The effects of low literacy and cognitive impairment on medication adherence in HIV-positive injecting drug users

Prevalence and variability of HIV/AIDS-associated neurocognitive impairments in Africa: a systematic review and meta-analysis

BACKGROUND

HIV/AIDS-associated neurocognitive impairments negatively affect treatment adherence, viral load suppression, CD4 count, functionality, and the overall quality of life of people with seropositive status. However, huge variability is observed across primary studies regarding the prevalence and determinants of neurocognitive impairment in people with HIV/AIDS. This systematic review and meta-analysis sought to determine the pooled prevalence of neurocognitive impairment and identify factors contributing to variations in its estimate among people living with HIV/AIDS in Africa.

METHODS

A comprehensive literature search of scientific databases (Medline/PubMed, SCOPUS, Web of Science, PsycINFO, and EMBASE) was performed from inception onward. Google and Google Scholar were also searched for grey literature. Research articles available until July 15, 2022 were included. We used STATA-version 14 statistical software for analysis. A random effect model was executed to pool the reported prevalence of neurocognitive impairments. Subgroup analysis was done to show variations in the prevalence of neurocognitive impairments and factors that might contribute to these variations.

RESULTS

A literature search resulted in 8,047 articles. After the removal of duplications and thorough evaluation, a total of 49 studies were included in the meta-analysis. The prevalence of HIV/AIDS-associated neurocognitive impairments was highly variable across studies, ranging from 14% to 88%, yielding the pooled prevalence of HIV/AIDS-associated neurocognitive impairment to be 46.34% [95% CI (40.32, 52.36)] and I² = 98.5% with a P-value of 0.001.

CONCLUSIONS

A large proportion of people living with HIV/AIDS in Africa have HIV/AIDS-associated neurocognitive impairment. This illustrates the need to establish practical approaches to early identification and effective control of HIV/AIDS-associated neurocognitive impairments. However, there were variabilities in the reported prevalence of HIV/AIDS-associated neurocognitive impairments across studies. This further demonstrates the need to have consistent measurement approaches.

TRIAL REGISTRATION

PROSPERO 2022, "CRD42020166572".

The Intersection of Cognitive Ability and HIV: A Review of the State of the Nursing Science

ABSTRACT

Neurocognitive problems have been endemic to the HIV epidemic since its beginning. Four decades later, these problems persist, but currently, they are attributed to HIV-induced inflammation, the long-term effects of combination antiretroviral therapy, lifestyle (i.e., physical activity, drug use), psychiatric, and age-associated comorbidities (i.e., heart disease, hypertension). In many cases, persons living with HIV (PLWH) may develop cognitive problems as a function of accelerated or accentuated normal aging and lifestyle rather than HIV itself. Nonetheless, such cognitive impairments can interfere with HIV care, including medication adherence and attending clinic appointments. With more than half of PLWH 50 years and older, and 30%-50% of all PLWH meeting the criteria for HIV-associated neurocognitive disorder, those aging with HIV may be more vulnerable to developing cognitive problems. This state of the science article provides an overview of current issues and provides implications for practice, policy, and research to promote successful cognitive functioning in PLWH.

Inhibitory control is associated with medication adherence in young HIV patients without comorbidities

OBJECTIVE

In the present study we evaluated the incremental contribution of executive cognition (EC) subprocesses to antiretroviral medication adherence.

METHOD

A comprehensive EC test battery assessing updating/working memory, mental flexibility, and inhibitory control, along with measures assessing non-executive cognitive functions were completed by 100 individuals with HIV. Medication adherence was determined via a visual analogue self-report scale and the Medication Adherence Questionnaire. Potential predictors, including demographic and clinical characteristics and neuropsychological performances on EC and other cognitive tasks were regressed to medication adherence. Predictive variables related to executive processes were added in the final block of the hierarchical regression model in order to assess their incremental predictive ability on medication adherence.

RESULTS

23% of the variance in the visual analogue scale was explained by treatment complexity, memory and EC performance. A measure of inhibitory control, in particular, predicted self-reported medication adherence above and beyond demographic, clinical and other cognitive factors.

CONCLUSIONS

The contribution of EC to self-reported medication adherence in young seropositive adults was limited, but inhibitory control was associated with proper medication management above and beyond demographic, clinical and other cognitive functions.

