Outpatient pharmacy care and HIV viral load response among patients on HAART

The Effect of an Integrated Health System Specialty Pharmacy on HIV Antiretroviral Therapy Adherence, Viral Suppression, and CD4 Count in an Outpatient Infectious Disease Clinic

BACKGROUND

Adherence to antiretroviral (ARV) therapy is critical in order to achieve and maintain viral suppression and improve immune function. Clinical pharmacists and pharmacies focused on human immunodeficiency virus (HIV) have demonstrated the ability to increase ARV medication adherence and subsequently have a positive effect on these lab markers.

OBJECTIVES

To evaluate the effect of an integrated health system specialty pharmacy service with a clinic-embedded, HIV-trained pharmacist and pharmacy technician on ARV medication adherence rate, viral load, and CD4 count.

METHODS

This was a single-center, retrospective cohort study conducted from August 7, 2017, to June 30, 2018, at an indigent outpatient infectious disease clinic within Atrium Health (AH), a not-for-profit health system based in Charlotte, NC. The intervention group (opt-in group) received HIV patient care that involved the health system specialty pharmacy service. Once a patient was enrolled in the specialty pharmacy service, medication reconciliation was completed by the pharmacist, financial assistance and prior authorizations were completed if needed; prescriptions were delivered to the patient; and monthly refills calls were conducted to assess adherence, tolerability, and medication changes. The control group (opt-out group) received HIV patient care that did not incorporate the health system specialty pharmacy. The primary endpoints were medication adherence, viral suppression, and CD4 counts. Within-group comparisons from baseline to follow-up were made along with group-to-group comparisons. Adherence was calculated using medication possession ratio.

RESULTS

For those patients using Atrium Health Specialty Pharmacy Service (AH SPS; n = 46), the overall median adherence rate was higher at 100% versus only 94% for those patients (n = 50) that opted out of the service (P < 0.01). All but 3 patients (21.7% at baseline vs. 6.5% at follow-up, P = 0.03) using AH SPS reached viral suppression, and all but 1 had improved immune function with a CD4 count of 200 or greater by the end of the observation period (P = 0.03). The change in viral suppression and CD4 count of 200 or greater was not statistically improved between baseline and follow-up in those opting out of using AH SPS. When comparing the 2 groups at reaching these endpoints, there was no statistically significant difference in viral suppression and CD4 count.

CONCLUSIONS

AH SPS was able to demonstrate improved ARV adherence in those patients using an integrated specialty pharmacy with an embedded pharmacy team, coordinated monthly medication delivery, and refill reminder and adherence calls. This in turn led to improved viral suppression and immune markers by the end of the observation window for patients using AH SPS.

DISCLOSURES

No outside funding supported this study. The authors have nothing to disclose.

Use of an On-Site Outpatient Pharmacy for Acquisition of Antiretroviral Medications Compared to Off-Site Pharmacy Options: Impact on Retention in Care and Clinical Outcomes in People Living With HIV

BACKGROUND

Few published studies have examined the relationship between pharmacy location and retention in care or clinical outcome in people living with HIV (PLWH).

OBJECTIVE

The study purpose was to determine whether using an on-site/in-clinic pharmacy to obtain antiretroviral therapy increased retention in care and virologic suppression rates.

METHODS

PLWH attending a Ryan White outpatient clinic in an academic center were matched based on age and insurance. Rates of retention in care ( ≥2 medical visits/calendar year) were assessed between patients using a pharmacy on-site in the clinic versus patients use off-site pharmacy options. Virologic suppression [viral load(VL)<200 copies/mL], completing ≥2 VL, and CD4 count were compared between pharmacy types.

RESULTS

137 on-site pharmacy patients and 274 off-site pharmacy patients met inclusion and matching criteria. 91.2% of on-site pharmacy users attended ≥2 clinic visits compared to 83.2% of off-site pharmacy users (P = .0275) and were approximately twice as likely to complete ≥2 clinic visits (odds ratio: 2.032; 1.071-3.857). A similar proportion of the on-site pharmacy group achieved virologic suppression compared to the off-site pharmacy group (92.7% vs 89.1%; P = .239, respectively).

