HIV-Positive Patients with Comorbidities Benefit from Personalized, Pharmacist-Led Care

HIV-specialized pharmacies meet the complex needs of HIV-positive patients, helping to provide comprehensive patient care and improve medication adherence to both anti-retroviral therapies and non-HIV medications.

Thanks to advances in modern medicine, the human immunodeficiency virus (HIV) has evolved from one of the most life-threatening and feared diseases to one that can be highly manageable. Patients with HIV who take their anti-retroviral therapy (ART) medications properly can enjoy near-normal life expectancy and a good quality of life.¹ However, taking the right medications at the right time is often no simple task.

Despite significant gains in easing ART regimens and reducing side effects, a number of issues common to the HIV population continue to create roadblocks to medication adherence and improved health outcomes. Nearly 90% of people living with the virus have at least 1 comorbidity² and nearly 30% suffer from mental illness,³ which magnifies the challenge of medication adherence. But by providing comprehensive care tailored to the needs of people with HIV and 1 or more additional conditions, Walgreens HIV-specialized pharmacies have made a significant difference in improving patient medication adherence.

Two recent Walgreens studies presented at the November 2013 Cell-The Lancet conference, “What Will it Take to Achieve an AIDS-free World?”, demonstrate the benefits of HIV-specialized pharmacies in helping patients adhere to their HIV and non-HIV medications.³

Coping with Comorbidities

Hypertension, high cholesterol, and heart disease are common in patients with HIV.⁴ Patients with these comorbidities are often prescribed medications to address health concerns by separate physicians, which could complicate treatment. A Walgreens study compared 1484 patients taking high blood pressure medication—either an angiotensin-converting enzyme or an angiotensin receptor blocker—who received care exclusively at a Walgreens HIV-specialized pharmacy with 1484 propensity score—matched patients who received those same medications at other Walgreens retail pharmacies. Blood pressure medication adherence, as measured by proportion of days covered (PDC), averaged 82.6% among Walgreens HIV-specialized pharmacy patients versus 79.7% for other Walgreens retail pharmacy patients. The results were similar when comparing 1372 patients who received their cholesterol-lowering statin medications at an HIV-specialized pharmacy to 1372 matched patients who received statins at other Walgreens retail pharmacies. The statin adherence was 83.8% among Walgreens HIV-specialized pharmacy patients versus 81.3% for other Walgreens retail pharmacy patients.

Walgreens research demonstrates that adherence to therapeutic treatments for HIV and associated comorbidities was significantly higher for patients using Walgreens HIV-specialized pharmacies than for patients using other Walgreens retail pharmacies. A study of HIV patients with serious mental illness further validates this finding.

Serious mental illness, including severe depression, bipolar mood disorder, anxiety disorder, and psychosis, is another comorbid condition of concern, and often is associated with a more rapid and harder to treat progression of HIV disease.⁵ HIV patients with serious mental illness often experience challenges associated with willingness and ability to take medication as prescribed, which can contribute to increased hospitalization and a 2-fold increase in hospitalization costs.⁶

A separate Walgreens retrospective study looked at 125,408 patients with HIV who received medications at a Walgreens retail pharmacy between January 1, 2011, and June 30, 2012. Of those, 28.6% had a serious mental illness: 13,637 of them received their medications exclusively at an HIV-specialized pharmacy and 22,028 used other Walgreens retail pharmacies. Among the Walgreens HIV-specialized pharmacy group, 32.7% of patients were adherent to their ART medications compared with 19.4% of those who received their medications from other Walgreens retail pharmacies. HIV patients with a serious mental illness who exclusively used Walgreens HIV-specialized pharmacies were more adherent to medication treating their comorbidities as measured by PDC than those who used traditional pharmacies.³

Comprehensive Care

The challenges of caring for patients with HIV have been apparent from the early days of the disease. In addition to a variety of comorbidities, patients with HIV often face stigma, lack of social support, low health literacy, and high medication costs.⁷ Those and other factors can result in poor medication adherence. Recognizing the difficulty physicians face in managing patients who they may see only once or twice a year, Walgreens developed the concept of HIV-specialized pharmacies at the beginning of the epidemic more than 30 years ago. Now numbering more than 700, Walgreens HIV-specialized pharmacies are located in communities with high rates of HIV and are designed to address the unique challenges of HIV patients through comprehensive, patient-centric care.

Walgreens HIV specially trained pharmacists receive HIV care training which has been designed and reviewed by HIV education experts at the National Alliance for HIV Education and Workforce Development, AIDS Education and Training Centers, and the American Academy of HIV Medicine. Trained pharmacists have the expertise to educate patients about the disease and its treatment, including ART and other medications, and will help patients understand the importance of taking medications as prescribed. Walgreens HIV specially trained pharmacists regularly see patients face-to-face or speak to them on the telephone, providing counsel and guidance, developing relationships, and building trust, all of which is vital in this population.

Regular contact between the pharmacy staff and patients also helps ensure the ongoing assessment of patients to determine whether they are experiencing any medication-related or other issues. Walgreens HIV specially trained pharmacists review all medications to assess potential drug interactions and offer guidance in managing common comorbidities such as hepatitis B and hepatitis C and potential medication side effects. Refills of all medications are aligned, making it easier for patients to stay adherent to their medications.

