HIV Counseling: Accessibility Is Key

SEPTEMBER 13, 2015
Mohamed Jalloh, PharmD
In the United States, more than 1.2 million people are estimated to be living with HIV,1 which is contracted and spread via anal or vaginal sex with infected individuals or by sharing needles or abusing substances with them.2 Over the past 2 decades, advances in HIV therapy have allowed patients to manage their infection through the use of long-term medication therapy. Without medication, most patients with HIV can develop full immunosuppression, as evidenced by the CD4 T lymphocyte (CD4) cell count; develop AIDS; and die prematurely.3

Stages of HIV Infection
When patients are infected with HIV, they go through 3 phases: (1) the acute infection stage, (2) the clinical latency stage, and (3) AIDS.4 The acute stage of an HIV infection occurs 2 to 4 weeks after infection. During this time, patients experience flu-like symptoms (eg, fever, sore throat, muscle and joint aches, fatigue), their immune response to the HIV infection. Their CD4 count may rise and rapidly decrease as HIV uses the cells to proliferate, even while destroying them in the process. While in this stage, patients are at an increased risk of transmitting HIV due to elevated levels of the virus in their blood.4 Eventually, a patient’s immune system responds and decreases the concentration of HIV to a low level (ie, viral set point), but the virus is not fully eliminated.4

After the acute stage, patients enter the clinical latency stage in which HIV is slowly proliferating in a patient’s body but does not produce significant symptoms, such as in the acute stage. Antiretroviral therapy (ART) is typically used during this stage for the long-term management of HIV. If patients fail to start ART, HIV will continue to proliferate and decrease the amount of active CD4 cells in a patient’s body.4

When a patient's CD4 count drops below 200 cells per cubic millimeter of blood (200 cells/mm3), the patient is considered to have AIDS and a high risk for developing various opportunistic infections ranging from pneumocystis jiroveci pneumonia to toxoplasmosis. Such opportunistic infections can ultimately lead to a premature death due to a low white blood cell count (ie, CD4 count).4,5

Diagnosis and Assessment
The early diagnosis of HIV in a patient is key to ensure that she or he will quickly be evaluated and treatment started.3 Adolescents and adults aged 15 to 65 years and pregnant women should be screened for HIV.6 Pharmacists can play a critical role in helping to screen patients by directing them to purchase HIV tests.

Patients can purchase an OTC rapid HIV test at a pharmacy (eg, Oraquick In-home HIV Single Use Test) and get results in 20 minutes. If the results are positive, patients should see their primary care provider to confirm the infection using a highly sensitive and specific immunoassay—the western blot. The results of the western blot should be available within 2 days of testing.3 

Treatment
There is no cure for HIV infection; however, ART has improved HIV-related morbidity and mortality rates. The goal of ART is to inhibit HIV replication to subdue plasma HIV RNA levels and improve immune function, lower the risk of both AIDS-defining and non– AIDS-defining complications, and improve and prolong patients’ lives. ART is recommended to all patients infected with HIV to reduce the risk of disease progression and transmission.3,5

More than 25 antiretroviral medications from at least 6 different classes are FDA-approved to treat and/ or prevent HIV infection. The 6 different classes are (1) nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs), (2) non-nucleoside reverse transcriptase inhibitors (NNRTIs), (3) protease inhibitors (PIs), (4) a fusion inhibitor, (5) a C-C chemokine receptor type 5 antagonist, and (6) integrase strand inhibitors (INSTIs). In addition, 2 drugs (pharmacokinetic enhancers, boosters) are used solely to improve the pharmacokinetic profiles of some HIV drugs.3

Current guidelines recommend that an initial ART regimen for a treatmentnaïve patient should consist of 2 NRTIs in combination with either an INSTI, an NNRTI, or a PI with a pharmacokinetic booster (eg, cobicistat or ritonavir) (Table 13,5,7). These combinations have been associated with decreasing the HIV RNA viral load and improving CD4 counts in patients with HIV. The specific regimens are listed in Online Table 23,5,7.6

Table 2: Candidates for PrEP Therapy
In a relationship with a partner who is infected with HIV
Is not in a monogamous relationship with a partner who tested HIV-negative and is either a gay/bisexual male who engages in sex without a condom or was diagnosed with an STD in the past 6 months
Is a heterosexual who does not regularly use condoms and engages with other individuals with a high risk of developing HIV
Has injected illicit drugs or shared related equipment with individuals who engage in illicit drug use
STD = sexually transmitted disease.
Adapted from references 3, 5, 7.


