The Pharmacist’s Role in Maximizing HIV Antiretroviral Therapy

In 2012, 9.7 million people worldwide received antiretroviral therapy (ART), representng an 11% increase from the previous year. ART is significantly contributing to the ongoing drop in new annual HIV infections around the world, which has resulted in improved life expectancy.1 With treatment advancements, HIV has evolved from a terminal illness to a manageable long-term chronic disease. Pharmacists are ideally positioned to provide a primary-line interface to patients with HIV. The expanding role of the pharmacist can significantly improve patient outcomes and ART results, and the integration of a pharmacist to an HIV care team can help to maximize ART adherence and drug resistance prevention and deliver HIV-focused medication therapy management (MTM) services.

The US National HIV/AIDS Strategy from HHS suggests that diversifying a support team’s skill set will strengthen the quality of care. Pharmacist integration into the HIV care team is based on patient accessibility and schedule flexibility. Patients have the flexibility to access pharmacist care at a time and place that is convenient; however, HIV clinics with set hours may present access challenges due to conflicting schedules. Community pharmacists provide easier access. Community pharmacists have demonstrated success in managing the medication needs of patients with chronic illness, leading to improvements in therapy adherence and drug resistance prevention. A 2007 evaluation of Medicare Part D recipients indicated that 90% of urban beneficiaries lived within 4 miles and 70% of rural beneficiaries lived within 15 miles of a community pharmacy.2

With the rise in drug resistance, treatment options have become limited and require a more complex individualized patient care strategy. As drug resistance is linked to ART nonadherence, pharmacists understand treatment goals and the greater need for resistance prevention through improved adherence. The National HIV/AIDS Strategy has 4 primary goals:3

1) Reduce the transmission of HIV infection.
2) Improve access to care and health outcomes for individuals infected with HIV.
3) Address health disparities and inequities among the HIV patient population.
4) Coordinate an effective national response to the epidemic.

Pharmacists understand the risk of resistance and complexities of ART dosing regimens. Regimens that contain at least 2 or 3 active drugs from ≥2 classes are recommended for virologic suppression.4,5 If a regimen fails, those active drugs can no longer be used due to potential resistance. Therefore, the choices available for a new 2-drug regimen become limited. Treatment plans are the same for both treatment-experienced and treatment-naïve patients, with the clinical end point being viral suppression while enabling immune recovery and minimizing adverse effects. Successful viral suppression will depend upon the adherence, safety, and tolerability of the chosen regimen.4 ART is essential to sustain viral suppression, reduce HIV-associated morbidity, prolong survival, and reduce HIV transmission. Pharmacist counseling and education improves medication adherence, which is key to reaching the clinical goals of patients with HIV.

In several well-documented studies, pharmacists improved ART adherence in patients with HIV. In a US Department of Veterans Affairs Medical Center adherence study, the results demonstrated a 10% increase in adherence associated with a viral load decrease.5 The Christiana Care Health System in Delaware also reported that patients who attended a pharmacist-led medication adherence clinic and at least 1 educational session from a clinical pharmacist had a statistically significant decrease in viral load 6 and 12 months after initiating therapy compared with patients who did not attend the clinic.6 Baseline CD4-positive (CD4+) T-lymphocyte counts and viral load data were similar for both groups.

In 2005, the California Department of Health Care Services developed a pilot program to evaluate the effectiveness of community-based, financially compensated, pharmacist-led MTM services for patients with HIV/AIDS. Ten pharmacies were selected to participate in the study, and 2234 patients used the pilot services. These services were individualized and patient specific, with pharmacists providing face-to-face services to the patients or, in limited circumstances, the patient’s caregiver. Following the first year of the program, study participants reported higher medication adherence rates, fewer excess fills, and fewer contraindicated regimens compared with patients not in the program. In addition, patients in the program remained on a single type of ART regimen throughout the study year, decreasing the likelihood of developing drug resistance and enhancing the ability to maintain their health over longer periods of time.7

