Active Patient Support and Personalization Key to Improving Adherence Rates and Reducing Viral Loads
Advances in the support of patients with HIV include remarkable new pharmaceutical therapies, collaborative care, outstanding patient support, and medication management.
The Status of HIV Medication Adherence and Viral Load Suppression
At the end of 2010, the American South accounted for 45% of the estimated 33,015 new AIDS diagnoses in the 50 states and the District of Columbia, followed by the Northeast (24%), the West (19%), and the Midwest (13%).1
Several studies have demonstrated that medication adherence is second only to CD4 count in accurately predicting progression to AIDS and death. For example, in a study of 76 HIV-positive patients that measured adherence by unannounced pill count every 3 to 6 weeks, no patient with >90% adherence progressed to AIDS over the 13-month follow-up period compared with 8% of those with adherence between 51% and 90%, as well as 41% with ≤50% adherence.
In bivariate analysis, each 10% difference in mean adherence was associated with a 28% reduction in the risk of progression to AIDS. Although medication adherence among chronically ill patients, including those with HIV, remains an ongoing issue, we seek to improve every single day in our efforts to improve patient care. Data from the Medical Monitoring Project, presented at the 2016 Conference on Retroviruses and Opportunistic Infections, indicate that the proportion of HIV-positive individuals “in care” with fully suppressed viral loads at their most recent test increased from 72% to 80% between 2009 and 2013.2
It is certain that much work remains to be done to combat HIV and the tens of thousands of new diagnoses every year. Nevertheless, there is reason for optimism through continuing improvements in the “medicine of infectious disease care,” inclusive of remarkable new pharmaceutical therapies, collaborative care, outstanding patient support, and medication management.
Recent Success Stories Offer Reasons for Optimism and Action
Presenting with a CD4 count of only 21, doctors gave Robert W. mere months to live. Weighing only 98 pounds, his HIV had progressed to stage 3 AIDS, and he was on his deathbed. Robert had been prescribed 7 different HIV medications and had a long history of struggling with compliance due to the complexity of his therapy coupled with the financial burdens of high co-pays.
Although he wanted to get better, he had to make decisions on which medications to buy based on what he could afford. Years of treating his condition with this hodgepodge approach left him resistant to many of the medications that could effectively treat his HIV. His roadblocks to adherence reached a crescendo when the loss of a brother he was close to left him hopeless and his inner fortitude to fight began to fade.
Complicating Robert’s case was the development of coronary artery disease that required a bypass. Surgeons could not consider him a candidate for the procedure until his HIV viral load became undetectable. Knowing that heart disease was what claimed his brother’s life at the age of 50, Robert gave up hope and lost his will to live. He was on the sidelines of a tragic race that would determine which condition would claim his life first: AIDS or heart disease.
This was Robert’s condition when he enrolled with Curant Health. The Curant Health team partnered with Robert’s clinical team at Virginia Commonwealth University to eliminate the roadblocks to compliance that were having the greatest impact on him. His medications were aggregated and sent in bubble packs to simplify the dosing schedule, making it much easier for him to adhere to his prescribed therapy.
As part of Robert’s outreach team program, an assigned patient care coordinator spoke with him every month to ensure he had no problems and was remaining compliant. She was his friendly reminder, a voice of compassion and knowledge that served equal parts encouragement and information source. But the most important roadblock Robert needed to have removed was financial. Even though he was covered by insurance, Robert faced medication co-pays totaling $700 per month. Since he received treatment at a 340B-covered clinic, however, the covered entity’s 340B funds could be used to cover those co-pays.
Thanks to an attentive team, the 340B program, and the manufacturers who support it, Robert no longer had to worry about affording the medications that would save his life. For the first time, he had full access to all of the treatments he needed at the same time. With fully covered medication, easy to administer bubble packs, and monthly check-ins, Robert began a remarkable recovery that surprised and delighted his health care team.
By July, his CD4 count rose to 96. More importantly, his viral load became undetectable, making him a candidate for the bypass surgery he needs to treat his heart disease. Assuming his bypass surgery is successful, Robert is likely to enjoy a normal lifespan.
In a broader example of success in larger populations of patients with HIV, the University of Alabama’s 1917 Clinic, a Ryan White grantee, presented a study during the 10th International Conference on HIV Treatment and Prevention Adherence. The results showed that out of 157 patients with HIV whose viral loads were not suppressed prior to enrollment in enhanced medication management protocols, 103 have now achieved viral suppression.
The Top Remaining Hurdles in HIV Care for Specialty Pharmacy
Health systems manager Amber Adams Keith works on the front lines of patient support, provider support and medication management for patients with HIV served by Curant Health.
She shares the following top hurdles these patients face in achieving suppressed viral loads and how to overcome them:
1) Access to medication (including insurance plans, co-pay cards and cost)
A high percentage of the HIV population lives within 150% of the federal poverty level. Medication for the treatment and prevention of HIV is very expensive. As such, patients are dependent on their health care team to help them gain access to their medications. Dedicated patient care coordinators are needed to identify and acquire co-pay cards that the patients might not be aware of.
Bridging the gap between the providers and the pharmacy, especially with respect to prior authorization burdens, is a high priority for our team. We facilitate prior authorization processes when needed, and we help health care facilities leverage programs, including 340B, to help the most vulnerable patients afford their medications.
2) Stigma circumvention
Unfortunately, patients with HIV still live with the stress of stigma, which, when combined with managing the disease itself, can be overwhelming for patients. Discretion among the care teams of patients with HIV is critical to value-based therapy success. Patients need regular, consistent contact, ideally from a trusted patient care coordinator trained on how to appropriately manage the patient and how to discuss medication needs.
The most appropriate, efficient, discrete methods and locations of delivery should be utilized, including boxes with no signs of pharmacy on the package. This approach is much less stressful than requiring patients to pick up medications from a local pharmacy, where they might run into someone they know or know the pharmacist filling the prescriptions.
3) Medication education
An HIV diagnosis can be very overwhelming for patients, and it is not uncommon for patients to ignore the diagnosis. A surprising number of patients often seek excuses not to get their medications filled. With regular outreach, contact, and education resource availability, patients often feel more comfortable with their therapy knowing they have a direct phone number and can e-mail their care coordinator should they have questions about their medication.
Inclusion of available educational materials in patients’ medication shipments should be standard practice. Examples include guide books with descriptions of the medications that identify them by shape, size, and color. We have learned that customized adherence packaging that sorts medication into pill packs by date and time increases medication adherence for many patients.
Improving outcomes and reducing viral loads for patients with HIV is going to require improvements in adherence on a national level; improvements in access to therapies, including simplification of prior authorization forms and processes; continuing support of the federal 340B program; and, perhaps most importantly, patient support services rooted in trusting relationships between pharmacists, patient care coordinators, and patients.
About the Author
Marc O’Connor is Chief Operating Officer for Curant Health. Curant Health treats patients nationwide through its medication management protocols, including medication reconciliation and establishment of personalized medication regimens, and supports its provider partners and care coordination with its award-winning EHR, MedPlan™. Curant’s healthcare professionals provide individualized care proven to improve the lives and reduce the overall healthcare costs of chronically ill patients.