CONCLUSIONS

On-site pharmacies may provide an opportunity to positively impact retention in care and clinical outcomes for PLWH.

An Innovative Approach to Addressing the HIV Care Continuum: Implementation of a Clinical Pharmacy Resident in a Veterans Affairs HIV Specialty Clinic

PURPOSE

Engagement of patients in the HIV care continuum and adherence to antiretroviral therapy (ART) continue to limit successful viral suppression. Innovative practices to improve this continuum and ameliorate potential physician shortages are needed. The objective of this evaluation was to determine the clinical benefits of incorporating pharmacy resident involvement on a multidisciplinary team in caring for patients with HIV.

METHODS

A single-center pre-post cohort pilot evaluation was conducted at the Tennessee Valley Healthcare Systems VA Medical Center. Patients were enrolled in an HIV pharmacotherapy clinic implemented by an ambulatory care pharmacy resident. The primary end point of the evaluation was the percentage of patients achieving an undetectable plasma HIV viral load after enrollment. Secondary end points included change from baseline in CD4 T-cell count and self-reported adherence.

RESULTS

A total of 55 patients were seen in the HIV pharmacotherapy clinic over a 28-week evaluation period. Of those patients with detectable viral load at enrollment, 70% reached viral suppression during follow-up, with a significant 0.75 log10 decrease in the median viral load ( P < .0001 for both). The median CD4 T-cell count increased from 464 to 525 cells/mm³ ( P = .01). Reported adherence, assessed using the Visual Analogue adherence Scale (VAS) increased significantly ( P = .0001).

CONCLUSION

After enrollment in an HIV pharmacotherapy clinic, a significant decrease in viral load was seen, as were improvements in secondary end points of CD4 T cells and adherence. These data demonstrate the clinical benefits of pharmacy resident involvement on a multidisciplinary team in caring for patients with HIV.

Evaluating the Effects of an Interdisciplinary Practice Model with Pharmacist Collaboration on HIV Patient Co-Morbidities

Treatment of HIV now occurs largely within the primary care setting, and the principal focus of most visits has become the management of chronic disease states. The clinical pharmacist's potential role in improving chronic disease outcomes for HIV patients is unknown. A retrospective cohort study was performed for HIV-positive patients also diagnosed with diabetes, hypertension, or hyperlipidemia. Characteristics and outcomes in 96 patients treated by an interdisciplinary team that included a clinical pharmacist (i.e., the intervention group) were compared to those in 50 patients treated by an individual healthcare provider (i.e., the control group). Primary outcomes were changes from baseline over 18 months of HbA1c, low density lipoprotein (LDL), and blood pressure, respectively. Secondary outcomes included number of drug-drug interactions, HIV viral load, CD4 count, percent change in smoking status, and percent of patients treated to cardiovascular guideline recommendations. The interdisciplinary team had a significant improvement in lipid management over the control group (LDL: -8.8 vs. +8.4 mg/dL; p=0.014), and the smoking cessation rate over the study period was doubled in the interdisciplinary group (20.4% vs. 11.8%). Among those with an indication for aspirin, a significantly higher percentage of patients were prescribed the medication in the interdisciplinary group compared to the control group (85.5% vs. 64.9%; p=0.014). An informal cost analysis estimated savings of more than $3000 per patient treated by the interdisciplinary team. Based on these results, pharmacist involvement in an HIV primary care clinic appears to lead to more appropriate management of chronic co-morbidities in a cost-effective manner.

