Testing and prevention remain key factors to stopping the spread of HIV, and being tested is an essential first step to identify patients eligible for treatment. Yet major barriers exist to the successful implementation of HIV testing and counseling strategies: 1) patients' recognition of their risk of HIV, 2) access to testing, 3) acceptance of testing, 4) receipt of results, and 5) entry into preventive and treatment services. A major reason for not undergoing HIV testing is that persons at risk may not perceive themselves to be at high risk for acquiring infection, and thus do not seek to be tested.24,25
However, to our knowledge, the association between the factors of health literacy and HIV testing has not been previously examined in the context of other barriers to HIV testing. Despite the fact that there are no reports to suggest that populations with low literacy level are at risk of undertesting for HIV, we were particularly interested in exploring whether patients' health literacy level impacted willingness to undergo HIV testing. Our results indicate that it does not in the setting of provision of a low-literacy educational pamphlet and health care provider recommendation.
Previous studies have found that individuals with low health literacy are less likely than individuals with adequate literacy to know essential information about their health,1–6
to have poorer health outcomes, and increased hospitalization rates.6,17,18
In addition, higher rates of low health literacy have been demonstrated in public hospital settings, where the patient population may be at higher risk for HIV4,7,10,11
compared to Medicare managed care populations.16
As HIV testing efforts are expanded and HIV testing is incorporated into the medical care setting, providers need to know the impact of health literacy on HIV testing behaviors.14
The associations of health literacy and HIV have only been studied among individuals who were already HIV positive.11,13,14
Among HIV-positive patients taking highly active antiretroviral therapy, low health literacy was associated with poor self-reported adherence to medications and thus worse outcomes.11
The relationship between literacy and control of HIV infection has been reported in three different cross-sectional studies. In these reports, better health literacy was associated with greater odds of undetectable viral load and greater odds of having CD4 counts greater than 300.11,13,14
Studies of health literacy and HIV prevention have found that instructions on condom packages and HIV/AIDS educational materials require a college reading level.28
Thus, low health literacy appears to be associated with problems disseminating HIV prevention messages and poorer treatment outcomes among patients already HIV infected.
Fortunately, the results of this study indicate that low health literacy may not be a barrier to patients accepting HIV testing when recommended by a health care provider. Specifically, low health literacy was found to be a predictor of HIV test acceptance among patients seeking care at an inner-city hospital. Other possible factors such as trust and dependence on health care providers should be considered as possibly influencing HIV testing acceptance, but these were not measured. Future studies evaluating factors affecting HIV test acceptance should include such measures. The distribution of low-literacy brochures as part of the HIV pretest counseling process during our study may have increased the proportion of people with low health literacy that accepted an HIV test. Provision of the brochures when the patient was registered allowed time for review in the waiting area of the clinic before being seen. In addition, the brochures were designed to be straightforward with a clear message, and written at a 6th grade level. Our study supports that the expected barrier of low health literacy can be overcome, and health care providers can utilize opportunities to increase HIV testing in health care settings that serve inner-city populations with expected high rates of HIV infection.
In summary, we found that patients with health literacy at or below a 6th grade level were more likely to accept HIV testing than patients with adequate health literacy. Furthermore, low health literacy was found to be associated with increased HIV testing controlling for age and education. Given the current dynamics of the HIV epidemic in the United States that increasingly affects minority inner-city populations where low health literacy is frequently found, campaigns using low health literacy ads and brochures may increase the number of people seeking HIV testing and counseling services.
Identifying strategies to overcome the above-mentioned barriers for HIV testing with prevention strategies that incorporate aspects such as health literacy, gender, race, and ethnicity may provide an invaluable avenue to improve the rates of HIV testing in the United States. We hope that these strategies will support the recommendations made by the CDC Serostatus Approach to Fighting the HIV Epidemic (SAFE) initiative.24
Further research in chronic diseases such as HIV infection should focus on comparing interventions directed specifically at reducing health-related barriers with other means of improving health outcomes.