Health literacy for people living with HIV/Aids: an integrative review

an integrative literature review, using six databases, was conducted between January and April of 2014. The descriptors aids and Health Literacy were used, in Portuguese, English and Spanish. A total of 130 articles were found and 14 were selected. Three categories were identified: educational technologies and health literacy for HIV/Aids; assessment of health literacy of patients with HIV/Aids; and health literacy and adherence to antiretroviral therapy.

Results:

analysis of health literacy, socioeconomic status and educational level of people living with HIV/ Aids was essential for implementation of educational strategies that increased adherence to health guidance.

Conclusion:

this study showed the importance of health literacy for working with people living with HIV/Aids, especially considering individuals who did not possess the minimum necessary for survival, which makes it relevant and encourages further research on the topic.

Descriptors:
HIV; Acquired Immunodeficiency Syndrome; Health Promotion; Nursing; Health Education

Title	Year	Purpose	Study design	Conclusion
Problem posing and cultural tailoring: developing an HIV/Aids health literacy toolkit with the African American community⁽¹⁶16 Rikard RV, Thompson MS, Head R, Mcneil C, White C. Problem posing and cultural tailoring: developing an HIV/AIDS health literacy toolkit with the African American community. Health Promot Pract [Internet]. 2012[cited 2014 Jan 11];13(5):626-36. Available from: http://hpp.sagepub.com/content/13/5/626.full.pdf+html http://hpp.sagepub.com/content/13/5/626.... ⁾.	2012	Development of an educational tool based on the educational philosophy of Paulo Freire, using focus groups and reading material, involving health literacy for prevention of infection and reinfection with HIV in Africa. Sample: 24 participants.	Development of the HIV/Aids health literacy toolkit occurred in two stages. In stage 1, a nonprofit organization and the research team established a collaborative partnership to develop a culturally tailored HIV/Aids HL toolkit. In stage 2, African American community members participated in focus groups conducted as Freirian cultural circles to further refine the HIV/Aids health literacy toolkit. In both stages, problem posing engaged participants’ knowledge, experiences, and concerns to evaluate a working draft toolkit.	The educational tool improved access to health information in an adapted manner to the culture of individuals.
Designing interventions to overcome poor numeracy and improve medication adherence in chronic illness, including HIV/Aids⁽¹⁷17 Moore JO, Boyer EW, Safren S, Robbins GK, Boudreaux ED, Rosen R, et al. Designing interventions to overcome poor numeracy and improve medication adherence in chronic illness, including HIV/AIDS. J Med Toxicol [Internet]. 2011[cited 2014 Jan 17];7(2):133-8. Available from: http://link.springer.com/article/10.1007%2Fs13181-011-0149-3 http://link.springer.com/article/10.1007... ⁾.	2011	Description of visual intervention using smartphones to improve medication adherence in populations with chronic diseases such as HIV/Aids. Sample: 12 participants.	Personalized graphical representations of plasma medication concentration and dynamic disease state simulation were used to overcome poor numeracy. These methods incorporate efficient, precise, and clear graphical data; cartographical techniques focused on judicious use of color intensities; and animation that increases engagement and accentuates information transfer.	An educational tool can improve adherence to therapy. It was found that numeracy, an element of health literacy, refers to the ability to understand related numerical information, describing the degree to which individuals can access, process, interpret and act on health information from graphical and probabilistic mechanisms, when threat to individual’s perception and response to treatment is deficient, with low levels of medication adherence.
