The Role of Pharmacists in HIV Care Continues to Expand

HIV affects 1.2 million people in the United States.¹ Despite the development of effective agents for treatment and prevention of HIV, current rates of viral suppression, pre-exposure prophylaxis and linkage to care fall short of the goals set by the CDC for ending the HIV epidemic.²

Additionally, the presence of pharmacists in specialty settings, including HIV, has expanded in recent years. Clinical pharmacists are essential components of the interdisciplinary team by providing comprehensive medication management to this complex patient population.

Addressing SDOH in HIV

Social determinants of health (SDOH) are nonmedical conditions that impact health outcomes.³ These may include socioeconomic status, housing, access to health services, or demographics. In the context of HIV treatment and prevention, SDOH may influence an individual’s risk of disease acquisition due to effects on behaviors that may increase risk of HIV transmission; limited access to testing sites, preventative measures, or medical care; or fear of the stigma associated with seeking HIV care. In the United States, HIV disproportionately affects minority groups, particularly Black/African American and Hispanic/Latino patients, and gay or bisexual men who have sex with men.⁴

Pharmacists can address SDOH by recommending screening for at-risk patients, recommending effective medication options for HIV treatment and prophylaxis, providing judgement-free medication counseling, and closely monitoring patients. Pharmacists therefore play an essential role in ensuring high-quality care and patient retention. They are also well-equipped to improve medication access by evaluating preferred insurance formulary options, enrolling eligible patients in copay card or patient assistance programs, and connecting patients to appropriate social services.

Pharmacists can address SDOH by recommending screening for at-risk patients, recommending effective medication options for HIV treatment and prophylaxis, providing judgement-free medication counseling, and closely monitoring patients. Image Credit: © jarun011 - stock.adobe.com

Managing HIV Treatment Regimens

According to the HIV treatment guidelines from the HHS, it is recommended to start antiretroviral therapy (ART) as soon as possible (rapid start) after diagnosis. The goal of therapy is to suppress the amount of virus (viral load) to an undetectable level. Only 3 antiretroviral regimens qualify for use as rapid ART under HHS and International AIDS Society-USA guidelines⁵:

• Bictegravir + emtricitabine + tenofovir alafenamide (Biktarvy; Gilead Sciences)
• Dolutegravir + tenofovir alafenamide (TAF) or tenofovir disoproxil fumarate (TDF) + emtricitabine (FTC) or lamivudine (3TC)
• People living with HIV who have used intramuscular cabotegravir for pre-exposure prophylaxis (PrEP) should use boosted darunavir + TAF or TDF + FTC or 3TC

Before initiation of ART, all patients who test positive for hepatitis B surface antigen (HBsAg) should be tested for hepatitis B virus (HBV). Because FTC, 3TC, TDF, and TAF have activity against both HIV and HBV, an antiretroviral (ARV) regimen for patients with both HIV and HBV should include TAF or TDF plus 3TC or FTC as the nucleoside reverse transcriptase inhibitor backbone of a fully suppressive ART regimen.

ART regimens consist of medications from at least 2 drug classes. A single tablet regimen (STR) contains 2 or more ARVs from at least 2 drug classes and forms a complete HIV treatment regimen. STRs are widely used by individuals who are treatment-naïve. Long-acting cabotegravir/rilpivirine is the first complete injectable ART regimen that is given as 2 intramuscular injections every other month (or monthly) in treatment-experienced individuals who meet clinical criteria.

ARTs that are approved by the FDA for highly-treatment-experienced individuals with multidrug-resistant virus include fostemsavir (Rukobia; ViiV Healthcare), maraviroc (Selzentry; ViiV Healthcare), lenacapavir (Sunlenca; Gilead Sciences), and ibalizumab-uiyk (Trogarzo; Theratechnologies).

People living with HIV/AIDS (PLWHA) who have maintained an undetectable viral load through effective ART are unable to pass the virus on to their sex partners. The Undetectable=Untransmittable (U=U) campaign aims to spread awareness of the efficacy of ART, end stigma, and empower PLWHA.⁶

Comprehensive Care and Education

Clinical pharmacists embedded in outpatient HIV clinics can provide services to PLWHA such as patient education, medication accessibility, adherence support, monitoring for drug interactions and adverse effects, immunization counseling, and collaboration with other health care professionals. PLWHA should receive comprehensive health care that goes beyond HIV management and also include screenings for comorbidities, such as cardiovascular disease (CVD), diabetes, bone health, and certain cancers.⁷

1. Cardiovascular health. PLWHA are at higher risk of CVD including myocardial infarction, heart failure, stroke, pulmonary hypertension, and sudden cardiac death than those without HIV. It is important to address modifiable risk factors such as hyperlipidemia, hypertension, and smoking.
2. Diabetes. Monitoring glucose levels, maintaining a healthy diet, and taking medications as prescribed are essential components of diabetes management.
3. Bone health. Some ART may affect bone density. Monitoring bone health includes ensuring adequate calcium and vitamin D intake, encouraging regular weight bearing exercises, and recommending bone density screening if appropriate.
4. Preventative care and vaccinations. Screenings for cancer, infectious diseases, and receiving recommended vaccinations, including those for influenza, pneumococcal infections, and hepatitis.

Clinical pharmacists embedded in outpatient HIV clinics play a crucial role in the comprehensive care and management for PLWHA. In this role, it is important to consider care for the potential comorbidities and AEs that PLWHA may face during the course of their care and treatment.

REFERENCES

1. CDC. The State of the HIV Epidemic in the U.S. CDC. Last updated June 23, 2022. Accessed November 12, 2023. https://www.cdc.gov/nchhstp/newsroom/fact-sheets/hiv/state-of-the-hiv-epidemic-factsheet.html
2. CDC. Ending the HIV Epidemic in the U.S. CDC. Last updated June 9, 2023. Accessed November 13, 2023. https://www.cdc.gov/endhiv/index.html
3. CDC. Social Determinants of Health at CDC. Last updated December 8, 2022. Accessed November 16, 2023. https://www.cdc.gov/about/sdoh/index.html
4. HIV Statistics Impact on Racial and Ethnic Minorities | HIV.gov
5. HIV/AIDS Treatment Guidelines. Clinicalinfo.HIV.gov. May 26, 2023. Accessed November 16, 2023. https://clinicalinfo.hiv.gov/en/guidelines
6. About – Prevention Access Campaign. Accessed November 16, 2023. https://preventionaccess.org/about-2/
7. Feinstein MJ. HIV, Subclinical Cardiovascular Disease, and Clinical Progression: Insights From Immunologic Heterogeneity. JAMA. 2022;328(10):931–932. doi:10.1001/jama.2022.15226