Consistent patient interaction also provides an opportunity to remind patients about additional health recommendations such as the importance of receiving influenza and pneumonia vaccinations specifically indicated for persons living with HIV. Pharmacists can also help patients navigate copays and access financial support programs to reduce costs, if needed. Walgreens HIV-specialized pharmacies offer additional services and programs, including HIV prevention information and HIV testing events, to address the needs of the surrounding communities by working with local organizations and health care providers to more effectively reach those who need HIV care. Holistically, Walgreens HIV-specialized pharmacies are designed to discreetly provide a range of services to help those living with HIV improve their health outcomes.

There’s no question that managing the complexities of HIV and its common comorbidities is challenging for patient and provider alike. With comprehensive pharmacist-led care that focuses on each individual patient, Walgreens has made significant progress in improved adherence, even in complex care situations such as the treatment of patients who also have mental illness comorbidity.

Building on its success, Walgreens is collaborating with the Centers for Disease Control and Prevention (CDC) to further develop and evaluate HIV patient-centered care through a national project aimed at more fully integrating clinical treatments and medication therapy management. The CDC has identified improved adherence to ART medication as a primary goal, noting that only 25% of Americans with HIV have the virus under control.⁸ As we continue to collect outcomes, work with other entities invested in improving HIV care, and learn more about how to provide the most effective care to patients with HIV, we are guided by our vision of an AIDS-free world. SPT

References

• Samji H, Cescon A, Hogg RS, et al. Closing the gap: increases in life expectancy among treated HIV-positive individuals in the United States and Canada. PLOS ONE. 2013;8(12):e81355.
• Magalhaes MG, Greenberg B, Hansen H, Glick M. Comorbidities in older patients with HIV: a retrospective study. J Am Dent Assoc.2007;138(11):1468-1475.
• DuChane J, Taitel M, Fensternheim L, et al. Two retrospective cohort studies exploring HIV medication and overall adherence at HIV-specialised pharmacies: implications for HIV patients with comorbid conditions and serious mental illness. Lancet. 2013;382:S3.
• Weiss JJ, Osorio G, Ryan E, Marcus SM, Fishbein DA. Prevalence and patient awareness of medical comorbidities in an urban AIDS clinic. AIDS Patient Care STDs. 2010;24(1):39-48.
• Rabkin JG. HIV and depression: 2008 review and update. Curr HIV/AIDS Rep. 2008;5(4):163-171.
• Conover CJ, Weaver M, Ang A, Arno P, Flynn PM, Ettner SL; the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study Group. Costs of care for people living with combined HIV/AIDS, chronic mental illness, and substance abuse disorders. AIDS Care. 2009; 21(12): 1547-1559.
• Guidelines for the use of antiretroviral agents in HIV-1 infected adults and adolescents. AIDSInfo website. www.aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv-guidelines/30/adherence-to-antiretroviral-therapy/. Published March 27, 2012.
• Hall HI, Frazier EL, Rhodes P, et al. Differences in human immunodeficiency virus care and treatment among subpopulations in the United States. JAMA Intern Med. 2013;173(14):1337-1344.

About the Author

Glen Pietrandoni, RPh, AAHIVP, is Walgreens senior director, virology. Glen is a lifelong resident of the Chicago area, where he been an active member of the HIV/AIDS community. After graduating from the St. Louis College of Pharmacy, Glen co-owned multiple independent pharmacies in Chicago and its suburbs for 10 years. He began his career with Walgreens in 1990, around the time of the approval of the first HIV/AIDS drugs. At that time, he began working with the lesbian, gay, bisexual, and transgender (LGBT) community, dispensing much-needed emotional support as well as medication during a time when people did not survive as long with HIV/AIDS as they do today.From 1996 to 2003, he managed a Walgreens pharmacy at the Howard Brown Health Center (HBHC) which specializes in HIV/AIDS—the first Walgreens pharmacy of its kind, located in an LGBT community center. Today, Walgreens has more than 200 locations within health centers (over 100 of them focus on HIV/AIDS) and more than 700 HIV specialized pharmacies in highly impacted communities across the country. Now a 25-year veteran with Walgreens, Glen is responsible for HIV/AIDS and hepatitis programs and services including those in the United States and abroad. Some of his key accomplishments include implementing patient support programs across multiple channels and providing pharmacist HIV/AIDS education.As part of his ongoing commitment to supporting patients with HIV/AIDS, Glen earned his American Academy of HIV Medicine credentials in 2008. He plays an active role in community initiatives, co-chairing gala committees for HBHC and the AIDS Foundation of Chicago, as well as currently serving on the boards of directors for two national AIDS organizations based in Washington, DC (AIDS United and ADAP Advocacy Association). Glen has also co-chaired WPRIDE, the Walgreens LGBT affinity group, and has been recognized for his service and leadership with numerous awards.In 2012, Elton John referenced the Walgreens commitment to contributing to the end of AIDS in his book “Love is the Cure,” citing their commitment to the cause and the difference being made at the local level by America’s largest drugstore company. Walgreens programs and the commitment of the thousands of employees have positioned Walgreens as a leader in HIV care, recognized by government agencies, advocacy organizations, medical providers and most importantly, by HIV consumers.