Adherence to antiretroviral therapy: the more you look, the more you see

There is evolving understanding of adherence to antiretroviral therapy (ART) and the consequences of nonadherence. The present review aims to discuss recent research findings that illuminate lingering clinical questions or contribute to the contextual framework for future research.

Although some patients can achieve undetectable viral load at moderate adherence levels, studies confirmed that achieving very high adherence optimizes virological and clinical outcomes. In computer modeling, earlier initiation of ART despite suboptimal adherence was associated with improved survival and quality-adjusted life years. Better adherence and virological outcomes occurred when ART was initiated during hospitalization versus outpatient setting, and when depressed patients were treated with selective serotonin reuptake inhibitors. Differential adherence to individual drugs in an antiretroviral regimen appears to be common. Preliminary data from randomized studies designed to evaluate patient-selected treatment partners showed no clear benefit on long-term viral suppression.

Earlier initiation of ART may be desirable even in some patients with suboptimal adherence. Adherence should be reinforced during periods of viral suppression, maximum adherence should be targeted, and attention paid to differential adherence and treatment of depression.