Pharmacists are drug therapy experts. We are responsible for ensuring medications are used safely, responsibly and effectively to maximize the benefits of treatment. This is especially true in the provision of care to people living with HIV.
But community pharmacists are often seen as separate from the HIV care team. We are largely left out of therapeutic decision-making, despite our central role in dispensing medications. But community pharmacists have demonstrated that we can play a vital role in HIV care.
Antiretrovirals: the cornerstone of HIV care
Clinical care for people living with HIV relies heavily on drug therapy, and antiretroviral medications are the cornerstone of any care plan aiming to treat the virus. The benefits of successful HIV treatment are numerous, including reductions in morbidity and mortality, improved quality of life and the prevention of transmission. But these outcomes are contingent on appropriate, effective and consistent use of antiretroviral drugs.
To a pharmacist working in a community setting, HIV treatment may seem intimidating, confusing, or complicated. I have seen pharmacists who are reluctant to counsel patients living with HIV on their medications, monitor care plans or make treatment decisions, instead referring back to the prescriber or clinical team. As a pharmacist working in a clinical setting, I see this as a missed opportunity to provide care and to build meaningful and trusting relationships with patients.
The primary goal of a community pharmacist in HIV care is to ensure the treatment regimen is complete, appropriate and safe to use. This can be done by keeping up to date with treatment guidelines and reviewing lab results, depending on scopes of practice which vary from province to province.
Identifying and resolving adherence challenges
Community pharmacists are generally more accessible to patients than the HIV clinical team, and we have more opportunities for patient interactions at regular intervals. Since the health benefits of ART rely on high levels of adherence, pharmacists are uniquely placed to identify adherence problems early on, and we can often help overcome these barriers. For example, we can compare fill dates to supply days to check if patients may be having difficulty taking their medication as prescribed.
Missed doses happen for a myriad of reasons, but to maintain a suppressed viral load and to reduce the chances of developing drug resistance, it’s important to recognize and address those issues early on. Community pharmacists can use strategies to improve adherence to treatment regimens, such as blister packing (even a single tablet regimen), or scheduling refills in advance to prevent delays. We can also discuss and encourage patients to adopt their own strategies, such as using a smartphone habit tracker or adherence app, or associating doses with an ‘anchor time’ such as a meal.
One of the overlooked barriers to adherence can be affordability. HIV treatment regimens are expensive, and our patchwork of drug insurance coverage across the country leaves many patients struggling to pay for their medications. Treatment interruptions can have devastating effects, both physical and emotional, for people living with HIV. Pharmacists should be aware of this when filling medications and review reimbursement information. Comparing co-pays to previous fills to identify unexpected changes can help the pharmacist flag if someone should speak with the patient about treatment access.
I find that it is always a good idea to ask the patient about the cost, as even low costs may not be affordable. Patients may be reluctant to admit they are having trouble paying for their medication. Many drug manufacturers offer patient assistance programs, or the patient may need help navigating their own private or provincial insurance programs.
Recognizing adverse effects and drug interactions
Although newer antiretrovirals are better tolerated than older regimens, adverse effects are still a major barrier to adherence. Pharmacists can work with patients to let them know what to expect from their medications and how to manage any issues that may arise. Being proactive by offering strategies to reduce nausea, diarrhea or sleep irregularities can be the difference between successful treatment and suboptimal adherence.
Knowing the clinical goals of each patient’s treatment regimen can help pharmacists to provide the most appropriate advice to their patients. If available, reviewing lab results can give insight into a patient’s treatment regimen, and help the pharmacist make decisions and recommendations. We shouldn’t hesitate to contact the HIV care team if we have concerns or questions.
Nowadays, drug interactions are becoming less of a concern as newer agents are released. Cleaner drug interaction profiles, less reliance on pharmacokinetic boosters, and a reduction in the number of agents needed for treatment are making this once major issue easier to manage. Although newer drugs are easier to use, it is still imperative that pharmacists review each patient’s entire profile and ask about other medications, supplements, recreational drugs or alternative medicines they may be taking. Seemingly minor drug interactions, such as proton pump inhibitors or antacids, can compromise treatment. Without proper intervention, these interactions can result in virologic failure and drug resistance. Pharmacists should regularly review medication profiles and use an HIV-specific drug interaction checker, such as the HIV/HCV Drug Therapy Guide.
Pharmacists can play a role in modernizing and optimizing patients’ HIV treatment regimens. Older regimens may work well at controlling a patient’s viral load, but newer options can do the same – with fewer side effects, fewer drug interactions, and a lower pill burden. Being aware of treatment guideline updates and new therapies is crucial for pharmacists to recognize outdated regimens and and improve a patient’s experience. The HIV/AIDS Treatment Guidelines from the U.S. Department of Health and Human Services includes useful and up-to-date information for pharmacists.
The broader health of people living with HIV
With treatment, people living with HIV can live long and healthy lives, and many are now experiencing the health issues faced by HIV-negative people as they age. Community pharmacists can play an important role in recognizing comorbidities and promoting good health. As the virus itself becomes less of a primary concern for people living with HIV as they grow older, pharmacists can help patients improve their health in other ways by discussing vaccinations, smoking cessation, diabetes, hypertension and kidney and bone health.
Although the world of HIV can seem overwhelming for some pharmacists, help is out there. The Canadian HIV and Viral Hepatitis Pharmacists Network (CHAP) provides many educational opportunities, such as the ability to discuss cases with HIV specialized pharmacists or spend time observing them in practice.
Mike Stuber, BSP, AAHIVP, is an HIV pharmacist with the Saskatchewan Health Authority – Regina and the Saskatchewan HIV Collaborative. He is the chair of the Canadian HIV and Viral Hepatitis Pharmacist Network (CHAP).