. Participants were recruited from infectious disease clinics and social services to complete computerized interviews, monthly-unannounced pill counts to monitor ART adherence, and daily cell-phone delivered interactive-text assessments for alcohol use. Forty-three percent of participants experienced food insecurity during at least one month of the study period. Food insecurity was independently associated with suboptimal ART adherence and less suppressed HIV viral load over. Individuals who experienced food insecurity also had histories of more medical and psychiatric hospitalizations, and greater mental health problems. Food insecurity is prevalent among alcohol using people receiving ART and food insecurity is associated with treatment non-adherence, poor health outcomes, and increased medical and psychiatric hospitalizations.

Viral suppression and antiretroviral medication adherence among alcohol using HIV-positive adults

BACKGROUND

Substance use is a known predictor of poor adherence to antiretroviral therapies (ART) in people living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome. Less studied is the association between substance use and treatment outcomes, namely, suppression of HIV replication.

METHODS

Adults living with HIV (N = 183) who reported alcohol use in the previous week and receiving ART were observed over a 12-month period. Participants completed computer interviews, monthly unannounced pill counts to monitor ART adherence, and daily cell-phone delivered interactive-text assessments for alcohol use. HIV viral load was collected at baseline and 12-month follow-up from medical records. Analyses compared participants who had undetectable HIV viral loads at baseline and follow-up (sustained viral suppression) to those with unsustained viral suppression. Analyses also compared participants who were adherent to their medications (>85 % pills taken) over the year of observation to those who were nonadherent.

RESULTS

Fifty-two percent of participants had unsustained viral suppression; 47 % were ART nonadherent. Overall results failed to demonstrate alcohol use as a correlate of sustained viral suppression or treatment adherence. However, alcohol use was associated with nonadherence among participants who did not have sustained viral suppression; nonadherence in unsustained viral suppression patients was related to drinking on fewer days of assessment, missing medications when drinking, and drinking socially.

CONCLUSIONS

Poor HIV treatment outcomes and nonadherence were prevalent among adults treated for HIV infection who drink alcohol. Drinking in relation to missed medications and drinking in social settings are targets for interventions among alcohol drinkers at greatest risk for poor treatment outcomes.

Medication adherence in people dually treated for HIV infection and mental health conditions: test of the medications beliefs framework

Beliefs about medication necessity and concerns predict treatment adherence in people with a wide-array of medical conditions, including HIV infection. However, medication beliefs have not been examined in people dually treated with psychotropic medications and antiretroviral therapy. In the current study, we used a prospective design to investigate the factors associated with adherence to psychotropic medications and antiretrovirals among 123 dually treated persons living with HIV. We used unannounced phone-based pill counts to monitor adherence to psychiatric and antiretroviral medications over a 6-week period. Hierarchical regression models included demographic, health and psychosocial characteristics as predictors of adherence followed by medication necessity and concerns beliefs. Results showed that medication necessity beliefs predicted both antiretroviral and psychiatric medication adherence over and above established predictors of adherence. Medication concerns also predicted psychotropic adherence, but not antiretroviral adherence. These models accounted for 31 and 22 % of the variance in antiretroviral and psychotropic adherence, respectively. Findings suggest that the necessity-concerns medication beliefs framework has utility in understanding adherence to multiple medications and addressing these beliefs should be integrated into adherence interventions.

Health behavior predictors of medication adherence among low health literacy people living with HIV/AIDS

One particularly vulnerable population for HIV treatment non-adherence is persons with poor health literacy skills. For these individuals, it is important to simplify medication taking as much as possible by integrating medication adherence into other routine health behaviors. This study aims to ascertain the relationship between medication adherence and other health behaviors. Adults living with HIV (N = 422) completed intake measures and 3 months of unannounced pill counts. Endorsement of diet and exercise behaviors at intake predicted higher medication adherence, over and above other known predictors of medication adherence such as HIV symptoms, depression, social support, and stress. These results support integrating strategies for medication management into a constellation of routine health practices.

Medication Adherence and Health Outcomes of People Living with HIV Who Are Food Insecure and Prescribed Antiretrovirals That Should Be Taken with Food

INTRODUCTION

Food insecurity is a well-established predictor of poor health outcomes. Antiretroviral therapies (ARTs) that should be taken with food to increase bioavailability may further challenge food insecure patients. This study examined factors associated with antiretroviral adherence and HIV viral suppression among people living with HIV who are food insecure and prescribed medications that require food.

METHODS

A community sample of 313 men and 105 women who experienced food insecurity in the previous month and were currently taking ART completed computerized interviews, urine screening for drug use, prospective biweekly unannounced pill count adherence assessments, and obtained their HIV viral load and CD4 cell counts from medical records.

RESULTS

Individuals taking ART regimens that should be taken with food were significantly more likely to be unemployed, were living longer with an HIV diagnosis, had lower CD4 cell counts, poorer HIV suppression, and endorsed more beliefs that taking medications was necessary for their health. Multivariable regression models controlling for potential confounding factors showed that receiving ART that requires food was significantly related to poorer ART adherence and unsuppressed HIV in this food insecure sample.

