Secondary Prevention 235Finally, aspects of the treatment itself, including patients•
knowledge about treatments and their experience with med-
ications in”uence adherence. Chesney et al. (2000) found
that patients who did not understand the relationship between
missed doses and the development of drug resistance were
more likely to report poor adherence. Confusion regarding
treatment doses may be particularly common among patients
with limited education and low rates of health literacy. For
example, “ndings from a community sample of persons liv-
ing with HIV revealed that low health literacy was a stronger
predictor of poor adherence than was substance use, depres-
sion, and attitudes toward health care providers (Kalichman
et al., 1999). Consistent with earlier studies of adherence
prior to the advent of protease inhibitors, multiple side effects
also play an important role in missed dosages or drug discon-
tinuation (Catz et al., 2000), as do patient beliefs regarding
perceived ef“cacy of treatments (e.g., Aversa & Kimberlin,
1996).
Clearly, there is still much to learn about the dynamics of
treatment adherence. Nonetheless, it is crucial that health be-
havior researchers and medical treatment teams proceed with
innovative approaches to improving HIV treatment adher-
ence. Although there are no published “ndings concerning
the comparative effectiveness of different approaches to im-
proving treatment adherence in HIV disease, approaches to
HIV treatment adherence can be informed by previous re-
search in other areas of behavioral medicine (Sikkema &
Kelly, 1996). These include intervention directed both to-
ward individual patients, as well as interventions directed
toward health care providers. Although adherence interven-
tions might occur within a variety of settings, the integration
of adherence interventions within health care and social
service settings already serving people with HIV is likely to
have the broadest patient impact (Kelly, Otto-Salaj, et al.,
1998).
In other areas of medicine, a common approach to improv-
ing patient adherence is to provide targeted interventions to
patients who are at greatest risk for adherence problems. In
HIV care settings, it may be most prudent to assume thatall
patients are vulnerable to adherence problems. Because of the
complexities of combination therapy regimens and because
many patients come from disadvantaged educational back-
grounds, health education strategies should start at the onset of
treatment (Wainberg & Cournos, 2000). Health care providers
need to supply information about the nature of HIV treatment
and its side effects, as well as both oral and written directions
concerning daily pill taking schedules. In addition, providers
should provide information about treatment ef“cacy, and a
clear description of the potentially dire consequences of poor
adherence (Laws, Wilson, Bowser, & Kerr, 2000).
Educational strategies alone are unlikely to be suf“cient
for most patients. Many HIV-infected individuals live in
chaotic environments involving multiple stressors, including
substance abuse, mental illness, or poverty. These multiple
stressors, taken together with the demanding nature of HIV
treatment regimens, suggest that a multimodal approach to
adherence may be most appropriate. Behavioral strategies,
including multiple reminders (e.g., daily pill boxes, daily
checklists, watch alarms), self-management skills training,
identi“cation of common relapse triggers, and problem solv-
ing to facilitate integration of medication regimens into daily
activities, are components that are likely to be useful when
developing individually tailored adherence interventions
(Rabkin & Chesney, 1999). Interventions should also help
patients to use social support networks and to strengthen self-
ef“cacy for following treatment plans because these factors
have been identi“ed as correlates of improved adherence
(e.g., Catz et al., 2000).
Treatment adherence may be improved by training
providers in effective communication skills to improve
adherence; developing integrative teams of care providers that
are accessible to patients; and encouraging providers (e.g.,
physicians, pharmacists) to provide ”exible patient schedul-
ing and easier access to prescriptions (see Kelly, Otto-Salaj,
et al., 1998). Many persons living with HIV require care for
other life circumstances. Providers must be trained to recog-
nize and address life-circumstances that can interfere with ad-
herence. Providing support and appropriate referral services
for patients struggling with problems such as substance abuse
or recurring psychiatric illness, as well as more basic needs
concerning housing, child care, or “nancial problems, can
reduce barriers to good treatment adherence and serve to
strengthen patient provider relationships. Unfortunately, the
provision of multidisciplinary care services to promote
adherence may only be feasible in large, well-funded HIV
care centers.Risk-Reduction among Persons Living with HIVImprovements in HIV care have led to a decline in AIDS-
related deaths, but rates of new infections have remained sta-
ble in recent years. As the population of HIV-positive men
and women grows, and as some with HIV disease continue to
experience improvements in health, attention must increas-
ingly be directed toward the sexual behavior and drug use
practices among infected persons. Although many persons
living with HIV do practice safer sex and refrain from risky
sexual behaviors, studies of gay men (Kalichman, Kelly, &
Rompa, 1997; Vanable, Ostrow, McKirnan, Taywaditep, &
Hope, 2000), injection drug users (Bluthenthal, Kral, Gee,