Pharmacists Are Transforming and Optimizing HIV Treatment

The HIV pharmacist serves as the medication expert on the multi-disciplinary HIV treatment team. They may practice in a variety of settings such as ambulatory care clinics, specialty pharmacies, or retail pharmacies. In general, their scope of practice includes patient counseling, improving medication adherence, resolving medication access issues, and optimizing treatment. To achieve the goal of HIV-related morbidity and mortality, antiretroviral therapy (ART) is used to suppress the HIV plasma viral load to an undetectable level (viral suppression).¹ In order to achieve viral suppression, contemporary ART regimens typically require 3 medications, but in some cases, 2-drug regimens may be used.

A pharmacist showing a patient her medication.

Treatment optimization can refer to changes to ART in the setting of either viral suppression or virologic failure. Clearly, if the regimen fails to suppress the viral load, there is an indication for change. However, there are also several reasons to change therapy despite treatment success. It is important to consider route of administration (oral vs. injectable), drug-drug/drug-disease interactions, pill burden, adverse effects, medication access, medication-related quality of life, and patient preferences (tablet size, time of administration, etc.).

There are several important steps in making medication changes. They include taking a thorough HIV and medical history, obtaining an accurate medication list, assessing potential for drug-drug interactions, providing patient education, and ensuring medication access.

Taking a thorough HIV and medical history can be done through a combination of patient interview and review of medical records, if available. A key portion of the medical record review includes a review of chart notes and laboratory results (HIV viral load, HIV drug resistance testing). Noting the reason for previous medication changes is helpful in deciphering potential drug resistance, potential for adverse effects, and other factors for selecting the next regimen. For example, if a patient changed regimens in the past due to food insecurity, it would be helpful to reassess this if considering a regimen that requires administration with food.

The next step is to have a complete understanding of the patient’s current medications and comorbidities. Comorbid conditions can often be inferred from a patient’s medication list, but a complete list can be reconciled in discussion with the patient and/or their care team. Comorbidities of interest related to ART include bone mineral density, hepatitis B virus (HBV), renal insufficiency, cardiometabolic disease, and potential for pregnancy. For individuals living with HBV, it is important to maintain appropriate anti-HBV therapy when changing regimens; if anti-HBV therapy is abruptly discontinued, there is a potential for severe acute exacerbation of HBV.

When obtaining the patient’s medication list, both prescription and non-prescription medications should be noted. In some cases, non-prescription medications can have clinically significant drug-drug interactions with ART. Drug-drug interactions may increase or decrease the concentrations of ART, but certain antiretrovirals may also affect exposure of other medications. Two common examples include administration of intranasal corticosteroids with ART pharmacokinetic enhancers (ritonavir, cobicistat) and polyvalent cations (often contained in multi-vitamins or antacids) with orally administered integrase inhibitors (raltegravir, elvitegravir, dolutegravir, bictegravir, cabotegravir). In the former scenario, it is possible to develop supratherapeutic systemic concentrations of the corticosteroids, which may lead to Cushing Syndrome.^2,3 In the case of polyvalent cations, they can significantly reduce absorption of integrase inhibitors and may contribute to virologic failure.1 The University of Liverpool Interaction Checker and the Natural Medicines Database are 2 resources to consult when screening for potential drug-drug interactions.^4,5

After considering these factors, select an optimal ART regimen in discussion with the patient and other members of the care team. Counsel the patient on dosing, adherence, administration, and common adverse effects. Patients should be instructed to reach out if they experience adverse effects, start or discontinue other medications, or have any additional questions. Patients may also have concerns around confidentiality of their HIV status, so it may be helpful to reassure them of patient privacy standards.

Finally, in order for therapy to be optimized, patients must be able to access their new medication(s). A large portion of medication access is related to third party medication coverage. In addition to patients’ prescription coverage, consider specific resources dedicated to patients with HIV such as the AIDS Drug Assistance Program or other Ryan White funding, if applicable, to ensure access to the optimal medication regimen. Ideally, medication coverage and the need for prior authorizations or copay assistance is assessed prior to a prescription being sent to the pharmacy to streamline access.

Pharmacists involved in dispensing should ensure that a complete regimen is provided to the patient. In most cases, patients are either on a single tablet or a 2-drug injectable regimen, but some may require multiple tablets or a combination of tablets and injections, particularly in the setting of drug-resistant HIV. Examples of complete regimens can be found in the Department of Health and Human Services Guidelines, and if questions remain, clarify with the prescriber.¹

Regardless of a pharmacist’s practice site or type, they play an integral role in ensuring the treatment success of patients with HIV.

About the Authors

Rajeev B. Shah, PharmD, AAHIVP, BCIDP, is Corresponding Author and Vaccines Medical Science Liaison at GSK.

Katy L. Garrett, PharmD, AAHIVP, BCIDP, is HIV/PrEP Medical Science Liaison at Gilead Sciences.

References

1. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. Department of Health and Human Services. Updated December 6, 2023. Accessed December 14, 2023. https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv

2. Al-Maqbali A, Kamble B, Al-Qassabi S, et al. Secondary adrenal insufficiency due to the co-administration of ritonavir and inhaled fluticasone propionate: case report. Sultan Qaboos Univ Med J. 2017;17(3): e339-e342. doi:10.18295/squmj.2017.17.03.014

3. Soldatos G, Sztal-Mazer S, Woolley I, Stockigt J. Exogenous glucocorticoid excess as a result of ritonavir-fluticasone interaction. Intern Med J. 2005;35(1):67-68. doi:10.1111/j.1445-5994.2004.00723.x

4. HIV Drug interactions. University of Liverpool. Accessed December 14, 2023. https://www.hiv-druginteractions.org/

5. NatMed Pro. Therapeutic Research Center. Accessed December 14, 2023. https://naturalmedicines.therapeuticresearch.com/