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Randomized Clinical Trial of HIV Treatment Adherence Counseling Interventions for People Living With HIV and Limited Health Literacy

Kalichman, Seth C. PhD*; Cherry, Chauncey MPH*; Kalichman, Moira O. MSW*; Amaral, Christina BA*; White, Denise MA*; Grebler, Tamar BA*; Eaton, Lisa A. PhD*; Cruess, Dean PhD*; Detorio, Mervi A. MS; Caliendo, Angela M. MD; Schinazi, Raymond F. PhD

JAIDS Journal of Acquired Immune Deficiency Syndromes: May 1st, 2013 - Volume 63 - Issue 1 - p 42–50
doi: 10.1097/QAI.0b013e318286ce49
Clinical Science

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.

*Department of Psychology, University of Connecticut, Storrs, CT;

Center for AIDS Research, Emory University School of Medicine and Veterans Affairs Medical Center, Atlanta, GA; and

Center for AIDS Research and Department of Pathology and Laboratory Medicine Emory University School of Medicine, Atlanta, GA.

Correspondence to: Seth C. Kalichman, PhD, Department of Psychology, University of Connecticut, 406 Babbidge Road, Storrs, CT 06269 (e-mail:

Supported by the National Institute of Mental Health Grant R01-MH82633 [to Kalichman, (principal investigator)]; Center for AIDS Research, Emory University School of Medicine, National Institutes of Health Grant P30 AI050409 (Detorio, Caliendo, and Schinazi); and the Department of Veterans Affairs (Detorio and Schinazi).

The authors have no conflicts of interest to disclose.

Received September 13, 2012

Accepted January 07, 2013

© 2013 Lippincott Williams & Wilkins, Inc.