CONCLUSION

People living with HIV who are food insecure likely experience multiple facets of poverty that challenge their medication adherence, but food insecurity is the only such factor that is directly related to the pharmacokinetics of some antiretroviral medications. Achieving optimal treatment outcomes for HIV infection will require routine assessment of access to food when determining patient-tailored ART regimens.

Reliability and validity of a single-item rating scale to monitor medication adherence for people living with HIV and lower health literacy

BACKGROUND

Monitoring medication adherence in clinical and research settings may be especially challenging for people with lower literacy skills.

OBJECTIVE

The current study examined the measurement properties of a single-item rating scale (SIRS) for assessing medication adherence in a sample of 468 people living with HIV and lower health literacy skills.

METHODS

Participants completed two versions (computerized and telephone interview) of an SIRS as well as unannounced monthly pill counts. We also collected measures of common correlates of adherence and obtained participants' HIV RNA viral load from medical records.

RESULTS

Results indicated that the SIRS is time stable over one month (r = 0.46 to 0.52). There was limited evidence for modality effects between the computerized and phone administered SIRS. Associations with unannounced pill counts demonstrated concurrent and predictive validity of the SIRS, and criterion-related validity by associations with viral load. However, the SIRS also demonstrated inflated adherence estimates relative to unannounced pill counts and these discrepancies were greatest for persons of lower income and who reported alcohol use.

CONCLUSIONS

A simple SIRS to monitor medication adherence may therefore be reliable and valid for use with people challenged by lower literacy skills in both clinical and research settings.

Continued Substance Use Among People Living With HIV-Hepatitis-C Co-Infection and Receiving Antiretroviral Therapy

BACKGROUND

Co-infection with human immunodeficiency virus (HIV) and Hepatitis-C virus (HCV) poses a significant threat to personal and public health. Substance use among co-infected persons leads to increased morbidity and mortality. The purpose of this study is to examine the continued substance use of people living with HIV-HCV co-infection and receiving antiretroviral therapy (ART).

METHODS

Individuals living with HIV infection in Atlanta, GA and currently receiving ART (N = 678) completed audio-computer-assisted self-interviews for demographic, health, and behavior characteristics; unannounced pill counts to assess ART adherence over one month; finger-stick blood specimens collected for HCV antibody testing and urine specimens for drug use screening; and obtained HIV viral load and CD4 cell counts from their medical provider. We performed cross-sectional analyses for behavioral and biological markers of health, health behaviors, and substance use.

RESULTS

Among participants, 131 (19%) were HIV-HCV co-infected; 53% were HIV-mono-infected, and 60% of HIV-HCV co-infected participants tested positive for use of at least one non-alcohol drug: tetrahydrocannabinol (THC) and cocaine were most prevalent. HIV-HCV co-infected individuals were older, with no other significant differences. Within the HIV-HCV co-infected participants, drug users (N = 87) did not differ from non-drug users (N = 53) in terms of ART adherence. However, drug users were significantly more likely to have uncontrolled HIV (17%) compared with those who did not test drug positive (4%).

CONCLUSIONS

Substance use is prevalent in persons with HIV-HCV co-infection and may interfere with ART. Research with a larger and more representative sample is needed to replicate and confirm these results.

Synergistic effects of food insecurity and drug use on medication adherence among people living with HIV infection

Food insecurity and drug use are closely connected in the context of poverty, and both have been suggested to interfere with HIV medication adherence among people living with HIV/AIDS (PLWH). Yet the potential interaction between the two factors on adherence has not been examined. For this study we collected longitudinal data on HIV medication adherence among PLWH in Atlanta, GA, to assess a possible synergistic effect between the two factors on HIV medication adherence. People informed about the study came to the research site and completed an audio computer-assisted self-interview and instructions for pill counting. Over the next 5 weeks participants received three unscheduled follow-up phone assessments conducted 2 weeks apart to collect pill counts of their HIV medication. The prevalence of food insecurity was 60 % (488) and that of drug use was 33 % (274) in the sample of 809 participants. Among 770 participants who completed follow-up phone assessments, both food insecurity and drug use were associated with HIV medication adherence after adjusting for socio-demographic characteristics. The negative association between drug use and adherence persisted after further adjusting for health-related characteristics. Moreover, drug use appeared to moderate the effect of food insufficiency on adherence, with drug users who were food insufficient being the least likely to achieve 85 % adherence. Results from the current study demonstrate a synergism between food insecurity and drug use that may impede adherence among PLWH. The findings imply that the disruptive effects of food insecurity and drug use on adherence are likely to be intensified with the presence of each other, and encourage interventions to address the problem of HIV medication adherence from a multi-faceted perspective that takes into account detrimental combination of problem factors.

