Pharmacists Play Key Role in Educating Patients About HIV Risk, Treatments

In the second part of his interview with Pharmacy Times, PharmD, CSP, AAHIVP, a clinical pharmacist and subject matter expert with Shields Health Solutions, discussed pharmacists’ role in HIV education and management.

Q: What are some common barriers to HIV treatment and management?

Paul Rainville, PharmD, CSP, AAHIVP: Yeah, I would say, you know, one of the biggest challenges we see as pharmacists is the access to and retention in care. You know, there may be changes in a patient's insurance coverage or maybe through the Medicaid programs, which is different for pharmacy, or doctors, etc. This change in health care coverage is very stressful and really taxing on a patient's mental health, not to mention whatever causes or whatever doesn't get covered, and it can be financially draining. About 75% of patients receive some HIV care, 54% were retained in care, and 66% are virally suppressed. So about two-thirds of patients were completely virally suppressed across the nation. And really, what our goals are are to get that much higher. And at Shields, I think we do a really nice job of meeting that lack of resources. It tends to be a big problem and a barrier to HIV treatment.

Which brings me back to not only those social determinants of health we just spoke about, but every step of Maslow's Hierarchy of Needs. If you can't fulfill your physiological needs—you know, water, food, sleep, and shelter—you're probably not going to have the bandwidth to focus on your health, on getting transportation, or your medication adherence. So, when we can take care of these other patients, their ability to receive and eat an adequate amount of food and to get shelter and sleep, if we can take care of those things, we can better focus on some of the more advanced, higher needs that a patient might have: getting their health uptake and medication adherence to an appropriate level, making sure that their mental health is addressed, because they've just been focusing on all these problems that they may be experiencing.

Another aspect that can run into, or that can cause barriers to HIV treatment and management, is poor health literacy, when we don't really understand medications or how they're working. And if it's not explained, well, you can’t expect the patient to do as well on the treatment. I think really getting down to a patient's level of understanding and being able to communicate with them, to their level of understanding, is really important. Sometimes we use giant words that have complex meanings and if we're not, you know, taking the time to really express what we're saying, some of the things can go right in one ear and out the other. I think it's really important. To me, I've seen the different communities, I've worked in different levels of health care literacy. And, you know, I think it's always really important to make sure not only that the patient heard you, which is, you know, first of all the most important thing to start, but to make sure that they actually understood you. Using important tools like the teach-back method and motivational interviewing can be really helpful in clarifying the patient actually understood what we're discussing. And then, you know, I think also just listening is really important with getting to know patients’ health literacy. You know, when we actively listen, we can get a little bit further as to why someone maybe is or is not taking the medication correctly.

Another aspect that can be helpful with patient motivation—and this can go back to what I was just saying about motivational interviewing—but redirecting patients’ goals can be really helpful when it comes to medication. Many of them have been on these medications since the ‘90s and have experienced loads of side effects and, you know, adverse reactions. They may just be tired of taking a pill every day, or a lot of times I'll see patients that are no longer sexually active, so they don't really understand why they should continue medication if they're not at risk of transmitting the virus to people. So what I like to do is try to redirect those goals, you know, help them to improve other parts of their health, whether it be inflammation in the back or knees, or trying to help out to improve those types of situations and to really help them understand, you know, where the risk is coming from, from not taking the medication, whether it be resistance or other similar aspects that that can be of concern. The last thing I'll say is just comorbidities, especially in HIV and a lot of substance use disorders, psychiatric conditions. But we definitely want to make sure that we're taking care of those comorbidities, and those can definitely be a barrier.

Q: How can pharmacists be involved in educating patients about HIV risk, testing, and treatments?

Paul Rainville, PharmD, CSP, AAHIVP: Yeah, so I think one of the things we can do is discuss transmission prevention with active HIV patients. If you've got a patient in care, you know, especially if they're not well under control, if we can discuss treatment, prevention, using protection like condoms, getting their partners on PrEP, or having that discussion and being able to be open with that, you know, then we can get to even more patients than just the ones who we’re directly counseling at the point of sale. You know, we can promote safe use and disposal, definitely decrease the number of patients that are getting it from injecting drugs. But, you know, IV drug use does remain one of the risks for transmission, so getting that help in their drug use and making sure that they understand the abuse and disposal and be helpful.

There's about 13% of people living with HIV in the US who are not aware that they are HIV positive, that are in need of testing, so we want to keep that in mind, you know, that there's a large population that don't know they're HIV-positive. So, we want to make sure that we're doing our best to help guide them to help, whether it's in store or at home testing, or getting to the right facilities to have proper testing, and not just getting testing and finding out but connecting them to care.

Q: Is there anything you want to add anything that we didn't touch on.

A: I think some of the most important things we can do is just make sure we're actively listening to our patients. It's a population that's not always heard from, and I think that when we can get to the root of a lot of their issues, we can help them to be more successful in their treatment, we can get better patient outcomes. You know, the food and shelter and the social determinants of health, these are part of their health care. So, if we're identifying these issues, if we can take them to the next level, get them some assistance, whether it's through a multidisciplinary team such as social workers or through our community programs, you know, that's an awesome way we can help these patients out.

Another important aspect is our policies and legislation. The PrEP Access and Coverage Act of 2023 is currently going through the House and Senate, that's going to increase access to PrEP treatments, education programs, for federally qualified health centers and nonprofit entities to be able to provide these services. So, you know, keep in mind this access to these medications that are preventing long-term treatment of patients and the morbidity and mortality associated with HIV. I think it's very important. You know, also making sure that we have the adequate staffing and technicians can be helpful, just to make sure that everybody's getting attention and they can counsel them appropriately. And then we've started seeing finally negotiation of drug prices by federal health programs. I think that’s going to be a really important step to help improve the financial burden of programs like Medicaid and Medicare, you know, and also help turn around those savings to be allocated into closing some of these gaps in health equity.