Nurse-delivered antiretroviral treatment adherence intervention for people with low literacy skills and living with HIV/Aids⁽¹⁸18 Kalichman SC, Cherry J, Cain D. Nurse-delivered antiretroviral treatment adherence intervention for people with low literacy skills and living with HIV/AIDS. J Assoc Nurses AIDS Care [Internet]. 2005[cited 2014 Jan 9];16(5):3-15. Available from: http://www.nursesinaidscarejournal.org/article/S1055-3290(05)00227-X/pdf http://www.nursesinaidscarejournal.org/a... ⁾.	2005	Pilot test of counseling intervention for adherence to HIV treatment guided by theory of behavior change, health and health education for people with low levels of health literary and antiretroviral medication adherence. Sample: 30 participants.	The authors undertook the development and pilot testing of a brief HIV treatment adherence improvement counseling intervention for people with low health literacy who were taking antiretroviral medications. Guided by a theory of health behavior change, health education principles for low literacy populations, and formative research, the authors designed a two-session plus one booster session nurse-delivered HIV treatment adherence intervention.	Results of a pilot test with 30 men and women with HIV and low health literacy showed that intervention increased knowledge about HIV/Aids, intention to improve and self-efficacy for medication adherence. Participants exposed to intervention also showed improvement in medication adherence, and reductions in the number of tablets forgotten.
Program to enhance health literacy and treatment adherence in low-income HIV-infected Latino men and women. Aids Patient Care and STDS⁽¹⁵15 Servellen GV, Carpio F, Lopez M, Garcia-Teague L, Herrera G, Monterrosa F, et al. Program to enhance health literacy and treatment adherence in low-income HIV-infected latino men and women. AIDS Patient Care STDS [Internet]. 2003[cited 2014 Jan 25];17(11):581-94. Available from: http://online.liebertpub.com/doi/pdf/10.1089/108729103322555971 http://online.liebertpub.com/doi/pdf/10.... ⁾.	2003	Evaluation of acceptance and effectiveness of a program to improve health literacy in low-income Latino men and women with HIV, who received antiretroviral therapy. It was a program of instructional modular support with follow-up of 5 weeks to 6 months by a nurse. Objectives of the program were to improve knowledge and skills, build confidence to follow the treatment regimen, and teach assertive communication. Sample: 81 participants.	Participants rated the program highly on measures of satisfaction, providing evidence of its acceptability. The effectiveness of the program was assessed in comparisons of the intervention (n=41) and standard care only (n=40) groups at baseline and 6-week intervals.	Program participants showed significant improvement on knowledge related to HIV/Aids, its treatment, and understanding of the technical terms related to HIV infection, compared to participants in the comparison group.

