Literacy, education and adherence to antiretroviral therapy in The Gambia A. Hegazi a *, R.L. Bailey a , B. Ahadzie b , A. Alabi b and K. Peterson b a London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; b MRC Laboratories, Fajara, POB 273, Banjul, The Gambia (Received 2 June 2009; final version received 2 February 2010) We examined the relationship of patients’ literacy and education to antiretroviral therapy (ART) adherence in an urban treatment centre in The Gambia. Information on education and literacy systematically collected before ART initiation was compared against selected adherence outcomes. Formally educated patients were significantly more likely to achieve virological suppression at both six and 12 months (87% vs. 67%, OR 3.13, P 0.03; 88% vs. 63%, OR 4.49, P 0.007, respectively). Literate patients had similar benefit at 12 months (OR 3.39 P 0.03), with improved virological outcomes associated with degree of literacy (P 0.003). A trend towards similar results was seen at 6 months for Koranically educated patients; however, this was no longer apparent at 12 months. No significant correlation was seen between socio- demographic characteristics and missed appointments. Our study suggests that literacy, formal education and possibly Koranic education may impact favourably on adherence to ART. Keywords: adherence; HIV; literacy; education; Koranic education Introduction Adherence to antiretroviral therapy (ART) is a major determinant of successful treatment of HIV, being strongly associated with viral load (VL), disease progression, drug resistance and death (Bangsberg et al., 2000; Paterson, Swindells, Mohr, Brester & Vergis, 2000) as well as a reduction in the onward transmission of the virus (Cohen, Gay, Kashuba, Blower & Paxton, 2007). In resource-constrained settings adherence has added importance as access to second-line therapies and monitoring of VL and drug resistance are extremely limited. While adherence in emerging African ART pro- grammes may be sub-optimal (Diabate, Alary & Koffi, 2007; Mouala, Kaba-Mebri, Wata & Rey, 2006), most studies show adherence similar to that in resource-rich settings (Laniece et al., 2003; Mills et al., 2006; Weiser et al., 2003) despite greater access barriers. The available data on adherence to ART in Africa remain limited and heterogeneous. No consis- tent correlation has been found between adherence and age, gender or socio-economic status (Diabate et al., 2007; Mouala et al., 2006; Weiser et al., 2003). Factors identified as negatively affecting adherence on the continent include cost, (Laniece et al., 2003; Weiser et al., 2003) non-disclosure of HIV status, (Weiser et al., 2003) depression (Tadios & Davey, 2006) and alcohol abuse (Dahab et al., 2008). Factors associated with better adherence include advanced disease (Diabate et al., 2007), social support (Diabate et al., 2007; Mouala et al., 2006), acceptance of HIV status and a good relationship with the health-care provider (Tadios & Davey, 2006). Simpler drug regimes (Diabate et al., 2007) or those that are based on efavirenz  as opposed to either a protease inhibitor (Laniece et al., 2003) or nevirapine (Nachega et al., 2008)  have also been associated with improved adherence. The relationship between educational attainment and adherence to ART in Africa is unclear. Some studies have found no correlation between the two (Byakika-Tusiime et al., 2005), others have found an inverse relationship, with completion of secondary or higher education paradoxically associated with in- complete adherence (Eholie et al., 2007; Weiser et al., 2003). In a Nigerian study, patients with a formal education were four times more likely to adhere to therapy (Iliyasu, Kabir, Abubakar, Babashani & Zubair, 2005), while in two East African studies patients with a secondary education were more likely to accept ART than those with a primary education (Karcher et al., 2006; Karcher, Omondi, Odera, Kunz & Harms, 2007). Koranic education is a long-standing parallel system of education throughout West Africa that takes many forms but in general focuses on reading and memorisation of the Arabic Koran (Easton, 1999). In The Gambia it is commonly pursued in *Corresponding author. Email: ahegazi@doctors.net.uk AIDS Care Vol. 22, No. 11, November 2010, 13401345 ISSN 0954-0121 print/ISSN 1360-0451 online # 2010 Taylor & Francis DOI: 10.1080/09540121003693514 http://www.informaworld.com