Drug Use and Life Chaos as Potential Factors Contributing to HIV Viral Load among People with Lower Health Literacy

Lower health literacy is associated with poorer health outcomes in people living with HIV (PLWH), but the explanatory mechanisms for these associations are not well understood. Factors such as drug use and life chaos may at least in part account for the relationship between lower health literacy and poor health outcomes. The current study tested the hypothesis that lower health literacy would predict drug use, which in turn would predict life chaos, and that all three factors would be related to poorer heath, defined by higher concentrations of HIV viremia. Methods: Patients receiving HIV care (N = 251) at an HIV clinic in the southeastern United States completed computerized interviews and permission to access their medical records. Process modeling tested direct and indirect effects of all variables in a serial mediation model. Results: The direct effects of lower health literacy and drug use were significantly related to HIV viremia. In addition, the indirect effect of health literacy on HIV viremia through drug use was significant. However, results did not demonstrate any effect, direct or indirect, of life chaos on HIV viremia. Conclusion: Findings from this study bolster previous research demonstrating lower health literacy and drug use as barriers to HIV care, and show that lower health literacy impacts HIV viremia, at least in part, through drug use. Interventions aimed to improve HIV treatment outcomes in lower health literacy populations may be enhanced by integrating evidence-based approaches to reducing drug use.

Neurocognitive Functioning is Associated with Self-Reported and Performance-Based Treatment Management Abilities in People Living with HIV with Low Health Literacy

OBJECTIVE

People living with HIV (PLWH) are at higher risk for poorer neurocognitive functioning and health literacy than uninfected persons, which are associated with worse medical outcomes. Aging research suggests that the effect of neurocognitive functioning on health outcomes may be more pronounced in those with low health literacy. We aimed to determine whether low health literacy might amplify the adverse effects of neurocognitive functioning on treatment management outcomes in 171 PLWH aged 40+.

METHOD

In this cross-sectional, observational study, participants completed a well-validated battery of neurocognitive, health literacy, and treatment management measures. A binary health literacy variable (low vs. adequate) was determined via established cut points on the well-validated health literacy tests. Treatment management outcomes included biomarkers of HIV (i.e., CD4 counts and viral load), self-management of HIV disease (i.e., self-reported medication adherence and self-efficacy for HIV disease management), and performance-based health-related decision-making.

RESULTS

Forty-seven percent of the sample met the criteria for low health literacy. Multivariable regressions adjusting for clinicodemographic (e.g., race, socioeconomic status) covariates revealed significant interactions for self-efficacy for HIV disease management and health-related decision-making, such that neurocognitive functioning was associated with these outcomes among those with low, but not adequate health literacy.

CONCLUSIONS

Findings suggest that low health literacy may increase the vulnerability of PLWH to the adverse effects of neurocognitive impairment on health outcomes, or conversely that adequate health literacy may provide a buffer against the health risks associated neurocognitive impairment. Interventions targeting health literacy in PLWH may mitigate the effects of neurocognitive impairment on health outcomes.

A Path Analysis of Patient and Social-Level Factors on Health Literacy and Retention in Care Among African Americans Living with HIV

Low health literacy and poor retention in care may contribute to HIV health disparities among African Americans, but causal pathways have not been examined. We utilized an adapted health literacy model to examine the role of health literacy on racial disparities in retention in care. Retention in care for 699 participants was assessed 24-months post survey and operationalized as 100% visit adherence versus less than 100% visit adherence. Most participants were African American (60%) and virally suppressed (93%). Results from a path analysis revealed that non-African American race was related to greater health literacy (p = .023) and to 100% visit adherence (p = .024). Greater health literacy was associated with 100% visit adherence (p = .008), which was in turn related to viral suppression (p < .001). Findings indicate that health literacy partially mediates the relationship between race and retention in care and are among the first to suggest these causal pathways.