HIV viral load: a concept analysis and critique

In this article, we examine the concept of HIV viral load and how it has evolved over time (1995-2013) in the field of HIV/AIDS. Although the term viral load is used extensively in this field, few efforts have been directed toward the conceptualization of HIV viral load, which is often left unquestioned, undertheorized, and portrayed as a neutral and objective laboratory value that has remained relatively stable over time--with the exception of progressive advancements in technology, techniques, and sensitivity. The purpose of this article is to apply the evolutionary concept analysis method developed by Rodgers (1989, 2000a) to the concept of HIV viral load. To set the stage, we establish the need for a concept analysis of HIV viral load and provide an overview of the evolutionary view. Then, drawing on the steps proposed by Rodgers (2000a), we outline the process of data collection, management, and analysis. We then offer an in-depth discussion of the findings (attributes, antecedents, and consequences) informed by Wuest's (2000) critical approach to concept analysis. We conclude by highlighting the implications of this analysis for clinical practice, research, and theory.

Reporting of critical information in studies of pharmacists in HIV care

OBJECTIVE

To evaluate manuscripts documenting HIV pharmacist interventions and assess adequacy of reporting as defined by CONSORT and STROBE criteria.

METHODS

PubMed, EMBASE, Cochrane Library, Web of Science, BIOSIS Previews, and PsycINFO databases were searched from inception - 1 June 2011. Studies were included if pharmacists performed an intervention to improve HIV patient care, and the study evaluated the intervention's impact. Qualitative studies, non-English language reports, abstracts and studies where the pharmacist did not intervene were excluded. Manuscripts were independently evaluated by two reviewers for the presence, absence or lack of applicability of STROBE (observational studies) or CONSORT (randomized studies) criteria, for presence or absence of description of pharmacist's duties, CD4+ cell count, HIV viral load and adherence measurement. Reviewers met to discuss the rationale behind their evaluation; a third arbiter was consulted when reviewers could not agree on a particular criterion.

KEY FINDINGS

Twenty-two manuscripts met inclusion criteria. Observational studies of HIV pharmacists (n = 19) included 56% of applicable STROBE criteria. Randomized studies of HIV pharmacists (n = 3) adhered more closely to CONSORT reporting guidelines (average 80% of applicable criteria). Manuscripts published after 2004 more consistently evaluated pharmacist impact on HIV outcomes such as CD4+ and viral load.

CONCLUSIONS

Thorough reporting increases the reader's ability to critically evaluate manuscripts of HIV pharmacist services. Increasing pharmacist awareness of manuscript guidelines such as CONSORT and STROBE may improve clarity of reporting in studies of HIV pharmacist interventions and clinical programmes.

Pharmacists' strategies for promoting medication adherence among patients with HIV

OBJECTIVES

To provide pharmacists' perspectives on medication adherence barriers for patients with human immunodeficiency virus (HIV) and to describe pharmacists' strategies for promoting adherence to antiretroviral medications.

DESIGN

Multisite, qualitative, descriptive study.

SETTING

Four midwestern U. S. states, from August through October 2009.

PARTICIPANTS

19 pharmacists at 10 pharmacies providing services to patients with HIV.

INTERVENTION

Pharmacists were interviewed using a semistructured interview guide.

MAIN OUTCOME MEASURES

Barriers to medication adherence, pharmacist interventions, challenges to promoting adherence.

RESULTS

Pharmacists reported a range of adherence barriers that were patient specific (e.g., cognitive factors, lack of social support), therapy related (e.g., adverse effects, intolerable medications), and structural level (e.g., strained provider relationships). They used a combination of individually tailored, patient-specific interventions that identified and resolved adherence barriers and actively anticipated and addressed potential adherence barriers. Pharmacist interventions included medication-specific education to enhance patient self-efficacy, follow-up calls to monitor adherence, practical and social support to motivate adherence, and patient referrals to other health care providers. However, the pharmacists faced internal (e.g., lack of time, lack of trained personnel) and external (e.g., insurance policies that disallowed patient enrollment in automatic prescription refill program) challenges.

CONCLUSION

Pharmacists in community settings went beyond prescription drug counseling mandated by law to provide additional pharmacy services that were tailored to the needs of patients with HIV. Given that many individuals with HIV are living longer, more research is needed on the effectiveness and cost effectiveness of pharmacists' interventions in clinical practice, in order to inform insurance reimbursement policies.

