The Art of ART: The Pharmacist’s Role in HIV Care

Over the past several decades, HIV has evolved into a chronic, manageable infection because of the progress made in early diagnosis, the speed of initiation of antiretroviral therapy (ART), and the quality of laboratory tests. Pharmacists collaborate with multidisciplinary teams to ensure comprehensive care for persons living with HIV (PLWH). Their role encompasses appropriate therapy selection, ensuring access to care, and providing patient education.

A systematic review published in 2012 found that pharmacists involvement in HIV care and treatment led to clinically and statistically significant improvements in ART adherence, with a majority of studies reporting that pharmacists involvement in patient care was associated with greater viral load suppression.¹ Despite a decrease in post-graduate training programs focused on HIV pharmacotherapy over the past decade, there is a growing need for HIV-specialized pharmacists to aid in ending the HIV epidemic, especially in the era of long-acting injectables.

Despite a decrease in post-graduate training programs focused on HIV pharmacotherapy over the past decade, there is a growing need for HIV-specialized pharmacists to aid in ending the HIV epidemic, especially in the era of long-acting injectables. Image Credit: © jarun011 - stock.adobe.com

Treatment Selection

Substantial progress in the development of novel treatment options for HIV has been made since the approval of zidovudine (Retrovir; GSK) by the FDA in 1987, including the use of combination ART beginning in 1996 and the approval of the first single tablet regimen efavirenz/emtricitabine/tenofovir (Atripla; BristolMyers Squibb and Gilead Sciences) in 2006. These developments have resulted in profound decreases in mortality, improved quality of life, and reduced pill burden.²

However, the complexity of HIV regimen selection persists. The HHS does provide evidenced-based guidance on the selection of ART, nevertheless, HIV-specialized pharmacists remain vital in the individualization of regimens.³ These pharmacists are trained to tailor therapy to the individual’s virus considering detected resistance mechanisms while balancing adverse effect (AE) profiles, patient preference, comorbidities, pill-burden, and cost. Their expertise becomes particularly valuable when complex resistance mutations knock out entire classes of ART leaving limited treatment options.

Increased interest in long-acting injectables to improve adherence and decrease pill burden in both HIV treatment or pre-exposure prophylaxis (PrEP) strategies has emphasized the value of pharmacists for both their expertise in pharmacotherapy, impeccable organizational skills, and availability to quickly triage patient’s concerns and/or AEs. Pharmacists can determine eligibility criteria, investigate coverage of the medication, and where collaborative practice agreements are allowed, monitor treatment efficacy and adherence.

Antiretroviral Stewardship

HIV-specialized pharmacists also extend their role beyond outpatient settings to inpatient management by facilitating transitions between home regimens to equivalent institutional formulary options, renally dose adjusting ART in the setting of altered or declining renal function, and monitoring for drug-drug interactions. Medication errors occur frequently for PLWH during hospital admissions, with most occurring at admission, and over one-third remaining uncorrected at time of discharge.^4-6 Antiretroviral stewardship programs have been shown to decrease medication errors in PLWH and prevent continuation of inappropriate regimens on discharge.^6,7

Access to Care

In addition to aiding in the selection of ART and monitoring for safety and efficacy, HIV-specialized pharmacists also play a crucial role in recognizing and addressing social determinants of health (SDOH). Data from the CDC has found that HIV continues to disproportionally impact persons with lower education status, median household income, and health insurance coverage.⁸ There is a well-defined intersection between SDOH and outcomes in HIV, but there is still greater work to be done to address these barriers to care. Pharmacists in the community or specialty pharmacy settings may be the most frequent contact PLWH have with the health care system; these frequent encounters make them the most likely clinicians to recognize barriers to care.

To assist in this vital aspect of care, pharmacists may collaborate with social workers to ensure access to transportation for clinic appointments, stable housing, and food programs. Pharmacists may also work with providers to eliminate food requirements in those with food insecurity or dispense smaller quantities of medications from clinic to decrease likelihood of theft or misplacement of their ART for patients experiencing homelessness. The financial burden of ART can be addressed in both community and ambulatory settings by obtaining prior authorizations, enrolling patients in manufacturer- or state-sponsored patient assistance programs, and modifying treatment regimens, when necessary. Finally, pharmacists collaborate with mental health professionals to ensure mental health concerns are addressed and minimize the contribution of ART on mental health conditions.

