Pharmacists Address Social Determinants of Health in HIV

In an interview with Pharmacy Times, Paul Rainville, PharmD, CSP, AAHIVP, a clinical pharmacist and subject matter expert with Shields Health Solutions, discussed the current state of HIV in the United States and pharmacists’ crucial role in addressing clinical outcomes and social determinants of health (SDOH).

Q: What is the current state of HIV in the United States?

A: In 2021, we have an estimated 1.2 million people in the United States aged 13 and over living with HIV. Our current US goals are to get a 75% reduction in new HIV infections by 2025 and a goal of 90% reduction in new HIV infections by 2030. So, you know, how are we going to reach these goals? I think this is a big focus in the US of how we're going to manage HIV. But a lot of the ways we're going to manage that infection is to prevent the infections from happening. How are we going to reach these goals? We're going to be using tools like PrEP and PEP, you know, also testing during and before pregnancy. And using tools like perinatal PEP to help prevent spread of the virus, both vertically and horizontally, transmissions from person to person.

We've seen a decrease in HIV diagnoses from the years 2017 to 2021 (that's the number to crack), declined by about 7%. In 2021, we did have an increase from the previous year, about 18%. This was likely caused by more patients being seen in hospitals following the COVID-19 pandemic, when there were some restrictions on access to HIV testing.

So, a look to the future of where our medications and treatments are going. We've had several approvals in the past year, in new medications that are long acting injectable, and these are potentially going to be used with other long-acting injectables or with failing regimens to help salvage them and help make sure the patient can stay on that regimen despite some partial resistance. And then we could potentially be using those with long-acting broadly neutralizing antibodies. And so, you'll see that there's new medications for HIV that are changing the whole way people are being treated. You know, instead of multiple tablets daily, we might be looking at patients taking one injection, maybe every month, maybe 5 months, even up every 6 months. So, it’s really made some changes there.

We’ve had a few cured patients; I believe the number is 5. These have been through stem cell transplants that have led to the cure of HIV. It's not a very practical approach to curing HIV in the larger public, but it does give us a positive outlook to where we might go with HIV in terms of can we prevent this virus? Can we treat this virus? And give us a more apt idea of how we're going to move forward with this treatment.

Q: Yeah, definitely. I know I was reading about the cures and it's fascinating. How have the populations that are most at risk of HIV changed over recent decades, and what is the role of SODH in this issue?

A: We do still see the current populations at risk, including men who have sex with men. You also see patients that are transgender female in a higher population of new diagnoses. But what we have been seeing most recently have been increases in both Black or African American patients, as well as Hispanic and Latino patients. So, you see that these new diagnoses in these racial groups have increased. Also, for women, specifically Black and African American women, they account for 54% of new HIV diagnoses for females whereas they don't represent that high of a population in our total population for the US. So, these are the areas we really need to be looking at where we can make improvements in prevention. But those are the immediate, most average groups right now.

We also see that that people who inject drugs have accounted for about 7% of the population. So, we do actually see a sudden decrease from previous numbers and the people who are injecting drugs getting HIV. And that may be because of education in regard to proper needle disposal, prevention of needle sharing, and just improvement in that overall education.

We also see most of our population that are newly diagnosed with HIV coming in the age group of 13 to 34, so 56% of patients that are newly diagnosed with HIV are going to be in that age group. For newly diagnosed patients, regionally, we have 52%, or about 18,000, living in the South, 20% live in the West, 14% in the Northeast, and 13% in the Midwest. And those are according to our 2021 numbers.

The second part of the question has to do with SDOH. Social determinants of health represent about 95% of what actually goes into health care; they really do determine how effective medications, treatment plan, all these things are going to come together based on what the SDOH are and how they influence it. So, just to describe what social determinants of health are, for those of you who haven't listened to or read into this recently, they are economic and social conditions that can influence health status. A few examples of those might be economic stability, housing, and consistent employment; they might have a history of incarceration and is that affecting their ability to get both housing and education. Not just, you know, their degrees and if they have a bachelor’s or associate degree, or have they've been to high school, but also their health care literacy. They've been taught about their medications; they've been taught about safe sex practices—that education determines a lot of how patients are going to buy into a medication treatment plan.

And then for the health care providers that are providing the care, you don't have the health care providers providing the same education and opportunities to learn about SDOH or about the disease state. Another big one that I think we see is food security. So, food insecurity affects a lot of patients, you know, and it can be in specific locations—maybe there are healthy food deserts, where you really don't have healthy food options. This can lead to risks of diabetes, hypertension, atherosclerotic diseases, or, you know, maybe it's a food that is healthy and available, is it unaffordable prices, which will affect the cost, despite there being healthy foods available. If health care systems are moving to more desirable locations, trying to get into areas where they can make more profits, you know, trying to avoid lower income or lower resource areas so that they can succeed financially, you can see that causing negative outcomes for patients, lowering their SDOH, and also like their neighborhood and physical environment. You know, if you're asking the patient to go get 150 minutes of exercise a week but they don't have any local gyms, they don't have a park, they can’t walk and they don't feel safe walking outdoors, you know, it may be difficult for them to reach those goals, so they can improve their health.

Another practice that kind of goes along with SDOH would be redlining, which is a discriminatory practice where services are withheld from potential customers and patients who reside in neighborhoods classified as hazardous. So really, if we can focus with our health care teams in identifying—but not just identifying, also resolving—these inequities in health care needs, [we can] help to improve the disparities and outcomes, including life expectancy, disease burden, disability, access and quality of life. One project that we were introduced by our our team here at Shields was the Everyone Project with the American Academy of Family Physicians. Their Neighborhood Navigator is a really great tool if you've already identified some gaps in social health, the Neighborhood Navigator really is a great resource to help you find the tools to fix those gaps and find some ways to make improvements for patients that are experiencing those issues.

Q: Yeah, that's wonderful. Turning it a little bit more clinical, why does viral load matter and how is it related to the goals of therapy?

A: Yes, that's very important for us, I think it's one of the things we look at first. It's probably the first thing I want to see, besides what medication patients are on, when I'm taking a look at a patient's chart. And, you know, the reason the viral load is so important, is it does indicate how their treatment is working, you know, have they been taking the medication? Is the medication effective? When the viral load is undetectable—that's really what our goal is going to be, is to keep these levels completely undetectable. But when we're below 200, we can really prevent the transmission of HIV. Anything below that level is very unlikely to transmit the virus. When we can maintain that suppressed viral level, when it's below the undetectable level, we can prevent things like inflammation that are secondary to viral replication, we can prevent other things like immune destruction from viremia, you know, from the virus actually just destroying a virus, or disease progression, which will lead to higher risk of mortality. If we can look into a patient, what's going on with them, maybe improve their adherence, look for drug interactions. When you can clear out those interactions or issues or, you know, just help the patient get over the hump with their therapy, we really can do a lot of things in preventing a risk of resistance, which still does occur.