The impact of HIV clinical pharmacists on HIV treatment outcomes: a systematic review

OBJECTIVE

Due to the rapid proliferation of human immunodeficiency virus (HIV) treatment options, there is a need for health care providers with knowledge of antiretroviral therapy intricacies. In a HIV multidisciplinary care team, the HIV pharmacist is well-equipped to provide this expertise. We conducted a systematic review to assess the impact of HIV pharmacists on HIV clinical outcomes.

METHODS

We searched six electronic databases from January 1, 1980 to June 1, 2011 and included all quantitative studies that examined pharmacist's roles in the clinical care of HIV-positive adults. Primary outcomes were antiretroviral adherence, viral load, and CD(4) (+) cell count and secondary outcomes included health care utilization parameters, antiretroviral modifications, and other descriptive variables.

RESULTS

Thirty-two publications were included. Despite methodological limitation, the involvement of HIV pharmacists was associated with statistically significant adherence improvements and positive impact on viral suppression in the majority of studies.

CONCLUSION

This systematic review provides evidence of the beneficial impact of HIV pharmacists on HIV treatment outcomes and offers suggestions for future research.

Pharmacist counseling in a cohort of women with HIV and women at risk for HIV

BACKGROUND AND METHODS

Achieving high adherence to antiretroviral therapy for human immunodeficiency virus (HIV) is challenging due to various system-related, medication-related, and patient-related factors. Community pharmacists can help patients resolve many medication-related issues that lead to poor adherence. The purpose of this cross-sectional survey nested within the Women's Interagency HIV Study was to describe characteristics of women who had received pharmacist medication counseling within the previous 6 months. The secondary objective was to determine whether HIV-positive women who received pharmacist counseling had better treatment outcomes, including self-reported adherence, CD4(+) cell counts, and HIV-1 viral loads.

RESULTS

Of the 783 eligible participants in the Women's Interagency HIV Study who completed the survey, only 30% of participants reported receiving pharmacist counseling within the last 6 months. Factors independently associated with counseling included increased age (odds ratio [OR] 1.28; 95% confidence interval [CI] 1.07-1.55), depression (OR 1.75; 95% CI 1.25-2.45), and use of multiple pharmacies (OR 1.65; 95% CI 1.15-2.37). Patients with higher educational attainment were less likely to report pharmacist counseling (OR 0.68; 95% CI 0.48-0.98), while HIV status did not play a statistically significant role. HIV-positive participants who received pharmacist counseling were more likely to have optimal adherence (OR 1.23; 95% CI 0.70-2.18) and increased CD4(+) cell counts (+43 cells/mm(3), 95% CI 17.7-104.3) compared with those who had not received counseling, though these estimates did not achieve statistical significance.

CONCLUSION

Pharmacist medication counseling rates are suboptimal in HIV-positive and at-risk women. Pharmacist counseling is an underutilized resource which may contribute to improved adherence and CD4(+) counts, though prospective studies should be conducted to explore this effect further.

Pharmacists’ Research Contributions in the Fight against HIV/AIDs

Pharmacists have made many contributions to HIV/AIDs research and are still showing their significance as members of the healthcare team through innovative clinical trials. Pharmacists are showing advances in several healthcare settings including inpatient, outpatient, and community pharmacies. Because of the complex regimens of highly active antiretroviral therapy (HAART), the increased life span of patients living with HIV, and other concomitant medications taken for comorbid disease states, there is a high risk for health-related complications and the development of adverse events. These adverse events may lead to decreased adherence to HAART, which may cause the development of HIV drug resistance. Pharmacists are providing examples through growing research on how they help combat medication-related errors and also continue to contribute as healthcare providers as a part of a holistic healthcare team.

Community Pharmacy Use Patterns of Women with HIV and Women At Risk for HIV in the San Francisco Bay Area

BACKGROUND

Community pharmacies play a key role in the care of patients when dispensing antiretroviral therapy. The primary objective of this study was to describe patterns of community pharmacy use of women enrolled in the San Francisco site of the Women's Interagency HIV Study (WIHS). The secondary objective was to determine whether the number of pharmacies a patient uses is associated with specific patient characteristics or virologic outcomes in HIV positive women.