Predictors of disparities in retention in care among African Americans living with HIV

Limited health literacy may contribute to racial disparities in retention in HIV care. The purpose of this study was to evaluate the effects of health literacy and patient and social-level factors on retention in care among African Americans living with HIV. This study included 699 participants recruited from outpatient HIV clinics and retention in care was defined as visit adherence. Multivariable logistic regression models were used to assess predictors of visit adherence among persons with 100% visit adherence compared to less than 100% visit adherence. Controlling for demographic factors, the odds of 100% visit adherence was greater among non-African Americans compared to African Americans. In models that included health literacy, race was no longer significant and health literacy was a significant predictor of 100% visit adherence. Among participants with less than 100% visit adherence, health literacy was not a significant predictor of visit adherence; however, age, marital status, and patient attitudes towards the health care provider were significant predictors. Findings suggest that health literacy may mediate the relationship between race and visit adherence. Future studies should further examine these relationships and develop interventions that target modifiable factors, with a goal of improving health equity and minimizing disparities.

Better executive function is independently associated with full HIV suppression during combination therapy

OBJECTIVE

HIV-associated neurocognitive impairment continues to be prevalent and clinically relevant. We examined the relationship between neurocognition and full plasma HIV RNA suppression among study participants over a 15-year period at a large research program.

DESIGN/METHODS

We analyzed the combined prospective studies of the HIV Neurobehavioral Research Program at the University of California at San Diego. Participants were eligible for analysis if on three drug combination antiretroviral therapy with comprehensive neuropsychological testing results. Participants who reported recent nonadherence were excluded. The primary outcome was plasma HIV RNA of 50 copies/ml or less. Generalized estimating equation was used to assess for associations with full virologic suppression taking into account longitudinal visits.

RESULTS

There were 1943 participants at baseline, of whom 69.4% had plasma HIV RNA of 50 copies/ml or less. Participants with full suppression were slightly older, less likely to abuse cocaine, and had significantly better executive function. Multivariate analysis with incorporation of longitudinal visits (total = 5555) confirmed current cocaine abuse to be strongly associated with lack of virologic suppression (odds ratio = 0.45, 95% confidence interval = 0.31-0.63). In contrast, increasing age, increasing years of HIV infection, and increasing executive function (odds ratio = 1.18 for T score change of 10, 95% confidence interval = 1.07-1.30) were associated with full virologic suppression. Lack of virologic suppression at baseline was associated with a significant subsequent decline in executive function.

CONCLUSION

In a 15-year research cohort of almost 2000 HIV-infected individuals on combination antiretroviral therapy, better executive function was associated with full virologic suppression, possibly as a result rather than a cause.

Health Literacy and Health Outcomes in Persons Living with HIV Disease: A Systematic Review

Low health literacy is associated with challenges for those living with HIV including medication non-adherence and poorer health outcomes. The aim of this study was to systematically review the literature on health literacy and health outcomes in persons living with HIV. The extended guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, as well as A Measurement Tool to Assess Systematic Reviews (AMSTAR) checklist were utilized to guide the approach to the review. A variety of electronic databases including PubMed, CINAHL, PsychInfo, and Cochrane Library were searched. Additional literature available on U.S. government websites was also included in the search. Search terms were used in a variety of combinations and included HIV, health literacy, adherence, and health outcomes. Forty-eight studies were identified that addressed health literacy and health outcomes in HIV. Although several studies in this review did not provide robust results of statistical significance linking health literacy with health outcomes, all of the studies addressed the key significance of health literacy within the scope of living with HIV disease. The relationship between health literacy and the identified health outcomes requires further research and explication.

Treatment Engagement Moderates the Effect of Neurocognitive Impairment on Antiretroviral Therapy Adherence in HIV-Infected Drug Users in Treatment

Neurocognitive impairment (NCI) and treatment engagement (TE) have been shown to significantly predict antiretroviral therapy (ART) adherence, but no studies have explored the ways and the extent to which similar outcomes might occur when these factors operate together, particularly for people who use drugs (PWUDs). We sought to discover whether TE moderated the effect of NCI on adherence to ART in HIV-infected individuals. One hundred sixteen HIV-infected, methadone-maintained people who reported HIV risk behaviors were enrolled in the study. Variables of interest (NCI, ART adherence, TE) were assessed using audio computer-assisted self-interview. Results revealed a significant interactive effect of NCI and TE on ART adherence, which supported the moderation effect. Findings from post hoc analyses showed that NCI was negatively associated with adherence to ART at low levels of TE. Findings suggest the need to accommodate individual NCI and improve TE as a means to enhance ART adherence in HIV-infected PWUDs.