Cognitive and field testing of a new set of medication adherence self-report items for HIV care

We conducted four rounds of cognitive testing of self-report items that included 66 sociodemographically diverse participants, then field tested the three best items from the cognitive testing in a clinic waiting room (N = 351) and in an online social networking site for men who have sex with men (N = 6,485). As part of the online survey we conducted a randomized assessment of two versions of the adherence questionnaire—one which asked about adherence to a specific antiretroviral medication, and a second which asked about adherence to their “HIV medicines” as a group. Participants were better able to respond using adjectival and adverbial scales than visual analogue or percent items. The internal consistency reliability of the three item adherence scale was 0.89. Mean scores for the two different versions of the online survey were similar (91.0 vs. 90.2, p < 0.05), suggesting that it is not necessary, in general, to ask about individual medications in an antiretroviral therapy regimen when attempting to describe overall adherence.

Unannounced telephone-based pill counts: a valid and feasible method for monitoring adherence

Phone-based unannounced pill counts to measure medication adherence are much more practical and less expensive than home-based unannounced pill counts, but their validity has not been widely assessed. We examined the validity of phone versus home-based pill counts using a simplified protocol streamlined for studies embedded in clinical care settings. A total of 100 paired counts were used to compare concordance between unannounced phone and home-based pill counts using interclass correlations. Discrepancy analyses using χ(2) tests compared demographic and clinical characteristics across patients who were concordant between phone and home-based pill counts and patients who were not concordant. Concordance was high for phone-based and home-based unannounced total pill counts, as well as individual medication counts and calculated adherence. This study demonstrates that a simplified phone-based pill count protocol can be implemented among patients from a routine clinical care setting and is a feasible means of monitoring medication adherence.

Treatment outcomes among people living with HIV who are food insecure and prescribed antiretrovirals taken with food

BACKGROUND

Food insecurity is a known barrier to medication adherence among people living with HIV. Antiretroviral therapies (ART) that require food likely pose added challenges to patients who do not have reliable access to food. This study examines the health implications of prescribing ART that requires food to patients who are food insecure.

METHOD

A community sample of 538 men and 221 women currently taking ART to treat their HIV infection completed computerized interviews, biweekly unannounced pill count adherence assessments, and obtained their HIV RNA (viral load) and CD4 cell count from medical records.

RESULTS

Sixty-three percent of participants experienced at least 1 indicator of food insecurity during the previous month, of which 274 (57%) were prescribed an ART regimen that requires food. Among participants who were food insecure, individuals taking ART requiring food indicated significantly greater HIV symptoms, had lower CD4 cell counts, and poorer HIV suppression. For participants who were food secure, those taking ART that requires food were significantly less adherent than those whose ART regimen does not require food.

CONCLUSIONS

People living with HIV who experience food insecurity are significantly more likely to be prescribed ART regimens that require food and experience poorer treatment outcomes. Determination of optimal ART regimens should take patient access to food into account and treatment guidelines should explicitly highlight the importance of food access in selecting ART regimens.

Elevated urinary leukocyte esterase as a potential surrogate marker for HIV sexual transmission risks in men receiving antiretroviral therapy

Local genital tract inflammation stimulates leukocyte activity and causes HIV shedding, potentially increasing HIV sexual infectiousness. Although there are available clinical markers for genital tract inflammation, such as urinary leukocyte esterase, none have yet been examined in relation to HIV sexual risk behaviours. We sought to examine the association between urinary leukocyte esterase and sexual practices. Sexually active men living with HIV and receiving antiretroviral therapy (ART, N = 290) provided urine specimens and completed behavioural health assessments. HIV RNA tests and CD4 cell counts were abstracted from medical records. Urine specimens were analysed for leukocyte esterase using a standard point-of-care dipstick test. Thirty-one (10.6%) participants tested positive for leukocyte esterase. Logistic regression models did not indicate differences between men with elevated and un-elevated leukocyte activity on demographic, health, recent sexually transmitted infection symptoms and diagnoses or substance use. However, men with elevated leukocyte activity indicated significantly greater sexual behaviour in the previous three months, including more recent unprotected sexual intercourse. A simple over-the-counter urine test may serve as an indicator of sexual HIV infectiousness to inform further evaluation and treatment of genital tract inflammation, as well as condom use decisions during times of increased genital tract inflammation.

The use of pill counts as a facilitator of adherence with antiretroviral therapy in resource limited settings

BACKGROUND

Pill counts are often used to measure adherence to ART, but there is little data on how they affect adherence. We previously showed a bivariate relationship between clinicians counting pills and adherence in patients receiving HIV care in Kenya. We present a secondary analysis of the relationship between numbers of pill counts and clinical outcomes in resource limited settings.

METHODS

Patients initiating ART at Kijabe Hospital were monitored for the number of discretionary pill counts performed by their clinician in the first 6 months of ART. Subjects were followed for at least 1 year after enrollment. The number of clinician pill counts was correlated to ART adherence. The primary endpoints were time to treatment failure, defined as a detectable HIV-1 viral load, death; or loss to follow-up.

