title: Explaining variability in the relationship between antiretroviral adherence and HIV mutation accumulation.
abstract: OBJECTIVE
  Determining the relationship between antiretroviral adherence and resistance accumulation is important for the design and evaluation of adherence interventions. Our objective was to explain heterogeneity observed in this relationship.
  
  
  METHODS
  We first conducted a systematic review to locate published reports describing the relationship between adherence and resistance. We then used a validated computer simulation to simulate the patient populations in these reports, exploring the impact of changes in individual patient characteristics (age, CD4, viral load, prior antiretroviral experience) on the shape of the adherence-resistance (A-R) curve.
  
  
  RESULTS
  The search identified 493 titles, of which 3 contained relevant primary data and 2 had sufficient follow-up for inclusion (HOMER and REACH cohorts). When simulating HOMER, the A-R curve had a high peak with a greatly increased hazard ratio (HR) of accumulating mutations at partial compared to complete adherence (simulation, HR 2.9; HOMER, HR 2.7). When simulating REACH, the A-R curve had a shallow peak with a slightly increased hazard of accumulating mutations at partial adherence (simulation, HR 1.2; REACH, HR 1.4). This heterogeneity was primarily attributable to differences in antiretroviral experience between the cohorts.
  
  
  CONCLUSIONS
  Our computer simulation was able to explain much of the heterogeneity in observed A-R curves.
authors.affiliation: Section of General Internal Medicine, Yale University School of Medicine and VA Connecticut Healthcare System, New Haven, CT, USA. ronald.braithwaite@va.gov
authors.forename: R S
authors.initials: RS
authors.lastname: Braithwaite
authors.forename: S
authors.initials: S
authors.lastname: Shechter
authors.forename: M S
authors.initials: MS
authors.lastname: Roberts
authors.forename: A
authors.initials: A
authors.lastname: Schaefer
authors.forename: D R
authors.initials: DR
authors.lastname: Bangsberg
authors.forename: P R
authors.initials: PR
authors.lastname: Harrigan
authors.forename: A C
authors.initials: AC
authors.lastname: Justice
mesh_terms: D044966:Anti-Retroviral Agents / Q000008:administration & dosage*; D023241:Antiretroviral Therapy, Highly Active; D015331:Cohort Studies; D003198:Computer Simulation; D024882:Drug Resistance, Viral / Q000235:genetics*; D006678:HIV / Q000235:genetics*; D015658:HIV Infections / Q000188:drug therapy* / Q000523:psychology / Q000821:virology*; D006801:Humans; D009154:Mutation; D010349:Patient Compliance
chemical_list: D044966:Anti-Retroviral Agents