Current Scenario of HIV/AIDS, Treatment Options, and Major Challenges with Compliance to Antiretroviral Therapy

The discovery of the human immunodeficiency virus (HIV) as the causative organism of acquired immunodeficiency syndrome (AIDS) and the inability of modern medicine to find a cure for it has placed HIV as one of the most dreaded pathogens of the 21(st) century. With millions of people infected with HIV, it was once thought to result in "medical apocalypse". However, with the advent of antiretroviral therapy (ART), it is now possible to control HIV. Adherence to ART helps to keep the viral load under control and prolong the time of progression to AIDS, resulting in near normal life expectancy. Even with the introduction of ART, a substantial number of patients fail to adhere due to a variety of reasons, including adverse side effects, drug abuse, mental disorders, socioeconomic status, literacy, and social stigma. With the availability of so many options for HIV treatment at each stage of the disease progression, physicians can switch between the treatment regimens to avoid and/or minimize the adverse effects of drugs. Close monitoring, major social reforms, and adequate counselling should also be implemented to circumvent other challenges.

Predictors of psychotropic medication adherence among HIV+ individuals living with bipolar disorder

OBJECTIVE

HIV infection and bipolar disorder are highly comorbid and associated with frontostriatal disruption, emotional dysregulation, and neurocognitive impairment. Psychiatric and cognitive factors have been linked to antiretroviral nonadherence; however, predictors of psychotropic adherence among HIV+ individuals with psychiatric comorbidities have not been explored. We evaluated predictors of psychotropic adherence among individuals with HIV infection and bipolar disorder.

METHOD

Psychiatric medication adherence of 50 participants with HIV infection and bipolar disorder was tracked for 30 days using Medication Event Monitoring Systems. Participants completed neurocognitive, neuromedical, and psychiatric batteries.

RESULTS

Mean psychotropic adherence rate was 78%; 56% of participants achieved ≥90% adherence. Younger age and onset of depressive symptoms, more severe current depressive symptoms, number of previous psychiatric hospitalizations and suicide attempts, poorer neurocognition, and more negative attitudes and self-beliefs toward medications univariably predicted worse psychotropic adherence (p's < .10). A multivariable model demonstrated a combination of current depressive symptoms and more negative attitudes toward medications significantly predicting poorer adherence (R(2 )= 0.27, p < 0.003). Secondary analyses revealed an interaction between neurocognition and mood, such that individuals with HIV infection and bipolar disorder who had greater executive dysfunction and depressive symptoms evidenced the poorest psychotropic adherence (p < 0.001).

CONCLUSIONS

Both psychiatric and neurocognitive factors contribute to poorer psychotropic adherence among HIV+ individuals with serious mental illness. Adherence interventions aimed at remediating these factors may be especially fruitful.

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.

"Keep it simple": older African Americans' preferences for a health literacy intervention in HIV management

PURPOSE

Health literacy is lower in minorities and older adults, and has been associated with nonadherence to medications, treatment, and care in people living with human immunodeficiency virus (HIV). Likewise, African Americans with HIV are more likely to be nonadherent to their HIV medications, less likely to keep their clinic appointments related to HIV treatment and care, and more likely to die during hospitalizations than their ethnic counterparts. The present study explored the preferences of older African Americans with HIV for a health literacy intervention to promote HIV management.

PATIENTS AND METHODS

In this qualitative study, 20 older adult African Americans living with HIV were recruited from an HIV/acquired immunodeficiency syndrome outpatient clinic in the southeastern region of the US. Using patient-centered participatory design methods, semi-structured individual interviews were conducted to determine patient preferences for intervention development and design. Health literacy was also measured using the Rapid Estimate of Adult Literacy in Medicine - Revised (REALM-R).

RESULTS

Four major themes emerged related to intervention development and design: keep health information simple; use a team-based approach for health education; tailor teaching strategies to patients' individual needs; and account for patients' low experience, but high interest, in technology. Forty-five percent of the study population had low health literacy based on the revised Rapid Estimate of Adult Literacy in Medicine.

CONCLUSION

Future interventions that target minorities and older adults living with HIV should consider patients' learning needs, sex-specific and mental health needs, and delivery approaches, in order to increase uptake and improve disease management and health outcomes.

