Pharmacy students must have a comprehensive understanding of antiretrovirals to ensure efficiency and optimization of patients’ medical treatment.
There are nearly 1.2 million people older than 13 years living in the United States with HIV.1 When the HIV/AIDS epidemic began, it was seen as a death sentence because there were no adequate treatments to keep people alive. Now, with medical advances and constant research, the development of antiretrovirals (ARVs) has enabled those with HIV to live long and full lives if they adhere to their medication.
As future drug experts, pharmacy students must understand common HIV medications to expand access to safe and effective care for those living with the virus or seeking prevention. A comprehensive understanding of ARVs, proper treatment regimens, and key counseling strategies is essential to achieving this goal.
HIV attacks and destroys an individual’s CD4+ cells. With a lack of white blood cells in the body, a person’s immune system becomes weakened and is unable to adequately fight off infections, leading to the patient becoming immunocompromised. A normal CD4+ cell range is anywhere between 500 to 1500 cells/mm3, but if that number drops below 200 cells/mm3, then a patient with HIV will develop AIDS. However, this diagnosis can be avoided if the patient is adherent to their medication, which will slowly increase and maintain a safe CD4+ cell level.1,2
ARVs are recommended for everyone with HIV to reduce their risk of morbidity and mortality as well as prevent the transmission of HIV with an undetectable viral load through sexual activity. Combinations of 2 or more FDA-approved ARV medications have been proven to show immense efficacy in patients with HIV. Various drug classes available on the market can be used to optimize treatment, as shown in Table 1.3,4 Combination brand names and active ingredients can be found in Table 2.5
HIV medication combinations require a backbone of at least 1 or 2 nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) and a drug in another class (eg, integrase strand transfer inhibitors [INSTIs], non-nucleoside/nucleotide reverse transcriptase inhibitors [NNRTIs], or protease inhibitors [PIs]). The most common ones in drug combinations are emtricitabine, lamivudine, and one of the tenofovir formulations, either tenofovir alafenamide or tenofovir disoproxil.
Rilpivirine and efavirenz are 2 of the most commonly used NNRTIs found in NNRTI-based regimens. These drug combinations include Odefsey (rilpivirine/emtricitabine/tenofovir alafenamide fumarate), Complera (rilpivirine/emtricitabine/tenofovir disoproxil fumarate), and Atripla (efavirenz/emtricitabine/tenofovir disoproxil fumarate).
It’s important to advise patients on rilpivirine to be careful when taking any acid-reducing agents. There is an absolute contraindication to combinations with proton pump inhibitors because they can decrease rilpivirine’s efficacy. Histamine type 2 receptor antagonists and antacids can be taken but require timed separation.
Rilpivirine should be taken with food, whereas efavirenz is suggested to be taken without food at bedtime. Taking efavirenz with food can increase a patient’s risk of experiencing central nervous system–related adverse effects, such as impaired concentration and abnormal dreaming. False-positive cannabinoid and benzodiazepine tests have also been reported with those taking efavirenz.
INSTIs, commonly referred to as integrase inhibitors, are some of the most frequently prescribed FDA-approved HIV medications. The names of these ARVs often end in -tegravir, and the drugs are often recognized for their low adverse effect profile, high tolerability, and low drug interaction profile. Some of the most common integrase inhibitor–based regimens are:
ARVs combined with cobicistat—such as elvitegravir—should be taken with food. One major drug interaction concern with integrase inhibitors is their contraindication to antacids and polyvalent cations. Elements such as aluminum, magnesium, calcium, and iron that can be found in multivitamins and supplements should never be combined due to a risk of decreasing the efficacy of the integrase inhibitors. It is recommended to space the substances out or take them together with food, depending on the antacid. Recommendations for each drug can be found at clinicalinfo.hiv.gov.5 These interactions do not apply to Apretude or Cabenuva because they are intramuscular injections.
PIs are ARVs whose names commonly end in -navir and are found in combination products such as Symtuza, which uses darunavir as its protease inhibitor, alongside cobicistat, emtricitabine, and tenofovir alafenamide fumarate. PIs such as darunavir and atazanavir are recommended to be taken with cobicistat, a pharmacokinetic enhancer designed to boost the therapeutic effects of PIs. It’s important to note that PIs should always be taken with food and are contraindicated if combined with statin medications such as lovastatin or simvastatin.
Zahara Anglin is a sixth-year (P4) pharmacy student at the College of Pharmacy and Health Sciences at St. John’s University in Queens, New York. Her passions and interests include HIV/AIDS pharmacotherapy, LGBTQ+ health, patient advocacy, and mental health support.
HIV medications are saving lives. As future drug experts, student pharmacists will be responsible for, or are already responsible for, improving their patients' health and livelihoods. To expand access to safe and effective care for those living with HIV or who wish to prevent contraction, it’s important for pharmacy students to understand what has been prescribed for their patients. Having a comprehensive understanding of ARVs, standard treatment regimens, and counseling tips are essential to achieving this goal.
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