Patient Counseling
The most effective treatment for any disease is prevention, and because of their high accessibility, pharmacists are well positioned to aid in the prevention of HIV (Online Table 33,5,7). Educate patients about the various forms of protection they can use during sexual intercourse and the replacement of contaminated needles for IV drug users.3 Also, counsel patients to speak to their prescriber for pre-exposure prophylaxis (PrEP) therapy if they are HIV-negative but at a high risk for contracting HIV (Online Table 2). PrEP therapy should be used in conjunction with other forms of protection (eg, condoms, sterile druginjection equipment) to prevent HIV.3,5,7

Table 3: Counseling Tips
Emphasize the importance of adhering to antiretroviral drug therapy. Nonadherence has been associated with treatment failure and progression of HIV infection.
Ask the patient to repeat the instructions for taking his or her medication to ensure that he or she fully understands the regimen.
Emphasize the importance of disclosing use of dietary supplements during HIV drug therapy. Some dietary supplements have been shown to interact and significantly decrease the level of HIV medications—thereby increasing the risk of treatment failure.
Discuss any economic burdens that a patient is experiencing. Some patients cannot afford to purchase HIV medications, which increases the risk of nonadherence. Counsel the patient regarding the availability of various drug benefit programs that can be used to help offset the costs of treatment.
Inform patients that they may experience adverse events while on therapy and they may make adjustments to offset their effects.
Inform patients that they may engage in constant therapeutic drug monitoring to ensure they get optimal drug efficacy with minimum toxic adverse effects.
Adapted from references 3, 5, 7.

Effective counseling also includes advocating for the patient to fully adhere to their ART regimen. This is critical to ensure they do not experience treatment resistance or failure. Once a patient with HIV develops resistance to 1 antiretroviral drug, he or she may develop resistance to others in the same therapeutic class, thereby complicating therapy.3,5,7

The incidence of adverse reactions also complicates therapy and is one of the primary reasons patients are not fully adherent to their antiretroviral regimen. Unfortunately, patients can experience a range of serious adverse effects (AEs), such as hypersensitivity, cardiomyopathy, and nephrotoxicity. Management of some of these AEs includes treating the AE, adjusting the dose of the antiretroviral medication causing the AE, and/or substituting the current antiretroviral with another that is less toxic but equally efficacious. Therefore, continually address the incidence of AEs during appointments.3,5,7

Counseling should include evaluating a patient’s use of complementary and alternative health solutions—namely dietary supplements. The results of a recent survey suggests that over 60% of patients with HIV report using complementary and alternative medicine yet feel reluctant to disclose this information to the health care providers managing their HIV medications. Some studies describe the significant reduction of HIV drug levels or even treatment failure with the concomitant use of various herbs. Because a majority of these herbs inhibit or induce the metabolism of the antiretrovirals, pharmacists should continually evaluate what dietary supplements patients are taking.3,5,7 Supplements such as St. John’s wort, vitamin C, garlic, calcium carbonate, and ferrous fumarate have been shown to significantly decrease many antiretroviral drug loads in the blood of healthy individuals and some patients with HIV. Therefore, coadministration should be discouraged.8-10

Final Thoughts
HIV should be approached as a chronic condition that will require a lifetime of monitoring and management. Long-term management can be difficult due to the stigma of HIV infection; however, pharmacists are readily available to help fight the disease with patients.


Dr. Jalloh is a community pharmacist and research fellow based in Omaha, Nebraska.

References
  1. Healthy People 2020 leading health indicators. Centers for Disease Control and Prevention – National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention website. www.cdc.gov/hiv/resources/factsheets/PDF/LHI-Factsheet-FINAL-6-26-12.pdf. Published June 2012. Accessed June 15, 2015.
  2. HIV transmission risk. Centers for Disease Control and Prevention website. www.cdc.gov/hiv/policies/law/risk.html. Updated July 1, 2014. Accessed June 15, 2015.
  3. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services website. https://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf. Updated April 8, 2015. Accessed June 11, 2015.
  4. Stages of HIV infection. AIDS.gov website. www.aids.gov/hiv-aids-basics/just-diagnosed-with-hiv-aids/hiv-in-your-body/stages-of-hiv/. Accessed June 11, 2015.
  5. Tseng A, Foisy M, Hughes CA, et al. Role of the pharmacist in caring for patients with HIV/AIDS: clinical practice guidelines. Can J Hosp Pharm. 2012;65(2):125-145.
  6. Human immunodeficiency virus (HIV) infection: screening: recommendation summary. U.S. Preventive Services Task Force website. www.uspreventiveservicestaskforce.org/Page/Topic/recommendation-summary/human-immunodeficiency-virus-hiv-infection-screening. Published April 2013. Updated March 2015. Accessed June 12, 2015.
  7. Pharmacists: partners in health care for HIV-infected patients. New York State Department of Health AIDS Institute website. www.hivguidelines.org/clinical-guidelines/hiv-and-pharmacy/pharmacists-partners-in-health-care-for-hiv-infected-patients/. Accessed June 20, 2015.
  8. Mills E, Montori V, Perri D, Phillips E, Koren G. Natural health product-HIV drug interactions: a systematic review. Int J STD AIDS. 2005;16(3):181-186.
  9. Lee LS, Andrade AS, Flexner C. Interactions between natural health products and antiretroviral drugs: pharmacokinetic and pharmacodynamic effects. Clin Infect Dis. 2006;43(8):1052-1059.
  10. Müller AC, Kanfer I. Potential pharmacokinetic interactions between antiretrovirals and medicinal plants used as complementary and African traditional medicines. Biopharm Drug Dispos. 2011;32(8):458-470. doi: 10.1002/bdd.775.
  11. Song I, Borland J, Arya N, Wynne B, Piscitelli S. Pharmacokinetics of dolutegravir when administered with mineral supplements in healthy adult subjects. J Clin Pharmacol. 2015 May;55(5):490-496. doi: 10.1002/jcph.439.



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