title: Health literacy, antiretroviral adherence, and HIV-RNA suppression: a longitudinal perspective.
abstract: 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) (< or = 6th grade, 7th to 8th grade, > or = 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% < or = 6th grade, 29% 7th to 8th grade, and 57% > or = 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 (< or = 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 > or = 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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA. mpo@bu.edu
authors.forename: Michael K
authors.initials: MK
authors.lastname: Paasche-Orlow
authors.forename: Debbie M
authors.initials: DM
authors.lastname: Cheng
authors.forename: Anita
authors.initials: A
authors.lastname: Palepu
authors.forename: Seville
authors.initials: S
authors.lastname: Meli
authors.forename: Vincent
authors.initials: V
authors.lastname: Faber
authors.forename: Jeffrey H
authors.initials: JH
authors.lastname: Samet
mesh_terms: D000328:Adult; D000428:Alcohol Drinking / Q000188:drug therapy / Q000453:epidemiology; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D004522:Educational Status; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology*; D015497:HIV-1; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D011446:Prospective Studies; D012367:RNA, Viral; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents; D012367:RNA, Viral