RESULTS

Clinician pill counts were done at 68% of clinic visits for 304 subjects. There was a positive correlation between the number of clinician pill counts and ART adherence (r = 0.21, p <0.001). Patients were divided into 3 groups (0 counts, 1 to 3 counts, 4 to 7 counts) and exhibited adherence of 76%, 84%, and 92%, respectively (p = 0.004). Time to treatment failure for these groups was 220 days, 438 days, and 497 days (P<0.01), respectively. Time to virologic failure in living patients remaining in the cohort was longer in those with more pill count (P =0.02). Multi-variate analysis adjusting for co-variates affecting time to treatment failure found that that clinician pill counts were associated with a decreased risk of treatment failure (HR = 0.69, p =0.04).

CONCLUSIONS

The number of clinician pill count performed was independently associated with better adherence and a decreased risk of treatment failure. The use of clinician pill counts should be further studied as an adherence promoter through a randomized clinical trial.

Assessing adherence to antiretroviral therapy in randomized HIV clinical trials: a review of currently used methods

Antiretroviral therapy for the treatment of HIV infection requires high levels of adherence to both maintain plasma HIV RNA at undetectable levels and prevent the emergence of drug resistance. As adherence to treatment is a major criterion for the evaluation of therapeutic outcomes, randomized clinical trials (RCTs) conducted among HIV-infected patients commonly include an assessment of adherence. However, there is still no gold-standard tool for assessing adherence behaviors in HIV RCTs. The methods currently used to collect and analyze adherence data are varied, which makes the comparison of results between studies difficult. The scope of this article is to review and discuss the range of adherence measures currently used in RCTs conducted among HIV-infected adults.

Randomized clinical trial of HIV treatment adherence counseling interventions for people living with HIV and limited health literacy

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 (N = 446) who scored <90% correct on a test of functional health literacy were partitioned into marginal and lower literacy groups and randomly allocated to 1 of 3 adherence-counseling conditions: (1) pictograph-guided adherence counseling, (2) standard adherence counseling, or (3) general health improvement counseling. Participants were followed for 9 months postintervention with unannounced pill count adherence and blood plasma viral load as primary end points.

RESULTS

Preliminary analyses demonstrated the integrity of the trial and >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 with 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 with the 2 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.

Requesting help to understand medical information among people living with HIV and poor health literacy

Health literacy is known to influence medication adherence among people living with HIV/AIDS. People who experience difficulty reading health information may benefit from asking others to assist them with reading, interpreting, and understanding medical information. We examined medical chart-abstracted HIV viral load, medication adherence assessed by unannounced pill counts, and adherence improvement strategies among 245 individuals with lower-health literacy who do not request assistance, and 229 who do request assistance with reading and understanding health information. Participants were people living with HIV who were taking antiretroviral therapy and scored below 90% correct on a standardized test of functional health literacy. After controlling for health literacy scores, requesting informational assistance was associated with strategies used to improve adherence; individuals who asked for assistance were significantly more likely to use multiple adherence strategies. However, despite requesting informational assistance and using more adherence strategies, participants who requested informational assistance evidenced poorer treatment adherence and poorer suppression of HIV replication. Requesting assistance was more common among those with the poorest health literacy and therefore greatest challenges to adherence. People living with HIV who have poor health literacy skills may benefit from medication adherence programs and requests for assistance afford opportunities for social interventions.

Intentional non-adherence to medications among HIV positive alcohol drinkers: prospective study of interactive toxicity beliefs

BACKGROUND

Antiretroviral therapy (ART) adherence is key to successful treatment of HIV infection and alcohol is a known barrier to adherence. Beyond intoxication, ART adherence is impacted by beliefs that mixing alcohol and medications is toxic.

PURPOSE

To examine prospective relationships of factors contributing to intentional medication non-adherence when drinking.

METHODS

People who both receive ART and drink alcohol (N = 178) were enrolled in a 12-month prospective cohort study that monitored beliefs about the hazards of mixing ART with alcohol (interactive toxicity beliefs), alcohol consumption using electronic daily diaries, ART adherence assessed by both unannounced pill counts and self-report, and chart-abstracted HIV viral load.

RESULTS

Participants who reported skipping or stopping their ART when drinking (N = 90, 51 %) demonstrated significantly poorer ART adherence, were less likely to be viral suppressed, and more likely to have CD4 counts under 200/cc(3). Day-level analyses showed that participants who endorsed interactive toxicity beliefs were significantly more likely to miss medications on drinking days.

CONCLUSIONS

Confirming earlier cross-sectional studies, the current findings from a prospective cohort show that a substantial number of people intentionally skip or stop their medications when drinking. Interventions are needed to correct alcohol-related interactive toxicity misinformation and promote adherence among alcohol drinkers.

Motivational Enhancement System for Adherence (MESA): pilot randomized trial of a brief computer-delivered prevention intervention for youth initiating antiretroviral treatment

OBJECTIVE

To pilot test a two-session computer-delivered motivational intervention to facilitate adherence among youth with HIV newly prescribed antiretroviral treatment (ART).