OBJECTIVES

The primary objective was to determine factors which were associated with using multiple dispensing pharmacies to obtain medications in a population of HIV+ and at-risk women. The secondary objective was to determine whether use of multiple pharmacies was associated with immunologic or virologic changes for the subset of HIV+ women.

METHODS

A survey on community pharmacy use was distributed to San Francisco WIHS participants from 2004-2007. Poisson, linear, and logistic regression methods were used to determine associations between specific patient characteristics and use of multiple dispensing pharmacies and associations between multiple pharmacy use and CD4+ cell count or viral load changes.

RESULTS

There was a trend towards an association between HIV status and use of multiple pharmacies (IRR=1.23; 95% CI 1.00-1.51, p =0.05). In multivariable analyses of HIV positive women, use of additional pharmacies (over the primary pharmacy) during the study period was not associated with statistically significant changes in CD4+ count or viral load.

CONCLUSION

HIV positive participants may tend to use multiple pharmacies more frequently than their HIV negative counterparts, though this practice does not appear to be associated with poorer immunologic or virologic outcomes. Future studies should be conducted to determine whether different patient patterns of community pharmacy use affect HIV treatment outcomes.

Utilização dos registros de dispensação da farmácia como indicador da não-adesão à terapia anti-retroviral em indivíduos infectados pelo HIV

Este estudo teve como objetivos avaliar os registros de dispensação de anti-retrovirais (ARV) por um período de 12 meses após a primeira prescrição e determinar os fatores associados com a retirada irregular ou abandono em dois serviços públicos de referência para AIDS, em Belo Horizonte, Minas Gerais, Brasil. Participaram 323 pacientes infectados pelo HIV, virgens de tratamento, recrutados entre maio de 2001 e maio de 2002. No período, 98 (30,3%) pacientes abandonaram a terapia e 187 (57,9%) tiveram pelo menos uma retirada irregular. Indivíduos com retirada irregular ou que abandonaram a terapia foram comparados àqueles com retirada regular. Análise multivariada multinomial indicou que morar fora de Belo Horizonte, ter contagem de linfócitos TCD4+ maior que 200 células/mm³ e uso de esquema sem inibidor de protease estavam associados com retirada irregular. Além dessas variáveis, o abandono mostrou associação com não fazer uso de outra medicação e ter registro de não-adesão no prontuário médico. Os registros da farmácia destacaram-se como potencial indicador de não-adesão, devendo ser incorporados à prática clínica. Ações que busquem os pacientes ausentes ou com retirada irregular devem ser priorizadas.

Optimizing the effects of stress management interventions in HIV

Scott-Sheldon, Kalichman, Carey, and Fiedler (2008) present a thoughtful, important, and timely meta-analysis of randomized controlled trials of stress management interventions in HIV. They differentiate controlled effect sizes across classes of acute outcomes including psychological distress, psychosocial processes, biological processes (immune status, viral, and hormonal) and fatigue. The authors join Scott-Sheldon et al., in considering future directions for this type of clinical psychosocial intervention research in HIV. Recommendations for addressing the high prevalence of psychosocial problems including diagnosable mental health disorders comorbid with HIV are presented. Suggestions for addressing medication adherence and accommodating interventions with concomitant substance use treatment are also considered. These recommendations are presented with an emphasis on expanding both the efficacy and effectiveness of psychosocial interventions in HIV. These recommendations are presented as realistic strategies for improving the modest treatment effect sizes for psychosocial outcomes and identifying meaningful effects on distal physiological outcomes associated with traditional stress management interventions in HIV.

Does distress tolerance moderate the impact of major life events on psychosocial variables and behaviors important in the management of HIV?

