055). When restricting the analysis to the subgroup of patients who were on the most common current regimens (i.e. boosted
PI- or NNRTI-based ART: 11 701 DCVL episodes and 269 rebound events), the adjusted RR for each 10% higher drug coverage was 0.94 (95% CI 0.88–1.00; P=0.037). This study shows that, among individuals who have already achieved VL suppression for at least 6 months, adherence as measured by drug coverage according to prescription refill data independently predicts the risk of viral rebound, and thus clinicians could benefit from routinely having such information available when seeing patients. In addition, our study shows that, among patients with BMN673 VL suppression, some have low to modest adherence and, while the risk of rebound is higher in such patients than in those with high adherence, the risk of rebound is still relatively low. Several studies have demonstrated the ability of adherence
to predict viral rebound in a suppressed population by means of self-report [45], MEMS [18], and pharmacy refill-based measures [36,39,46]. The main issue is that, among objective adherence measures, MEMS and therapeutic monitoring of plasma drug concentrations are very expensive and therefore not able to be implemented in clinical practice, in particular in low-income settings, where the prevalence of HIV is higher and adherence is a big issue. Therefore, the most widespread ART adherence measure used is self-report adherence, but it is known Doxorubicin in vitro that this measure is subjective, tends Ixazomib chemical structure to overestimate adherence and is vulnerable to social desirability bias. This is why we attempted to assess whether adherence, based on drug prescription coverage, could be used to predict VL rebound. This measure is objective and cheap, and can be easily collected in most clinical settings, even in low-income settings. The only
difficulty is that this measure is able to be implemented only in a closed health system, where patients have a single source of medication. Among the studies that have demonstrated that an adherence measure is a useful tool for the prediction of VL rebound, the most similar to ours was the study conducted by Gross et al. [39], in that the period of adherence assessment was comparable, the two adjoining refills considered corresponded more or less to 6 months, and the time to the endpoint VL was around 3 months. Differently from our study, VL suppression was defined as two consecutive VLs <500 copies/mL and viral rebound as the second of two consecutive VL values >1000 copies/mL, and the ART adherence measure was based on drug pick-up (pharmacy refill) as opposed to the issue of prescriptions. Our study has several limitations. The first concerns drug coverage as a measure of adherence. The main advantage of this measure is that it is simple and easy to calculate and apply.