METHODS

Youth (N = 76) newly prescribed ART were recruited from 8 sites, and were randomized to the intervention or an active nutrition and physical activity control. Primary outcomes were HIV-1 viral load at baseline, 3 months, and 6 months, and self-reported adherence at 3 and 6 months.

RESULTS

Satisfaction ratings were high. Effect sizes suggested that the intervention group showed a greater drop than controls in viral load from baseline to 6 months (Cohen's d = 0.39 at 3 months; d = 0.19 at 6 months), and had greater percent undetectable by 6 months (d = 0.28). Effects sizes were medium to large for 7-day and weekend adherence.

CONCLUSIONS

A brief computer-delivered motivational intervention showed promise for youth starting ART and is ready to be tested in a full-scale clinical trial.

Assumed infectiousness, treatment adherence and sexual behaviours: applying the Swiss Statement on infectiousness to HIV-positive alcohol drinkers

OBJECTIVES

The success of antiretroviral therapy (ART) for treating HIV infection is now being turned towards HIV prevention. The Swiss Federal Commission for HIV/AIDS has declared that HIV-positive persons who are treated with ART, have an undetectable viral load, and are free of co-occurring sexually transmitted infections (STIs) should be considered noninfectious for sexual transmission of HIV. This study examined the implications of these assumptions in a sample of HIV-positive individuals who drink alcohol.

METHODS

People living with HIV/AIDS (n = 228) were recruited through community sampling. They completed confidential computerized interviews and underwent monthly unannounced pill counts for ART adherence. HIV viral loads were obtained from medical records.

RESULTS

One hundred and eighty-five HIV-positive drinkers were currently receiving ART and 43 were untreated. Among those receiving ART, one in three were not virally suppressed and one in five had recently been diagnosed with an STI. Adherence was generally suboptimal, including among those assumed to be less infectious. As many as one in four participants reported engaging in unprotected intercourse with an HIV-uninfected partner in the past 4 months. There were few associations between assumed infectiousness and sexual practices.

CONCLUSIONS

Less than half of people who drank alcohol and took ART met the Swiss criteria for noninfectiousness. Poor adherence and prevalent STI threaten the long-term potential of using ART for prevention. In the absence of behavioral interventions, the realities of substance use and other barriers call into question the use of ART as prevention among alcohol drinkers.

Benefits of adherence to psychotropic medications on depressive symptoms and antiretroviral medication adherence among men and women living with HIV/AIDS

BACKGROUND

Psychotropic medications are commonly used for depressive symptoms among people living with HIV/AIDS.

PURPOSE

We examined the relationships between adherence to psychotropic medications, depressive symptoms, and antiretroviral adherence.

METHODS

We assessed depressive symptoms among 324 people living with HIV/AIDS across a 3-month period (70% men; mean age 45 years; 90% African-American). Psychotropic and antiretroviral adherence was assessed using monthly, unannounced telephone pill counts. Multiple-regression and mediation analyses were utilized to examine associations under investigation.

RESULTS

Greater depressive symptoms were associated with lower antiretroviral and psychotropic medication adherence. Greater adherence to psychotropic medications regardless of medication class was positively related to higher antiretroviral adherence. Greater adherence to psychotropic medications also significantly mediated the association between depressive symptoms and antiretroviral adherence.

CONCLUSIONS

This study demonstrates the benefits of adherence to psychotropic medications on both depressive symptoms and antiretroviral adherence. Future work examining psychotropic medication adherence on disease outcomes in people living with HIV/AIDS is warranted.

Adherence to varenicline among African American smokers: an exploratory analysis comparing plasma concentration, pill count, and self-report

INTRODUCTION

Measuring adherence to smoking cessation pharmacotherapy is important to evaluating its effectiveness. Blood levels are considered the most accurate measure of adherence but are invasive and costly. Pill counts and self-report are more practical, but little is known about their relationship to blood levels. This study compared the validity of pill count and self-report against plasma varenicline concentration for measuring pharmacotherapy adherence.

METHODS

Data were obtained from a randomized pilot study of varenicline for smoking cessation among African American smokers. Adherence was measured on Day 12 via plasma varenicline concentration, pill count, 3-day recall, and a visual analogue scale (VAS; adherence was represented on a line with two extremes "no pills" and "all pills").

RESULTS

The sample consisted of 55 African American moderate to heavy smokers (average 16.8 cigarettes/day, SD = 5.6) and 63.6% were female. Significant correlations (p < .05) were found between plasma varenicline concentration and pill count (r = .56), 3-day recall (r = .46), and VAS (r = .29). Using plasma varenicline concentration of 2.0 ng/ml as the cutpoint for adherence, pill count demonstrated the largest area under the receiver operating characteristic curve (AUC = 0.85, p = .01) and had 88% sensitivity (95% CI = 75.0-95.0) and 80% specificity (95% CI = 30.0-99.0) for detecting adherence.