Title	Year	Purpose	Study design	Conclusion
Seeking information about HIV/Aids: a qualitative study of health literacy among people living with HIV/Aids in a low prevalence context⁽¹⁹19 Zukoski AP, Thorburn S, Stroud J. Seeking information about HIV/AIDS: a qualitative study of health literacy among people living with HIV/AIDS in a low prevalence context. AIDS Care [Internet]. 2011[cited 2014 Jan 22];23(11):1505-8. Available from: http://www.tandfonline.com/doi/pdf/10.1080/09540121.2011.582077 http://www.tandfonline.com/doi/pdf/10.10... ⁾.	2011	Analysis of the level of health literacy of a rural population with HIV/Aids. Sample: 19 participants	In qualitative semi-structured interviews, participants’ primary sources of information, types of information sought, and barriers to accessing information were explored.	It was necessary to expand research and specific interventions on health literacy to address social and structural barriers among those who lived in areas of low HIV prevalence, such as in rural areas, which had low health literacy.
The relationship between health literacy, knowledge of health status, and beliefs about HIV/Aids transmission among Ryan White clients in Miami⁽²⁰20 Mooss A, Brock-Getz P, Ladner R, Fiaño T. The relationship between health literacy, knowledge of health status, and beliefs about HIV/AIDS transmission among Ryan White clients in Miami. Health Educ J [Internet]. 2012[cited 2014 Jan 30];72(3):292-9. Available from: http://hej.sagepub.com/content/72/3/292.full.pdf+html http://hej.sagepub.com/content/72/3/292.... ⁾.	2012	Analysis of the level of health literacy of patients with HIV/Aids in Miami. Sample: 694 participants.	Convenience sampled, quantitative analysis captured with closed- and open-ended interviews.	A significant proportion of patients with HIV/Aids had low levels of health literacy, having difficulty receiving health education, or reading educational materials.
The association among literacy, numeracy, HIV knowledge and health-seeking behavior: a population-based survey of women in rural Mozambique⁽²¹21 Ciampa PJ, Vaz LM, Blevins M, Sidat M, Rothman RL, Vermund SH, et al. The association among literacy, numeracy, HIV knowledge and health-seeking 7(6):e39391. Available from: http://journals.plos.org/plosone/article/asset?id=10.1371%2Fjournal.pone.0039391.PDF http://journals.plos.org/plosone/article... ⁾.	2012	Validation of a scale to assess literacy, numeracy, knowledge and behavior regarding HIV, in a population of women in rural Mozambique. Sample: 3,557 participants.	A validated measure of literacy and numeracy, the Wide Range Achievement Test, version 3 (WRAT-3), was translated into Portuguese, adapted for a Mozambican context, and administered to a cross-section of female heads-of-household.	The subscales of literacy and numeracy were valid and adapted for use in rural Mozambican women. Limited literacy and numeracy skills were common and associated with less knowledge about HIV.
Health literacy and health outcomes in HIV seropositive persons⁽⁷7 Nokes KM, Coleman CL, Cashen M, Dole P, Sefcik E, Hamilton MJ, et al. Health literacy and health outcomes in HIV seropositive persons. Res Nurs Health [Internet]. 2007[cited 2014 Dec 12];30(6):620-7. Available from: http://onlinelibrary.wiley.com/doi/10.1002/nur.20219/pdf http://onlinelibrary.wiley.com/doi/10.10... ⁾.	2007	Evaluation of the influence of the personal characteristics and health literacy in relation to body changes, depression and intensity of symptoms resulting from HIV infection. Sample: 489 participants.	Cross-sectional study. Health literacy was measured with the Rapid Estimate of Adult Literacy in Medicine (REALM) instrument.	Despite the fact that health literacy was associated with better health outcomes, people with higher literacy reported significantly worse health outcomes. This unexpected relationship required further exploration using longitudinal studies and scales to more specifically assess health literacy.
Do brief screening questions or provider perception accurately identify persons with low health literacy in the HIV primary care setting?⁽²²22 Ohl M, Harris A, Nurudtinova D, Cai X, Drohobyczer D, Overton ET. Do brief screening questions or provider perception accurately identify persons with low health literacy in the HIV primary care setting? AIDS Patient Care STDS [Internet]. 2010[cited 2014 Feb 12];24(10):623-9. Available from: http://online.liebertpub.com/doi/pdf/10.1089/apc.2009.0319 http://online.liebertpub.com/doi/pdf/10.... ⁾.	2010	Determining the accuracy of a screening instrument with brief questions for people with low health literacy in the context of HIV in primary care, raising the hypothesis that a brief screening to identify low health literacy was more accurate than the perception of the provider or self-reporting. Sample: 147 participants.	The accuracy of provider perception and previously described brief screening questions for identification of low health literacy among persons attending two HIV specialty clinics were examined.	The brief screening tool had insufficient information on the likelihood of low health literacy, which made the instrument insufficient for use in screening in primary care for people with HIV. In the absence of screening tools for health literacy that are fast and accurate, healthcare professionals should consider interventions to improve health communication with patients. Simple interventions include creating clinical materials written at a reading level accessible to all patients, the routine use of visuals, confirmation of patient understanding when discussing care, and avoiding the use of technical terms. These interventions could benefit all patients, especially those with low health literacy.

