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Trajectories of Antiretroviral Therapy Adherence and Virologic Failure in Women With HIV in the United States
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JAIDS June 1 2023
Adherence Trajectories and Time to Virologic Failure
Virologic failure occurred among 173 of 1437 (12.0%) women. Women classified in the consistently low adherence trajectory experienced more virologic failure (103; 21.4%) compared with participants in the moderate decreasing (46; 10.2%), moderate increasing (7; 5.1%), and consistently high (17; 4.5%) trajectories by the end of follow-up, (P < 0.001). Figure 3 depicts time to virologic failure among the 4 adherence trajectories. In conclusion, our study emphasizes that adherence to ART remains a challenge among WHIV because approximately one-third of the women were found to be in the consistently low adherence category. Grouping women based on their adherence to multiple trajectories rather than using the conventional method of dichotomizing them into adherent and nonadherent could be of great value to help in designing multilevel behavioral interventions that concomitantly address poor adherence, alcohol consumption, and depression, such interventions are urgently needed.
Based on the results of this study, we identified several clinical recommendations that may improve nonadherence and decrease the rate of virologic failure. First, future interventions should focus on women who follow low and moderate decreasing trajectories. Second, behavioral interventions to address the problem of heavy alcohol consumption amongwomen who followed a consistently low trajectory are critical for increasing adherence and improving biological markers.37 Last, among the same group of women, adherence may be improved by implementing cognitive behavioral therapy that concomitantly addresses both depression and poor adherence.38
Our observed rate of virologic failure (12.0%) among women followed up between 2014 and 2019 indicates a substantially lower rate of failure compared with that in a previous analysis of the WIHS by McFall et al30 who found that nearly half of the women enrolled in the WIHS between 2006 and 2011 experienced virologic failure. Notably, the adherence levels were similar between the 2 studies; 68% of the women reported at least a 95% level of adherence to ART in the study conducted by McFall et al compared with 67% of the women in the current analysis. The difference in the rate of virologic failure may be attributed to the advancements made in the development of modern antiretroviral medications with low toxicities, coupled with the changes in the recommendations in 2012 regarding the initiation of ART irrespective of CD4 count compared with starting the treatment at prespecified cutoff points in the previous guidelines.31

Women with HIV (WHIV) in the United States face many challenges with adherence to antiretroviral therapy (ART), and suboptimal adherence often leads to virologic failure. This study aimed to determine the association between ART adherence trajectories and the risk of virologic failure.
We included WHIV (aged 18 years or older) enrolled in the Women's Interagency HIV Study in the United States from April 2014 to September 2019 who had at least 2 consecutive measurements of HIV RNA and ≥3 measurements of self-reported adherence. Group-based trajectory modeling was used to identify adherence trajectories. Cox proportional hazard ratios were used to measure the association.
Main Outcome Measure:
Virologic failure was defined as HIV RNA ≥200 copies/mL at 2 consecutive visits.
We included 1437 WHIV (median age 49 years). Of all women, 173 (12.0%) experienced virologic failure.
Four adherence trajectories were identified, namely "consistently high" (26.3%), "moderate increasing" (9.5%), "moderate decreasing" (30.6%), and "consistently low" (33.5%). Women in the consistently low adherence group consumed alcohol and experienced depression more than other groups.
Compared with the "consistently high" trajectory, the risk of virologic failure was higher among women with "consistently low" [adjusted hazard ratio (aHR) 2.8; 95% confidence interval (CI): 1.6 to 4.9; P < 0.001] and "moderate decreasing" adherence trajectories (aHR 1.8; 95% CI: 1.0 to 3.2; P = 0.04), but it was similar to those with "moderate increasing" adherence trajectory (aHR 1.0; 95% CI: 0.4 to 2.5; P = 0.94).
Adherence to ART remains a challenge among WHIV. Multilevel behavioral interventions to address poor adherence, alcohol consumption, and depression are needed.

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