Title: Health Literacy and Adherence to Antiretroviral Treatment among Human Immunodeficiency Virus (HIV) Infected Youth
Description: Poor health literacy has been associated with a range of negative health outcomes and few studies have assessed the relationship between adolescent health literacy and health outcomes. Human immunodeficiency virus (HIV) infected adults with lower health literacy have suboptimal treatment adherence, but this association has not be examined in the adolescent HIV-infected population. Research incorporating more comprehensive models of health literacy including beliefs about HIV treatment may help to better define the connection between health literacy and adherence to HIV treatment. The primary objective of this study was to examine the association between health literacy, literacy, beliefs about medications, media use and adherence to antiretroviral treatment in HIV-infected adolescents. Methods: Using a cross-sectional descriptive survey design, a convenience sample of 50 HIV-infected youth was recruited from four HIV clinical settings. The primary outcome was adherence to antiretroviral treatment and was measured with 3- day self reported adherence estimates.

Instruments to measure the predictor variables of interest were the Test of Functional Health Literacy in Adults (TOFHLA), Beliefs about Medication Scale (BAMS), Rapid Estimate of Adult Literacy in Medicine-teen version (REALM-teen), and media use was evaluated with a brief investigator-developed questionnaire. Descriptive statistics, bivariate and multivariate analyses using logistic regression were computed with the level of significance set to 0.05. Results: The sample population included 50 participants, ages 13-24 years (median age=20.4 years) either perinatally (n=40) or behaviorally (n=10) infected. The median and mean +SD self reported adherence estimates were 100% (range 0-100) and 86.0% + 26.92, respectively. Adherence estimates were highly correlated with HIV-viral load (Spearman's rho=-0.615, p=0.000). Adequate levels of health literacy were demonstrated in 80.0% (n=40) of youth. Below grade level reading was observed in 72.0% (n=36) of participants, despite 48.0 % (n=24) of the sample having completed high school and or currently enrolled in college.

Common media devices (computer, internet access, DVD/VCR player, television, cable/satellite television) were reported in the homes of > 90.0% of youth and cellular phone ownership was reported in 46 of 50 (92.0%) participants. More than half of participating HIV-infected youth reported not spending any time reading offline (56.0%) or online (60.0%) and 74.0% reported going online during the preceding day. Using self reported 3-day adherence estimates (100% adherent, > 100% adherent) in a fitted logistic regression model, health literacy was not predictive of adherence (p=0.152). Participants with higher positive outcome expectancy scores were significantly more likely to have self reported adherence estimates of 100% (Adjusted OR=1.066, 95% CI=1.018-1.117) and the odds of 100% adherence was significantly lower among the 63.9% (23/36) of participants with below age level reading, compared to the 85.7% of youth (12/14) with > age level reading and 100% adherence (Adjusted OR=0.066, 95% CI=0.005-0.831).

Conclusions: These finding provide support for the integration of beliefs into health literacy models with HIV-infected youth in the study of treatment adherence. Although health literacy was not associated with antiretroviral adherence in this study, this may have been explained by the small sample size, and additional research with a larger sample is needed to adequately describe this relationship. Considering the association of age level reading ability to antiretroviral adherence and the large percentage of youth with below grade level reading in this sample, this relationship warrants further exploration in this population. Finally media may offer the potential for new and improved methods to deliver health education, especially in HIV-infected youth with low literacy skills.