Title	Year	Purpose	Design	Conclusion
Stress and poverty predictors of treatment adherence among people with low-literacy living with HIV/Aids⁽²³23 Kalichman SC, Grebler T. Stress and poverty predictors of treatment adherence among people with low-literacy living with HIV/AIDS. Psychosom Med [Internet]. 2010[cited 2014 Feb 9];72(8):810-6. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016469/pdf/nihms260158.pdf http://www.ncbi.nlm.nih.gov/pmc/articles... ⁾.	2010	Analysis of association between social development, health, and stressors related to poverty in relation to antiretroviral therapy adherence in a sample of people with low literacy living with HIV/Aids in southeastern United States. Sample: 188 participants.	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 non adherence. HIV treatment adherence was monitored prospectively, using unannounced pill counts.	The shortage of food, hunger, depression, internalized stigma, drug use and social stressors associated with HIV contributed to non adherence to antiretroviral therapy. In socially disadvantaged people in developing countries, poverty, food insufficiency and hunger should be directly addressed.
Association between health literacy and HIV treatment adherence: further evidence from objectively measured medication adherence⁽²⁴24 Kalichman SC, Pope H, White D, Cherry C, Amaral CM, Swetzes C, et al. Association between health literacy and HIV treatment adherence: further evidence from objectively measured medication adherence. J Int Assoc Physicians AIDS Care [Internet]. 2008[cited 2014 Feb 3];7(6):317-23. Available from: http://jia.sagepub.com/content/7/6/317.full.pdf+html http://jia.sagepub.com/content/7/6/317.f... ⁾.	2008	Analysis of the association between health literacy and adherence to HIV treatment. Sample: 145 participants.	Men and women receiving antiretroviral therapy completed a test of health literacy and measures of common adherence markers. Medication adherence was monitored by unannounced pill counts.	Association between literacy and adherence existed and was confirmed using an objective measure of medication adherence.
HIV treatment adherence, patient health literacy, and health care provider-patient communication: results from the 2010 Aids treatment for life international survey⁽²⁵25 Nachega JB, Morroni C, Zuniga JM, Schechter M, Rockstroh J, Solomon S, et al. HIV treatment adherence, patient health literacy, and health care provider-patient communication: results from the 2010 AIDS treatment for life international survey. J Int Assoc Physicians AIDS Care [Internet]. 2012[cited 2014 Jan 22];11(2):128-33. Available from: http://jia.sagepub.com/content/11/2/128.full.pdf+html http://jia.sagepub.com/content/11/2/128.... ⁾.	2012	International survey aimed to analyze patients from different countries in relation to the level of adherence to antiretrovirals, health literacy and communication with health professionals. Sample: 2,035 participants.	The Aids Treatment for Life International Survey was a multicountry cross-sectional study. A 40-minute interview was conducted using a standardized self-report adherence questionnaire.	Different levels of adherence to antiretrovirals in different geographic regions and low health literacy can determine the low adherence to treatment, by requiring more behavioral and clinical educational interventions, to achieve and maintain optimal levels of adherence, virologic suppression and long-term treatment success.
Requesting help to understand medical information among people living with HIV and poor health literacy⁽⁸8 Kalichman SC, Pellowski J, Chen Y. Requesting help to understand medical information among people living with HIV and poor health literacy. Aids Patient Care STDS [Internet]. 2013 [cited 2014 Dec 8];27(6):326-32. Available from: http://online.liebertpub.com/doi/pdf/10.1089/apc.2013.0056 http://online.liebertpub.com/doi/pdf/10.... ⁾.	2013	Analysis of adherence to antiretroviral therapy for people living with HIV who had poor health literacy skills. Sample: 474 participants.	Five sources of data were collected in the current study: literacy assessments, information-related assistance interviews, health behavior assessments, unannounced medication adherence pill counts, and chart abstracted viral load and CD4 counts.	Individuals who sought informational assistance were significantly more likely to adhere to multiple strategies. However, despite asking for information and using more strategies of control, participants who requested informational assistance showed lower adherence to treatment and less suppression of HIV replication. People living with HIV with poor skills and health literacy could benefit from medication adherence programs.
Program to enhance health literacy and treatment adherence in low-income HIV-infected Latino men and women. Aids Patient Care and STDS⁽¹⁵15 Servellen GV, Carpio F, Lopez M, Garcia-Teague L, Herrera G, Monterrosa F, et al. Program to enhance health literacy and treatment adherence in low-income HIV-infected latino men and women. AIDS Patient Care STDS [Internet]. 2003[cited 2014 Jan 25];17(11):581-94. Available from: http://online.liebertpub.com/doi/pdf/10.1089/108729103322555971 http://online.liebertpub.com/doi/pdf/10.... ⁾.	2003	Evaluation of acceptance and effectiveness of a program to improve health literacy in low-income Latino men and women with HIV, who received antiretroviral therapy. It was a program of instructional modular support with follow-up of 5 weeks to 6 months by a nurse. Objectives of the program were to improve knowledge and skills, build confidence to follow the treatment regimen, and teach assertive communication. Sample: 81 participants.	Participants rated the program highly on measures of satisfaction, providing evidence of its acceptability. The effectiveness of the program was assessed in comparisons of the intervention (n=41) and standard care only (n=40) groups at baseline and 6-week intervals.	Program participants showed significant improvement on knowledge related to HIV/Aids, its treatment, and understanding of the technical terms related to HIV infection, compared to participants in the comparison group.

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[1] CORRESPONDING AUTHOR: Gilmara Holanda da Cunha. E-mail: gilmaraholandaufc@yahoo.com.br