Pharmacists Optimize HIV Treatment in Ambulatory Care Settings

Although less than half of attendees of a symposium at the American Society of Health-System Pharmacists 2014 Midyear Clinical Meeting indicated that they treat HIV-infected patients regularly, the presenters said pharmacists’ role in HIV care across ambulatory care settings is expanding.

For instance, E. Kelly Hester, PharmD, BCPS, AAHIVP, an associate clinical professor at the Auburn University Harrison School of Pharmacy, pointed out that pharmacists can monitor HIV patients’ adherence to antiretroviral therapy (ART), which is necessary for successful virologic suppression. In addition, clinical pharmacists can reduce drug-related problems by ensuring the accuracy of ART dosing and addressing potential drug-drug interactions with polypharmacy.

While HIV patients have an increased risk for cardiovascular disease, Dr. Hester said pharmacists can substantially lower that risk by providing smoking cessation counseling; addressing underutilization and optimization of therapy for dyslipidemia, hypertension, and diabetes; and offering advice on lifestyle modifications. To reduce the risk of additional comorbidities, clinical pharmacists can improve vaccination rates by educating HIV-infected patients on vaccine-preventable diseases such as hepatitis B, influenza, and human papillomavirus.

“We have some real opportunities to assist in the primary care of HIV patients,” Dr. Hester noted.

To help pharmacists feel confident about seizing those opportunities, Douglas Slain, PharmD, FCCP, BCPS, an associate professor and infectious diseases clinical specialist in the Department of Clinical Pharmacy at West Virginia University, reviewed best practices for selecting drug therapies for HIV patients.

In order to achieve the goals of maximal and durable viral load suppression alongside restored or preserved immunologic function, Dr. Slain suggested starting a standard ART regimen that contains a pair of nucleoside reverse transcriptase inhibitors supported by a non-nucleoside reverse transcriptase inhibitor, a protease inhibitor “boosted” by ritonavir, or an integrase inhibitor. When choosing an appropriate therapy, pharmacists should consider the toxicities and adverse events associated with each drug, such as nephrotoxicity with tenofovir, dyslipidemia with efavirenz, and hyperglycemia with all protease inhibitors.

Although Dr. Slain recommended switching to a different ART whenever a patient fails to maintain undetectable HIV RNA levels, he said modifiable causes like medication nonadherence and drug-drug interactions must be considered and corrected first.

“ART has dramatically improved the lives of HIV-infected patients and many around them, (but) these therapies have complex interactions and complications,” Dr. Slain said. “Pharmacists must use the best resources when managing pharmacotherapy in HIV-infected patients.”