The HIV continuum of care described by Gardner and colleagues in 2011 established the cascade that patients experience once diagnosed with HIV. Barriers to engaging in care and adherence to antiretroviral medications are still significant problems. An interdisciplinary approach to treatment is an effective way to identify barriers to adherence and tailor the treatment to the individual. Pharmacists are key frontline health care professionals who are the most accessible to patients. The role of pharmacists in the continuum of care is not just to fill prescriptions, but to be an impactful resource for patients and providers.
Pharmacists ideally should be involved in the initial stages of the continuum of care, establishing trust and relationships with patients. There are two major areas where pharmacists are involved with the engagement and retention of care: in the community, providing refills of antiretroviral (ARV) medications, and in HIV clinics, providing education and follow-up appointments. A growing area of complexity for providers is the new agents for patients with HIV coinfections with hepatitis — an area in which pharmacists can provide drug expertise.
Pharmacists in the community see patients every time they fill a prescription — more often than patients see their clinicians. Anywhere there is a pharmacy, a patient can discuss issues or ask questions of the pharmacist. Patients may be more comfortable discussing issues with medication adherence with their local pharmacists than providers. Community pharmacists can encourage patients to have all of their prescriptions filled at a single pharmacy to better monitor adherence and identify any drug interactions.
Pharmacists in the community also can serve as intermediaries for the patient and clinician by discussing with the clinician any concerns the patient may have and find strategies to improve adherence. In one study by Walsh and colleagues, the most frequent reasons for “sometimes” missing a dose of ARV medications were eating a meal at the wrong time (38.2%), oversleeping (36.3%), forgetting (35%) and being in a social situation (30.5%). Pharmacists can help reinforce the importance of adherence and offer adherence tools such as pillboxes, reminder phone calls for refills and strategies to overcome side effects. Frequently, pharmacists will make recommendations for patients to manage ARV side effects. Pharmacologic interventions are sometimes necessary with OTC medications, and should be verified by the pharmacist not to have drug-drug or drug-disease interactions. Nonpharmacologic interventions such as taking medications with food or at the most optimal times during the day are routinely recommended by pharmacists. These strategies can prevent discontinuance and improve adherence to the regimens.
A chief function of a community pharmacist is to prevent medication errors regarding dosing, administration frequency or major drug interactions. Prescribing errors do happen, and pharmacists are trained to prevent them from reaching patients and contacting prescribers for clarifications. If these errors were to reach patients, direct harm and mistrust can occur between clinicians and patients. Community pharmacists play a pivotal role in promoting and maintaining adherence in the HIV care continuum in order to achieve the goal of continued viral suppression.
Ambulatory care pharmacists
There are many HIV clinics that have pharmacists experienced in both ambulatory care and HIV care. These pharmacists have training in motivational interviewing, which can strongly encourage patients to continue to engage in care and adhere to medications. Motivational interviewing also can be used to re-engage patients and address behavioral issues. Ambulatory care pharmacists can see patients in scheduled appointments after initial clinician visits to reinforce the importance of adherence and help patients understand that poor adherence can lead to higher viral loads as well as increase HIV transmission potential and HIV resistance. They are well equipped to explain the role of each agent in their ARV therapy. This increases the patient’s exposure to care, which is especially crucial in newly diagnosed individuals. Ambulatory care pharmacists also can see patients in between provider visits, offering follow-up to medication adherence, allowing time for the patients to voice any concerns with the medications, and monitoring for adverse drug reactions.
Pharmacists in the HIV clinics stay up to date on new ARV agents and the adverse reactions or drug interactions with the newer agents. These pharmacists are a great resource for providers dealing with unique HIV resistance patterns and patients with renal or liver dysfunction. The aging HIV population is presenting with new, long-term challenges, including diabetes, hypertension, dyslipidemia and cardiac issues. Pharmacists trained in ambulatory care are ready to help with ARV-related comorbidities that require additional medications, assisting with drug choices to avoid or limit drug-drug interactions or drug-disease interactions.
Ambulatory care pharmacists have the ability to provide ongoing education to patients with HIV on ARV therapy. They can help maintain the continuum of care through adherence and clinic appointments in between provider visits. These pharmacists are trained to effectively manage multiple comorbidities and complex behavioral barriers.
Patients with HIV who are coinfected with hepatitis B and C can have significant liver and renal dysfunction, requiring medication dose adjustments or avoidance of certain medications. Pharmacists recognize that certain combination products contain medications in which one drug is without issue in organ dysfunction, while another may be contraindicated in the same product. Pharmacists are staying up to date with new medications that become available for treating hepatitis B and C. There are potential overlapping drug toxicities and drug interactions with antiviral agents with activity against hepatitis B or C and HIV ARV therapy. Pharmacists are an excellent resource for providers with questions about toxicities or drug interactions in patients with HIV and hepatitis B or C coinfections.
Pharmacists in the community and ambulatory care clinics are trained to monitor and counsel patients on adverse drug reactions that can lead to poor adherence. The medication regimens for patients with HIV can be complicated, and with an aging population, comorbidities that must be addressed pharmacologically are increasing in prevalence. Pharmacists can help wade through drug choices, interactions and dose adjustments for organ dysfunction. This can be especially helpful with hepatitis coinfected patients. Reaching out to your patients’ pharmacists to make sure they are an active part of the interdisciplinary team can potentially lead to better adherence and engagement in care. Patients see their pharmacists more often than their clinicians. Pharmacists can be a trusted resource for HIV-infected patients and can lend drug expertise to prescribers. Barriers to adherence and maintaining engagement in care will continue to be a challenge. Interdisciplinary teams that involve pharmacists can help patients overcome these barriers and provide guidance throughout each stage of the HIV continuum of care.
Gardner EM, et al. Clin Infect Dis. 2011;doi:10.1093/cid/ciq243.
Krummenacher I, et al. AIDS Care. 2011;doi:10.1080/09540121.2010.525613.
New York State Department of Health AIDS Institute. Pharmacists: Partners in health care for HIV-infected patients. 2006. Accessed March 9, 2015 at: http://www.hivguidelines.org/clinical-guidelines/hiv-and-pharmacy/pharmacists-partners-in-health-care-for-hiv-infected-patients/.
US Department of Health and Human Services. HIV Care Continuum. 2015. Accessed March 9, 2015 at: https://www.aids.gov/federal-resources/policies/care-continuum/.
Walsh JC, et al. AIDS Care. 2001;13:709-720.
For more information:
Kati Shihadeh, PharmD, is a clinical pharmacy specialist in infectious diseases at Denver Health Medical Center. Shihadeh can be reached at firstname.lastname@example.org.
Joanne Smith, PharmD, is a pharmacy practice resident at Denver Health Medical Center, Denver.
Disclosures: Shihadeh and Smith report no relevant financial disclosures.