Risk and protective factors for retention in HIV care

Retention in care for HIV is essential for effective disease management; however, factors that may confer risk or protection for adherence to regular HIV care are less well understood. This study tested whether HIV-associated cognitive impairment (CI) and low health literacy reduced adherence to routine HIV medical and phlebotomy visits and if social support and patient-provider relationship conferred a protective effect. Participants were 210 HIV-infected patients enrolled in outpatient care and followed for 28-weeks. Results showed that those attending >75 % of phlebotomy visits were more likely to be virally suppressed. Health literacy was unassociated with adherence to medical or phlebotomy visits. CI was not directly related to medical or phlebotomy visit adherence; however those with CI and greater use of social support were less likely to miss medical visits. Utilizing social support may be an effective means of managing visit adherence, especially among patients with CI.

Health literacy: impact on the health of HIV-infected individuals

Health literacy is known to affect vulnerable communities such as persons living with HIV/AIDS. The purpose of this review was to provide a current summary of research on the impact of health literacy on the health of persons living with HIV/AIDS and to address future areas of need. Contemporary studies focused on expanding the reach of health literacy in HIV/AIDS to retention in HIV care, use of technology for assessing and intervening to improve health literacy, and health literacy across the globe, for example. A number of studies did not find health literacy to explain health behaviors whereas other studies supported such a relationship. Future issues relevant to health literacy in HIV/AIDS include the aging of the HIV population and associated comorbidities, studies to understand the role of health literacy in specific populations affected by HIV/AIDS, and the continued need to refine the definition and measurement of health literacy.

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.

HIV Clade-C Infection and Cognitive Impairment, Fatigue, Depression, and Quality of Life in Early-Stage Infection in Northern Indians

HIV disease progression is associated with declining quality of life and overall health status, although most research in this domain has been conducted among Western populations where B is the infecting clade. This study sought to determine the effects of early-stage clade-C HIV infection (CD4 count ≥400 cells/mm(3)) on neurocognitive functioning, cognitive depression, and fatigue by comparing a matched sample of HIV-positive and HIV-negative Northern Indians. This study also examined the impact of these factors on quality of life within the HIV-positive individuals. HIV-positive participants demonstrated reduced cognitive functioning, increased fatigue, and lower quality of life. Fatigue and cognitive impairment interacted to negatively impact quality of life. Results suggest that early-stage HIV clade-C-infected individuals may experience subclinical symptoms, and further research is needed to explore the benefit of therapeutic interventions to ensure optimal clinical outcomes and maintain quality of life in this vulnerable population.

Personal HIV knowledge, appointment adherence and HIV outcomes

HIV knowledge may impact patient access, understanding, and utilization of HIV medical information. This study explored the relationship between personal HIV knowledge, appointment adherence and treatment outcomes. HIV-infected individuals (n = 210) were assessed on factors related to HIV knowledge and appointment adherence. Adherence data and laboratory values were extracted from medical records. HIV knowledge was measured by participants' knowledge of their CD4 count and viral load (VL) and adherence was defined as attendance at >75 % of appointments. Two-thirds of participants were adherent, but only one-third knew their CD4 count and VL. Controlling for time since last appointment, HIV knowledge more than doubled the odds of appointment adherence. In combination with relationship with provider, knowledge predicted increased CD4 count and increased odds of an undetectable VL by almost five times. Personal HIV knowledge may be a valuable indicator of engagement in care and may also facilitate improved treatment outcomes.

Lower cognitive reserve among individuals with syndromic HIV-associated neurocognitive disorders (HAND)

HIV-seropositive individuals with low cognitive reserve are at high risk for developing HIV-associated neurocognitive disorders (HAND). The present study evaluated the hypothesis that cognitive reserve would also play a unique role in the expression of everyday functioning complications among those with HAND (i.e., syndromic versus subsyndromic impairment). Eighty-six individuals with HIV infection were evaluated; 53 individuals evidenced normal neurocognitive performance, 16 had subsyndromic HAND (i.e., asymptomatic neurocognitive impairment), and 17 were diagnosed with syndromic HAND based on a comprehensive neurobehavioral evaluation. Cognitive reserve represented a combined score including years of education, estimated verbal IQ, and highest occupational attainment. The groups were comparable (e.g. demographics), and the HAND groups had similar rates of global neurocognitive impairment. The syndromic HAND group evidenced lower reserve scores relative to both other groups, suggesting that individuals with lower reserve may be less able to effectively counteract their neurocognitive impairment to maintain independence in daily living activities than HIV-infected individuals with high cognitive reserve.