CONCLUSIONS

Of 3 commonly used adherence measures, pill count was the most valid for identifying adherence in this sample of African American smokers. Pill count has been used across other health domains and could be incorporated into treatment to identify nonadherence, which, in turn, could maximize smoking cessation pharmacotherapy use and improve abstinence rates.

Use of dietary supplements among people living with HIV/AIDS is associated with vulnerability to medical misinformation on the internet

Background

Use of dietary supplements is common among people living with HIV/AIDS. Because dietary supplements are used in the context of other health behaviors, they may have direct and indirect health benefits. However, supplements may also be associated with vulnerability to medical misinformation and unfounded health claims. We examined use of dietary supplements among people living with HIV/AIDS (PLWH) and the association between use of dietary supplements and believing medical misinformation.

Methods

A convenience sample of 268 men and 76 women living with HIV was recruited from AIDS services and clinics in Atlanta, GA. Participants completed measures of demographic and health characteristics, dietary supplement use, beliefs about dietary supplements, internet use, and an internet evaluation task designed to assess vulnerability to medical misinformation.

Results

One out of four PLWH currently used at least one dietary supplement product excluding vitamins. Dietary supplement use was associated with higher education and greater use of the internet for health-related information. Dietary supplement users also endorsed greater believability and trust in unfounded claims for HIV cures.

Conclusions

Dietary supplement use is common among PLWH and is associated with a broad array of health information seeking behaviors. Interventions are needed to reduce the vulnerability of PLWH, particularly dietary supplement users, to medical misinformation propagated on the internet.

Use of InfCare HIV to identify and characterize suboptimally treated HIV patients at a Danish HIV clinic: a cross-sectional cohort study

BACKGROUND

The software program InfCare HIV is a combined clinical decision support tool and database. This study investigated the usefulness of InfCare HIV for identifying and characterizing suboptimally treated HIV-infected patients at a Danish HIV clinic.

METHODS

This cross-sectional cohort study included data on all HIV-infected patients treated at the Department of Infectious Diseases, Aarhus University Hospital, Skejby, Denmark on a specific date. InfCare HIV was used to identify and characterize suboptimally treated patients defined as patients with virological failure (VF) or untreated patients with a CD4 + count below 350 cells/μl. Patient characteristics were analyzed (i.e. age, sex, ethnicity, and nadir and latest CD4 + cell count). Treatment history and reasons for suboptimal treatment were also investigated.

RESULTS

Among all 530 patients, 421 were receiving highly active antiretroviral therapy (HAART) and had undergone at least 48 weeks of treatment on 29 October 2010. Of these, 27 (6.4%) had ongoing VF. Four were untreated despite a CD4 + count below 350 cells/μl. Among patients on HAART, patients with VF were younger and had lower median nadir CD4 + cell counts than patients without VF. Further, 33.3% (6/18) of African Black men but only 4.1% (10/244) of Caucasian men on HAART had VF (p < 0.001). The primary reason for VF was non-adherence. Three untreated patients had refused HAART, and 1 was not treated because of concerns of non-adherence.

CONCLUSIONS

InfCare HIV was successfully used to identify patients with suboptimal treatment. A surprisingly high percentage of African Black men had VF.

Methodological issues in the assessment of diabetes treatment adherence

Improving treatment adherence in patients with diabetes remains an important objective of behavioral science research. However, progress is often limited by the heterogeneity in methods used to measure treatment adherence and difficulties in generalizing across methodologies. Various measurement methods are often used with little attention paid to questions regarding validity. Doubts about validity of adherence measurement often lead investigators to measure distal clinical outcomes instead, such as glycemic control, resulting in a loss of information. This article provides an overview of the literature on diabetes medication adherence, with a focus on measurement issues. We also consider work conducted in other chronic illnesses, particularly HIV/AIDS, that may have value in guiding future directions of diabetes medication adherence research. We highlight the need for focused investigation on how characteristics of self-report methodologies affect the validity of patient responses and conclude with practical recommendations based on the current state of the science.

Food insufficiency and medication adherence among people living with HIV/AIDS in urban and peri-urban settings

Food insufficiency is associated with medication non-adherence among people living with HIV/AIDS. The current study examines the relationship between hunger and medication adherence in a US urban and peri-urban sample of people living with HIV/AIDS. Men (N=133) and women (N=46) living with HIV/AIDS were recruited using snowball sampling and small media in Atlanta, Georgia. Participants completed computerized behavioral interviews that included measures of demographics, food insufficiency, social support, depression, and substance use, and provided blood specimens to determine HIV viral load. Participants also completed monthly unannounced pill counts to prospectively monitor medication adherence over 8 months. Results indicated that 45% of participants were less than 85% adherent to their medications and that food insufficiency was related to non-adherence; nearly half of non-adherent participants reported recent hunger. Geocoding of participant residences showed that 40% lived more than 5 miles from the city center. Multivariable logistic regression controlling for demographics and common factors associated with adherence showed that the interaction between distance from downtown and experiencing hunger significantly predicted non-adherence over and above all other factors. Medication adherence interventions should address access to food, particularly for people living outside of urban centers.

