, Volume 21, Issue 8, pp 835-840

Health literacy, antiretroviral adherence, and HIV-RNA suppression

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BACKGROUND: Low health literacy has been associated with worse adherence to antiretroviral therapy (ART) and higher HIV-RNA levels, but these relationships have not been evaluated in longitudinal analyses.

METHODS: We evaluated literacy using the Rapid Estimate of Adult Literacy in Medicine (REALM) (≤6th grade, 7th to 8th grade, ≥9th grade) in the HIV-Alcohol Longitudinal Cohort study of HIV-infected persons with a history of alcohol problems, conducted from 1997 to 2001. We tested HIV-RNA levels and administered a standardized questionnaire regarding demographics, substance use, receipt of ART, and adherence with ART, every 6 months for up to 7 occasions. Among the 235 subjects on ART, we investigated the relationship between literacy and 2 outcomes: 100% 3-day self-reported adherence and HIV-RNA suppression (<500 copies).

RESULTS: Subjects’ literacy levels were the following: 14% ≤6th grade, 29% 7th to 8th grade, and 57% ≥9th grade. In 66% of the observations (478/725), subjects reported 100% 3-day adherence with ART. Of the 685 HIV-RNA assays from these subjects, 62% had <500 copies. In unadjusted analyses, subjects with the lowest literacy level (≤6th grade) had a higher odds of adherence (odds ratio [OR] 2.23, 95% confidence interval 1.15 to 4.30) and HIV-RNA suppression (OR 2.01, 95% confidence interval 1.03 to 3.90) compared with those with ≥9th grade literacy. This trend persisted but was no longer statistically significant in adjusted models of adherence (AOR 1.93, 95% confidence interval 0.86 to 4.31) and HIV-RNA suppression (AOR 1.70, 95% confidence interval 0.79 to 3.65).

CONCLUSION: Contrary to our hypothesis, low literacy was not associated with a lower odds of adherence or virologic suppression in this longitudinal analysis of HIV-infected patients with a history of alcohol problems. Indeed, trends in these data suggest the possibility that low literacy may be associated with a higher odds of adherence and virologic suppression. These counterintuitive findings underscore the need to pursue a fuller understanding of the mechanisms by which literacy affects health outcomes.

None of the authors have any conflicts of interest to declare.
The authors appreciate the contributions of the clinical staff of the HIV Diagnostic Evaluation Unit at Boston Medical Center, including Colleen LaBelle, RN, and Jennifer Doyle.
Support for this study came from the following grants from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) of the NIH: RO1-AA13766 (Clinical Impact of HCV and Alcohol in HIV-Infected Persons); RO1-AA11785 (Medication Adherence in Alcohol Abusing HIV Patients); and RO1-AA10870 (Enhanced Linkage of Alcohol Abusers to Primary Care).