Student Pharmacists Can Help End the HIV/AIDS Epidemic

Since the start of the epidemic in the early 1980s, 88.4 million people across the globe have been diagnosed with HIV and 42.3 million have lost their lives to the disease.¹ At the end of 2023, it is estimated that nearly 40 million people globally are currently living with HIV, with about 1.2 million individuals above the age of 13 years old living in the United States.^1,2

As future health care professionals, pharmacy students need to understand various elements of HIV to expand access to care and effective treatment. Students should have an understanding of what HIV/AIDS is, available testing options, HIV pharmacotherapy, pre-exposure prophylaxis (PrEP), and post-exposure prophylaxis (PEP) to help aid in the fight against the epidemic.

HIV blood test | Image credit: Gamjai | stock.adobe.com

What is HIV/AIDS?

Human immunodeficiency virus, or HIV, attacks and destroys one’s CD4+ cells, a white blood cell responsible for strengthening the immune system. A patient’s normal CD4+ cell range is anywhere between 500 and 1500 cells/mm³. However, someone with an active but untreated HIV infection can develop acquired immunodeficiency syndrome (AIDS). An AIDS diagnosis can be made when the CD4+ cell count drops below 200 cells/mm³, increasing a patient’s chances of developing numerous opportunistic infections such as tuberculosis and candidiasis.

HIV is primarily transmitted through bodily fluids such as breast milk, semen, vaginal secretions, and blood. It is strongly advised that intravenous drug users avoid sharing needles to prevent contraction. Within the first few weeks of being infected, some people may or may not experience flu-like symptoms such as fever, headache, rash, or sore throat.³ As one’s immune system worsens due to lack of treatment, they might experience weight loss, swollen lymph nodes, or diarrhea.³

HIV Testing

Those living with HIV who are undiagnosed or not taking medication may see signs of an HIV infection within 5 to 10 years or sooner. However, it can take 10 to 15 years or more between the time of HIV transmission and an AIDS diagnosis. Because of this, there is an immense emphasis on prompt HIV testing and medication dispensation.

Per the CDC, those aged 13 to 64 should get tested at least once yearly as part of their routine health care visits.⁴ Those who are at greater risk of contracting HIV should participate in more frequent testing. Men who have sex with men, Black/African Americans, Hispanic/Latinos, transgender women, and people who inject drugs are advised to get tested every 3 to 6 months due to their increased risk of infection.

There are 2 methods available for HIV testing: oral swabs and blood tests. For those looking for an OTC option, the OraQuickIn-Home HIV Test is an oral swab test that provides results in 20 minutes. The average cost of a test ranges from $30 to $50 and can be found at popular retail stores such as CVS, Walgreens, and Amazon, as well as on the OraQuick website. After the results, receiving a confirmatory blood test is still important.

The cost of clinic testing may vary, but several institutions offer free testing. For those who may need help looking for a testing site, the CDC has a website that helps those seeking affordable testing facilities in their local area for HIV, sexually transmitted infections, and other viral infections. Students having access to resources like the GetTested CDC website is crucial, as they can provide this information for susceptible patients.

Clinic testing sites often look for antibodies/antigens or a viral load. A patient’s viral load is the number of HIV copies in 1 milliliter of blood (copies/mL). The main goal of active HIV testing for those on antiretrovirals (ARVs) is to reach U=U status, or Undetectable = Untransmittable. A person living with HIV and on treatment can achieve a viral load so low that it is not detectable through testing. The individual still has HIV but is unable to pass it on through sexual activity. However, it is still possible to transmit HIV through shared needles or breastfeeding.

HIV Pharmacotherapy

The Department of Health and Human Services recommends ART for everyone with HIV to reduce morbidity and mortality and to prevent the transmission of HIV to others. The most commonly used antiretroviral drug classes in clinical practice today are listed in table 1.

Table 1. Commonly used antiretroviral drug classes

Using a combination of at least 2 FDA-approved antiretroviral medications has been proven to decrease the viral load and increase the CD4+ count in HIV patients. Decreasing a patient's viral load will help to reduce their morbidity and mortality. With adherence, the patient can reach undetectable status and prevent the transmission of HIV to others through sexual activity. Increases in CD4+ counts prevent an AIDS diagnosis and allow them to fight off infections.

Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs)

There are two formulations of tenofovir: tenofovir alafenamide (TAF) and tenofovir disoproxil fumarate (TDF). TAF is the newest formulation of tenofovir, known for having fewer side effects on bone density and renal function. Because tenofovir is used in almost all HIV combination medications, it's important to keep in mind other patient considerations to determine if it's appropriate.

Abacavir (ABC) is a unique NRTI that requires genetic testing for the HLA-B*5701 variation. If a patient tests positive, then they are susceptible to experiencing a hypersensitivity reaction to abacavir that can be fatal. No patient should be on this medication if testing has not been conducted.