Sexual HIV transmission and antiretroviral therapy: a prospective cohort study of behavioral risk factors among men and women living with HIV/AIDS

BACKGROUND

Using antiretroviral therapies for HIV prevention relies on patient adherence and avoidance of co-occurring sexually transmitted infections.

PURPOSE

The objective of this study is to simultaneously examine HIV treatment adherence and sexual risks for HIV transmission.

METHODS

This study is a prospective cohort of 201 men and 55 women diagnosed with HIV/AIDS infection.

RESULTS

A total of 32% men and 39% women engaged in unprotected intercourse with at least one HIV negative or unknown HIV status sex partner over 12 months. Nearly half (46%) of participants with HIV negative or unknown HIV status unprotected sex partners had detectable HIV viral load and were significantly more likely to have contracted a sexually transmitted infection since their HIV diagnosis. Individuals at higher risk for transmitting HIV were also less adherent to antiretroviral therapies.

CONCLUSIONS

Programs that aim to use antiretroviral therapies for HIV prevention require careful attention to adherence, sexually transmitted co-infections, and substance use.

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.

Monthly unannounced pill counts for monitoring HIV treatment adherence: tests for self-monitoring and reactivity effects

BACKGROUND

Unannounced home-based pill counts conducted in person or on the telephone are reliable and valid for monitoring medication adherence. However, expecting to have one's pills counted, organizing medications for pill counts, and increased attention from the person conducting the pill counts may have reactive effects and inadvertently improve adherence. The current study determined whether monthly unannounced pill counts conducted by telephone influence adherence over time.

METHODS

Two prospective cohorts, one drawn from a social support condition in a behavioral intervention trial (n=186) and the other an observational study (n=187), were followed for 12 months and 8 months, respectively. Medication adherence was monitored using monthly unannounced pill counts conducted by telephone. In addition, blood plasma viral load was collected at the final pill count for the observational cohort.

RESULTS

Analyses did not indicate increases in medication adherence over time for antiretroviral or psychiatric medications among men, women, people with detectable and undetectable viral loads, and various medication regimens.

CONCLUSIONS

Unannounced pill counts conducted by telephone do not demonstrate reactivity effects and remain a viable, unobtrusive, objective method of 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.

Unannounced telephone pill counts for assessing varenicline adherence in a pilot clinical trial

BACKGROUND

Despite consistent evidence linking smoking cessation pharmacotherapy adherence to better outcomes, knowledge about objective adherence measures is lacking and little attention is given to monitoring pharmacotherapy use in smoking cessation clinical trials.

OBJECTIVES

To examine unannounced telephone pill counts as a method for assessing adherence to smoking cessation pharmacotherapy.

RESEARCH DESIGN

Secondary data analysis of a randomized pilot study.

PARTICIPANTS

46 moderate-to-heavy (>10 cigarettes per day) African-American smokers.

MAIN MEASURES

Smokers received 1 month of varenicline (Pfizer Global Pharmaceuticals, New York, NY) in a pill box at baseline. Unannounced pill counts were completed by telephone 4 days prior to an in-person pill count conducted at Month 1. At both counts, each compartment of the pill box was opened and the number of remaining pills was recorded.

RESULTS

Participants were a mean age of 48 years (SD = 13), predominately female (59%), low income (60% < $1800 monthly family income), and smoked an average of 17 (SD = 7) cigarettes per day. A high degree of concordance was observed between the number of pills counted by phone and in-person (r(s) = 0.94, P < 0.001). Participants with discordant counts (n = 7) had lower varenicline adherence (mean [SD] = 77% [18%] vs 95% [9%], P < 0.0005), but reported better medication adherence in the past (1.0 [0.8] vs 2.8 [1.0], P < 0.0004) than participants with matching phone and in-person counts (n = 39).

CONCLUSION

Unannounced telephone pill counts appear to be a reliable and practical method for measuring adherence to smoking cessation pharmacotherapy.

"There is no proof that HIV causes AIDS": AIDS denialism beliefs among people living with HIV/AIDS

AIDS denialists offer false hope to people living with HIV/AIDS by claiming that HIV is harmless and that AIDS can be cured with natural remedies. The current study examined the prevalence of AIDS denialism beliefs and their association to health-related outcomes among people living with HIV/AIDS. Confidential surveys and unannounced pill counts were collected from a convenience sample of 266 men and 77 women living with HIV/AIDS that was predominantly middle-aged and African American. One in five participants stated that there is no proof that HIV causes AIDS and that HIV treatments do more harm than good. AIDS denialism beliefs were more often endorsed by people who more frequently used the internet after controlling for confounds. Believing that there is a debate among scientists about whether HIV causes AIDS was related to refusing HIV treatments and poorer health outcomes. AIDS denialism beliefs may be common among people living with HIV/AIDS and such beliefs are associated with poor health outcomes.

