Pictorial Aids Don't Affect Medication Adherence for HIV Patients Comorbid With Diabetes, Hypertension

Patients living with HIV and another comorbidity demonstrated higher ART adherence than adherence for their comorbid condition.

A pictorial aid intervention comprised of a photographic representation of medications, dosing schedules and medication indications does not significantly impact HIV patients’ adherence to hypertension and/or diabetes medications, yet these interventions are feasible and easy to implement in care regimens.1

“Overall, participants reported that the pictorial aid helped them remember which medications to take and was easy to understand,” according to study investigators Dr. Anne Monroe et al. “Most participants had a long duration of HIV and engagement in care…[and] because of this, they had a relatively high baseline medication understanding, making a pictorial aid less effective than it might have otherwise been.”

Investigators recruited adult HIV patients with coexisting diabetes mellitus (DM) and/or hypertension (HTN) who were considered at risk for poor health outcomes (N = 46). Participants were randomized to either a pictorial aid intervention (n = 23), consisting of a photo of their medications, indications and dosing schedule, or a list of clinic visit discharge medications (n = 23).

A study physician generated a PictureRx card demonstrating the pictorial representation of each patient’s medications’ appearance, indications and daily dosing schedule. At baseline and follow-up visits, researchers obtained self-reported adherence to HIV and diabetes and/or HTN medications, social support, health literacy, depression, medication understanding and self-efficacy for appropriate medication use.

Medication adherence was calculated as the medication possession ratio, which was defined as the number of days covered by medication for a total of 180 days prior to and following each intervention visit.

Approximately 57% of the total sample had HTN, whereas 37% had HTN and diabetes and 6% had HTN only. A trend existed toward higher HIV medication adherence versus HTN and/or diabetes medication adherence in the total cohort (baseline median MPR for ART 0.92; baseline median MPR for the medication for the comorbid condition 0.79, P = 0.07).

No significant difference was found between the intervention and control group in regard to change in antiretroviral therapy adherence (P = 0.96). While the pictorial aid intervention demonstrated high satisfaction (mean [SD] satisfaction score of 24.8 [4.0] on a 28-point scale), it was not significantly associated with improvement in adherence to diabetes/HTN medications (P = 0.32).

Although there wasn’t a clear-cut benefit to using the pictorial aid in this small HIV sample, the investigators suggest pictograms may still hold utility if they are carefully targeted to those who could benefit from them the most.

“Our results showed high satisfaction with the intervention; therefore, if a target population for whom the intervention is effective were determined, pictograms would likely be well received in future trials or clinical venues,” concluded the investigators. “Patients living with HIV and another comorbidity demonstrated higher ART adherence than adherence for their comorbid condition, suggesting that patients place higher value on their HIV medications than other medications.”

Additionally, they conclude future trials using the same methods in a larger patient population with “a more narrowly defined population” may demonstrate the intervention’s efficacy for improving adherence to medications treating comorbid conditions.

“In an era of HIV care where adherence to both antiretroviral therapy and medications for comorbid conditions are crucial, different interventions to improve adherence are needed," the researchers added.


  1. Monroe AK, Pena JS, Moore RD, et al. Randomized controlled trial of a pictorial aid intervention for medication adherence among HIV-positive patients with comorbid diabetes or hypertension. AIDS Care. 2018;30(2):199-206. doi: 10.1080/09540121.2017.1360993.

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