A 3-year follow-up to this pilot program was reported in 2011. The evaluation showed a continuation of results in which patients reported higher adherence rates to ART, fewer excess fills, and fewer contraindicated regimens. Patients remained on a single type of ART regimen each year of the study, indicating the decreasing likelihood of developing drug resistance and preserving therapeutic options in the future.8

By the same token, HIV has evolved into a manageable chronic disease and has created an even greater need for HIV-focused MTM services. The results of 1 study showed MTM services resulted in a 31% reduction in total health expenditures per patient, from $11,965 to $8197, and a 14% increase clinical goals achieved.9 A comprehensive medication review should start immediately with ART initiation. Pharmacist counseling of patients with HIV includes several key aspects: an evaluation to ensure appropriate dosage, patient administration counseling, ART adherence education, medication interactions, and possible adverse effect management. If lab data are available, monitoring of CD4+ cell counts and HIV RNA viral load could also be reviewed.

Through ongoing quarterly targeted medication counseling follow-up sessions, the pharmacist may identify ART noncompliance. They also provide routine communications back to the provider and the entire care team, which eases that burden on the patient. Adequate patient education, drug-focused expertise, and care coordination are essential for the overall MTM model. A true collaborative environment focused on the care of patients with HIV is vital to the success of any MTM program. Treatment goals are focused on early diagnosis, engagement, and integration of the patient into a comprehensive care program, retention of the patient in the program, and providing access to ART. With the US population of patients with HIV growing annually, there will be an ongoing need for comprehensive supportive care, and pharmacists can help meet this growing need by providing specialized MTM to these patients.2

References
  1. World Health Organization (WHO). (2013). Global update on HIV treatment 2013: Results, Impact and Opportunities. Retrieved from http://www.who.int/hiv/pub/progressreports/update2013/en/ October 1, 2018.
  2. Kauffman, Y., Nair, V., Herist, K., Thomas, V., & Weidle, P. J. (2012). HIV medication therapy management services in community pharmacies. Journal of the American Pharmacists Association. American Pharmacists Association. https://doi.org/10.1331/JAPhA.2012.12063
  3. National HIV/AIDS Strategy for the United States: Updated to 2020, Accessed at https://www.hiv.gov/federal-response/national-hiv-aids-strategy/nhas-update, October 1, 2018
  4. Cihlar, T., & Fordyce, M. (2016). Current status and prospects of HIV treatment. Current Opinion in Virology18, 50–56. https://doi.org/10.1016/j.coviro.2016.03.004
  5. Grossberg R, Zhang Y, Gross R. A time-to-prescription-refill measure of antiretroviral adherence predicted changes in viral load in HIV. J Clin Epidemiol. 2004;57(10):1107-10.
  6. Cantwell-McNelis K, James CW. Role of clinical pharmacists in outpatient HIV clinics. Am J Health Syst Pharm. 2002;59(5):447-52.
  7. Hirsch, J. D., Rosenquist, A., Best, B. M., Miller, T. A., & Gilmer, T. P. (2009). Evaluation of the First Year of a Pilot Program in Community Pharmacy: HIV/AIDS Medication Therapy Management for Medi-Cal Beneficiaries. Journal of Managed Care Pharmacy15(1), 32–41. https://doi.org/10.18553/jmcp.2009.15.1.32
  8. Hirsch, J. D., Gonzales, M., Rosenquist, A., Miller, T. A., Gilmer, T. P., & Best, B. M. (2011). Antiretroviral Therapy Adherence, Medication Use, and Health Care Costs During 3 Years of a Community Pharmacy Medication Therapy Management Program for Medi-Cal Beneficiaries with HIV/AIDS. Journal of Managed Care Pharmacy17(3), 213–223. https://doi.org/10.18553/jmcp.2011.17.3.213
  9. Isetts BJ, Schondelmeyer SW. Clinical and economic outcomes of medication therapy management services: The Minnesota experience. J Am Pharm Assoc. 2008;48:203-11







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