Relationship of Medication Management Test-Revised (MMT-R) performance to neuropsychological functioning and antiretroviral adherence in adults with HIV

While performance-based tests of everyday functioning offer promise in facilitating diagnosis and classification of HIV-associated neurocognitive disorders (HAND), there remains a dearth of well-validated instruments. In the present study, clinical correlates of performance on one such measure (i.e., Medication Management Test-Revised; MMT-R) were examined in 448 HIV+ adults who were prescribed antiretroviral therapy. Significant bivariate relationships were found between MMT-R scores and demographics (e.g., education), hepatitis C co-infection, estimated premorbid IQ, neuropsychological functioning, and practical work abilities. MMT-R scores were not related to HIV disease severity, psychiatric factors, or self-reported adherence among participants with a broad range of current health status. However, lower MMT-R scores were strongly and uniquely associated with poorer adherence among participants with CD4 T cell counts <200. In multivariate analyses, MMT-R scores were predicted by practical work abilities, estimated premorbid functioning, attention/working memory, learning, and education. Findings provide overall mixed support for the construct validity of the MMT-R and are discussed in the context of their clinical and research implications for evaluation of HAND.

Neurocognitive impairment and HIV risk factors: a reciprocal relationship

Cognitive impairment among populations at risk for HIV poses a significant barrier to managing risk behaviors. The impact of HIV and several cofactors, including substance abuse and mental illness, on cognitive function is discussed in the context of HIV risk behaviors, medication adherence, and risk-reduction interventions. Literature suggests that cognitive impairment is intertwined in a close, reciprocal relationship with both risk behaviors and medication adherence. Not only do increased risk behaviors and suboptimal adherence exacerbate cognitive impairment, but cognitive impairment also reduces the effectiveness of interventions aimed at optimizing medication adherence and reducing risk. In order to be effective, risk-reduction interventions must therefore take into account the impact of cognitive impairment on learning and behavior.

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.

Neurocognition, health-related reading literacy, and numeracy in medication management for HIV infection

Successful medication management is an essential ingredient for effective treatment for HIV. Risk factors for poor medication adherence, including neurocognitive impairment and low health literacy, are common in HIV patients. To better understand the most salient risks for poor management of HIV medications, we tested the interrelation of neurocognitive functioning, reading literacy for health related information, and numeracy and their effect on self-management of a simulated HIV medication regimen. Cross-sectional data on 191 HIV-positive men and women recruited from HIV outpatient clinics in South Florida were collected. Exploratory factor analysis was conducted with literacy, numeracy, and neurocognitive scores and suggested that four factors were present representing executive skill, verbal memory, planning, and motor speed. Both the literacy and numeracy scores loaded on the executive factor. Adjusted analyses showed that executive and planning skills were significantly related to medication management. Findings suggest that patients must rely on higher order cognitive skills to successfully navigate medication self-management, and that efforts to simplify health information that merely lowers readability are likely to meet with limited success.

[Neurocognitive impairment related to acquired immunodeficiency syndrome in socially-excluded former intravenous drug abusers]

OBJECTIVE

To analyze differences in neuropsychological test results of former intravenous drug abusers, who were divided into 2 groups based on the presence or absence of HIV-1 infection.

METHODS

Higher-level cognitive functions were assessed with neuropsychological tests in 40 former drug abusers (20 with and 20 without HIV-1 infection).

RESULTS

As compared to individuals without infection, patients with HIV-1 infection showed significantly poorer performance in areas related to attention, learning, working memory, verbal fluency, information processing, problem solving, and flexibility.

CONCLUSION

Independently of the effect of drug addiction, HIV infection was associated with cognitive alterations in all the areas examined.

Cigarette smoking and HIV: more evidence for action

As many as 50-70% of persons infected with HIV are current smokers. Compelling evidence concerning the risks of cigarette smoking to persons living with HIV urges the inclusion of smoking treatment protocols in contemporary models of HIV care. Yet in spite of growing awareness of this problem, persons living with HIV are not being effectively treated for tobacco use. To further an understanding of contributing factors and define directions for evidenced-based intervention, factors associated with smoking behavior among persons living with HIV are examined.