Stress and poverty predictors of treatment adherence among people with low-literacy living with HIV/AIDS

OBJECTIVE

To examine the association of social, health, and poverty-related stressors in relation to antiretroviral therapy adherence in a sample of people with low-literacy living with HIV/AIDS in the southeastern United States. Emotional distress is among the more common factors associated with HIV treatment adherence. Typical barriers to adherence may be overshadowed by poverty experiences in the most disadvantaged populations of people living with HIV/AIDS, such as people with lower-literacy skills.

METHODS

One hundred eighty-eight men and women living with HIV/AIDS who demonstrated poor health literacy completed measures of social and health-related stress, indicators of extreme poverty, as well as other factors associated with nonadherence. HIV treatment adherence was monitored prospectively, using unannounced pill counts.

RESULTS

Two-thirds of the sample demonstrated adherence <85% of pills taken. Multivariable analyses showed that food insufficiency and hunger predicted antiretroviral therapy nonadherence over and above depression, internalized stigma, substance use, and HIV-related social stressors.

CONCLUSIONS

Interventions for HIV treatment nonadherence with the most socially disadvantaged persons in developed countries should be reconceptualized to directly address poverty, especially food insufficiency and hunger, as both a moral and public health imperative.

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.

Adherence to antiretroviral therapy and HIV transmission risks: implications for test-and-treat approaches to HIV prevention

HIV transmission may be prevented by effectively suppressing viral replication with antiretroviral therapy (ART). However, adherence is essential to the success of ART, including for reducing HIV transmission risk behaviors. This study examined the association of nonadherence versus adherence with HIV transmission risks. Men (n = 226) living with HIV/AIDS and receiving ART completed confidential computerized interviews and telephone-based unannounced pill counts for ART adherence monitoring. Data were collected between January 2008 and June 2009. Results showed that nonadherence to ART was associated with greater number of sex partners and engaging in unprotected and protected anal intercourse. These associations were not moderated by substance use. The belief that having an undetectable viral load leads to lower infectiousness was associated with greater number of partners, including nonpositive partners, and less condom use. Men who had an undetectable viral load and believed that having an undetectable viral load reduces their infectiousness, were significantly more likely to have contracted a recent STI. Programs aimed at testing and treating people living with HIV/AIDS for prevention require attention to adherence and sexual behaviors.

A simple single-item rating scale to measure medication adherence: further evidence for convergent validity

BACKGROUND

Self-report measures of medication adherence are inexpensive and minimally intrusive. However, the validity of self-reported adherence is compromised by recall errors for missed doses and socially desirable responding.

METHOD

Examined the convergent validity of 2 self-report adherence measures administered by computerized interview: (a) recall of missed doses and (b) a single-item visual analogue rating scale (VAS). Adherence was also monitored using unannounced phone-based pill counts that served as an objective benchmark.

RESULTS

The VAS obtained adherence estimates that paralleled unannounced pill counts (UPCs). In contrast, self-reported recall (SR-recall) of missed medications consistently overestimated adherence. Correlations with participant characteristics also suggested that the computer-administered VAS was less influenced by response biases than SR-recall of missed medication doses.

CONCLUSIONS

A single-item VAS offers an inexpensive and valid method of assessing medication adherence that may be useful in clinical as well as research settings.

A comparison of adherence assessment methods utilized in the United States: perspectives of researchers, HIV-infected children, and their caregivers

This study sought to elucidate methodological issues in adherence research by comparing multiple methods of assessing adherence to antiretroviral medication. From 2003 to 2004, 24 youths with vertically infected HIV disease (mean age = 14.0 years; range, 8-18) and their caregivers participated in a 6-month study. These children were all on highly active antiretroviral therapy (HAART) and were relatively healthy (mean CD4 absolute count = 711.8 +/- 604.5). Adherence was assessed with the Medication Event Monitoring System (MEMS), pill counts, and interviews. Patients and caregivers completed the Perceptions of Adherence Study Participation (PASP) questionnaire. MEMS provided the most detailed adherence information, and good reliability was indicated by significant correlations with medical markers. Pill counts provided similar adherence rates, while patients and caregivers reported nearly perfect adherence in interviews. Problems were experienced with each method: MEMS were expensive, had cap malfunctions, and lack a consistent guiding principle for data interpretation. With pill counts, families forgot to bring all medication bottles to clinic, and interviews were compromised by social desirability and difficulty reaching families by telephone. Most patients and caregivers believed study participation improved the child's adherence, although PASP ratings were unrelated to adherence at the study endpoint. While MEMS may be most reliable, pill counts offer comparable data and are less costly, while interviews seemed least accurate in this study. Most participants reported positive perceptions of their research experience. A consensus among researchers is needed for defining and measuring adherence, and specific recommendations are offered for achieving this goal.

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.

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.