Patient Counseling

Patient education is another critical component to optimizing HIV care. In general, research has found that patients want to be directly involved in treatment decisions and have greater understanding of their conditions. However, poor health literacy can act as a barrier. Pharmacists are trained to provide comprehensive and easily-digestible information to patients which may empower them to actively participate in their care, make informed health decisions, and thereby achieve optimal health outcomes.⁹

Specifically, HIV-specialized pharmacists are crucial in providing an overview of ART and its purpose, potential AEs, and the importance of adherence. They can also help patients determine optimal adherence strategies, provide practical tips for incorporating their medication into daily routines, and emphasize the impact of missed doses. Additionally, they may provide education regarding safe sex practices, PrEP, and treatment as prevention. Pharmacists also serve as a resource for PLWH who are taking steps towards family planning, as pharmacists can educate patients on any associated risks or mitigation strategies to prevent fetal transmission or determine if a switch in ART is recommended. Finally, HIV-specialized pharmacists are at a unique position to educate the community at large on HIV and combat associated stigma.

Overall, HIV-specialized pharmacists contribute to multidisciplinary teams to improve the care of persons living with HIV. This includes optimizing therapy, ensuring financial coverage of medications, and educating patients so they are empowered to take an active role in their HIV care. The development of long-acting injectables and the challenges of implementing this novel treatment strategy underscores the importance of HIV-specialized pharmacists as part of the care team and emphasizes the need to make more specialized training in this area available to pharmacy learners. As PLWH continue to live longer and efforts intensify to end the epidemic, HIV-specialized pharmacists continue to play a vital role in ensuring safe, effective, and patient-centered therapeutic strategies.

REFERENCES

1. Saberi P, Dong BJ, Johnson MO, Greenblatt RM, Cocohoba JM. The impact of HIV clinical pharmacists on HIV treatment outcomes: a systematic review. Patient Prefer Adherence. 2012;6:297-322. doi:10.2147/PPA.S30244
2. A Timeline of HIV and AIDS Epidemic. HIV.gov. 2023. Accessed January 2, 2024. https://www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline/
3. HIV/AIDS Clinical Guidelines. HIV.gov. 2023. Accessed January 2, 2024. https://clinicalinfo.hiv.gov/en/guidelines
4. Li EH, Foisy MM. Antiretroviral and Medication Errors in Hospitalized HIV-Positive Patients. Ann Pharmacother. 2014;48(8):998-1010. doi:10.1177/1060028014534195
5. Pastakia SD, Corbett AH, Raasch RH, Napravnik S, Correll TA. Frequency of HIV-related medication errors and associated risk factors in hospitalized patients. Ann Pharmacother. 2008;42(4):491-497. doi:10.1345/aph.1K547
6. Zucker J, Mittal J, Jen SP, Cheng L, Cennimo D. Impact of Stewardship Interventions on Antiretroviral Medication Errors in an Urban Medical Center: A 3-Year, Multiphase Study. Pharmacotherapy. 2016;36(3):245-251. doi:10.1002/phar.1716
7. Billedo JA, Berkowitz LB, Cha A. Evaluating the Impact of a Pharmacist-Led Antiretroviral Stewardship Program on Reducing Drug Interactions in HIV-Infected Patients. J Int Assoc Provid AIDS Care. 2016;15(1):84-88. doi:10.1177/2325957415600700
8. Social Determinants of Health Among Adults with Diagnosed HIV Infection, 2019: Commentary. CDC. Last reviewed March 9, 2022. Accessed January 2, 2024. https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-27-no-2/content/commentary.html
9. Bhattad PB, Pacifico L. Empowering Patients: Promoting Patient Education and Health Literacy. Cureus. 2022;14(7):e27336. doi:10.7759/cureus.27336