Modeling HIV dynamics and antiviral response with consideration of time-varying drug exposures, adherence and phenotypic sensitivity.

Highly active antiretroviral therapies consisting of reverse transcriptase inhibitor drugs and protease inhibitor drugs, which can rapidly suppress HIV below the limit of detection, are currently the most effective treatment for HIV infected patients. In spite of this, many patients fail to achieve viral suppression, probably due to existing or developing drug resistance, poor adherence, pharmacokinetic problems and other clinical factors. In this paper, we develop a viral dynamic model to evaluate how time-varying drug exposure and drug susceptibility affect antiviral response. Plasma concentrations, in turn, are modeled using a standard pharmacokinetic (PK) one-compartment open model with first order absorption and elimination as a function of fixed individual PK parameters and dose times. Imperfect adherence is considered as missed doses in PK models. We discuss the analytic properties of the viral dynamic model and study how time-varying treatment efficacies affect antiviral responses, specifically viral load and T cell counts. The relationship between actual failure time (the time at which the viral growth rate changes from negative to positive) and detectable failure time (the time at which viral load rebounds to above the limit of detection) is investigated. We find that an approximately linear relationship can be used to estimate the actual rebound failure time from the detectable rebound failure time. In addition, the effect of adherence on antiviral response is studied. In particular, we examine how different patterns of adherence affect antiviral response. Results suggest that longer sequences of missed doses increase the chance of treatment failure and accelerate the failure. Simulation experiments are presented to illustrate the relationship between antiviral response and pharmacokinetics, time-varying adherence and drug resistance. The proposed models and methods may be useful in AIDS clinical trial simulations.