Integrase Inhibitor-Based Regimens

Integrase inhibitor-based regimens are the most prescribed FDA-approved HIV medications, with bictegravir, emtricitabine, and tenofovir alafenamide (Biktarvy; Gilead) being the most-sold HIV medication. They are highly regarded for their low adverse effect profile, high tolerability, and minimal drug interaction profile. Table 2 lists the most common integrase inhibitor-based regimens, their active ingredients, and important patient counseling tips.

Table 2. Common integrase inhibitor-based regimens

Non-nucleoside Reverse Transcriptase Inhibitor (NNRTI)-Based Regimens

Rilpivirine and efavirenz are among the most commonly used in NNRTI-based regimens. Efavirenz is suggested to be taken without food at bedtime due to potential central nervous system adverse effects, such as drowsiness, dizziness, and impaired concentration. Abnormal dreaming and false-positive cannabinoid or benzodiazepine tests have also been reported.

Table 3. Commonly used NNRTI-based regimens

Protease-Based inhibitors

Darunavir, cobicistat, emtricitabine, and tenofovir alafenamide (Symtuza, Janssen) is a protease-based inhibitor medication. Within its formulation, it uses cobicistat, a pharmacokinetic enhancer working to boost the therapeutic effects of darunavir. It should be taken with food and is contraindicated if combined with lovastatin or simvastatin.

PrEP vs PEP

PrEP is medication taken daily to prevent contracting HIV. PrEP can reduce the risk of contracting HIV from sex by about 99% and from injection drug use by 74%.⁵ PrEP is recommended for anyone who:⁵

• Has had anal or vaginal sex in the past 6 months and has 1 or more of the following:
  • A sexual partner with HIV
  • Not been continuously using a condom
  • Been diagnosed with an STI in the past 6 months
• Injects drugs, uses shared injection equipment such as needles, or has an HIV-positive injection partner
• Been prescribed PEP before and has reported continued risky behavior or has had multiple courses of PEP

Currently, 3 FDA-approved medications are indicated for PrEP: emtricitabine and tenofovir disoproxil fumarate (Truvada; Gilead), emtricitabine and tenofovir alafenamide (Descovy; Gilead), and cabotegravir (Apretude; ViiV Healthcare). Truvada and Descovy are the only 2 daily oral medications for PrEP. Both medications require a negative HIV status and testing must be done at least every 3 months. Descovy is not approved for use in those who are assigned female at birth or who are at risk of contracting HIV through receptive vaginal sex. This is due to the clinical trials' failure to involve these patient populations significantly.

Apretude is a subcutaneous injection given every 2 months. Its prescription may require an oral lead-in and is an excellent alternative for patients who may have trouble adhering to daily oral PrEP medications.

PEP is medication taken within 2 to 72 hours after sex and for 28 days after possible exposure to HIV to prevent transmission. There are 2 types of PEP:

• Occupational PEP (oPEP), such as a nurse experiencing a needlestick injury or who is exposed to blood and other bodily fluids
• Non-occupational PEP (nPEP), such as consensual or non-consensual sex, needle sharing, and exposure to blood and other bodily fluids

Options for PEP are Truvada combined with either raltegravir or dolutegravir. Patients can receive 2 doses of raltegravir: 1200 mg (QD) or 400 mg (BID). High dose raltegravir at 1200 mg should not be used in pregnant patients. Those taking Truvada with dolutegravir and also taking metformin should limit the dose of metformin to 1000 mg to avoid adverse effects.

Some states, including New York, Virginia, Nevada, and California, allow pharmacists to prescribe PrEP and or PEP at their local pharmacies. For more information, you can check the American Pharmacists Association website or local government.

Conclusion

For pharmacy students, having a comprehensive understanding of HIV/AIDS, including its transmission and prevention, is an integral part of being not only a future pharmacist but a future health care professional. To combat the HIV/AIDS epidemic, we must advocate and understand methods of testing, ensure those with HIV have appropriate and adequate treatment, promote PrEP and PEP education, and advocate the importance of U=U. Although there is currently no cure for HIV, people can live long and healthy lives. And as future health care professionals, student pharmacists can be right there with them.

REFERENCES

1. HIV. World Health Organization. Accessed October 12, 2024. https://www.who.int/data/gho/data/themes/hiv-aids

2. US Statistics. HIV.gov. Updated August 15, 2024. Accessed October 12, 2024. https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics

3. HIV and AIDS. World Health Organization. July 22, 2024. Updated July 22, 2024. Accessed October 12, 2024.https://www.who.int/news-room/fact-sheets/detail/hiv-aids

4. Getting Tested for HIV. Centers for Disease Control and Prevention. May 15, 2024. Updated September 6, 2024. Accessed October 12, 2024. https://www.cdc.gov/hiv/testing/index.html#cdc_testing_when_to_tested-when-to-get-tested

5. Pre-Exposure Prophylaxis. HIV.gov. Updated June 27, 2024. Accessed October 12, 2024. https://www.hiv.gov/hiv-basics/hiv-prevention/using-hiv-medication-to-reduce-risk/pre-exposure-prophylaxis