Living with HIV involves management of multiple stressful disease-related and other life events. Distress tolerance may provide a functional, individual-based context for qualifying the established relationships between major life events and psychosocial variables important in the management of HIV. The present study provided a preliminary test of the hypothesis that distress tolerance moderates the impact of major life events on these predictors of disease progression. HIV-positive patients (n=116) completed psychosocial and medical questionnaires. Results indicated that major life events interacted with distress tolerance such that lower distress tolerance and higher life events were associated with significantly higher levels of depressive symptoms, substance use coping, alcohol and cocaine use, and medication adherence. In addition, distress tolerance was directly related to self-reported HIV-related symptoms. These results suggest that low distress tolerance, particularly in the face of major life events, may present significant challenges to adaptive management of HIV. Distress tolerance assessment may help to specify targets for cognitive-behavioral and stress management treatments for people living with HIV.

Effect of clinical pharmacists on utilization of and clinical response to antiretroviral therapy

OBJECTIVE

To determine the association of clinical pharmacists with health outcomes and utilization measures among HIV-infected patients.

METHODS

Observational study of 1571 HIV-infected patients prescribed their initial highly active antiretroviral therapy (HAART) regimen in clinics with and without a clinical pharmacist. Outcomes analyzed were changes in plasma HIV RNA level, CD4 T-cell counts, and service utilization (hospital days, emergency department visits, and office visits) over 24 months based on exposure to a clinical pharmacist.

RESULTS

Patients exposed to a clinical pharmacist tended to be more likely to achieve an HIV RNA level <500 copies/mL at 12 months (adjusted odds ratio [OR] = 2.01, 95% confidence interval [CI]: 0.92 to 4.37). At 24 months, however, results depended on the provider panel size; the ORs for panel sizes < or =50 and >50 HIV-infected patients were 1.67 (95% CI: 0.60 to 4.62) and 0.97 (95% CI: 0.39 to 2.41), respectively. CD4 T-cell counts were modestly but nonsignificantly higher for the patients exposed to a clinical pharmacist. Utilization also depended on the provider panel size; pharmacist exposure was associated with 64% (95% CI: 30% to 108%) and 9% (95% CI: -11% to 33%) increases in total hospital days for panel sizes < or =50 and >50 HIV-infected patients, respectively. Pharmacist exposure was also associated with a 19% (95% CI: -13% to -24%) decrease in office visits for panel sizes < or =50 HIV-infected patients, with minimal effect for larger panel sizes.

CONCLUSION

Clinical pharmacists seem to contribute to lower office visit rates in antiretroviral-naive patients initiating HAART.

Psychosocial factors predict CD4 and viral load change in men and women with human immunodeficiency virus in the era of highly active antiretroviral treatment

OBJECTIVE

Most previous longitudinal studies demonstrating relationships between psychosocial variables and human immunodeficiency virus (HIV) disease progression utilized samples of gay men accrued before the era of highly active antiretroviral treatment (HAART), without including viral load (VL) as an indicator of disease progression or assessing the impact of medication adherence. This study sought to determine whether psychosocial variables would predict both CD4 and VL changes in a diverse sample assessed entirely during the era of HAART and accounting for adherence effects.

METHODS

This longitudinal study assessed a multiethnic HIV+ sample (n = 177) of men and women in the midrange of illness (CD4 number between 150 and 500; no previous acquired immunodeficiency syndrome [AIDS]-defining symptom) every 6 months for 2 years. Hierarchical linear modeling was used to model change in CD4 and VL controlling for sociodemographics (age, gender, ethnicity, education) and medical variables (baseline CD4/VL, antiretroviral medications at each time point, adherence).

RESULTS

Baseline depression, hopelessness, and education predicted the slope of CD4 and VL. Avoidant coping and life event stress predicted VL change. Cumulative variables produced stronger relationships (depression, avoidant coping, and hopelessness with CD4/VL slope and life events stress with VL slope). High cumulative depression and avoidant coping were associated with approximately twice the rate of decline in CD4 as low scorers and greater relative increases in VL. Social support was not significantly related to CD4 or VL slope.

CONCLUSIONS

Psychosocial factors contribute significantly to the variance in HIV disease progression (assessed through CD4 number and VL) in a diverse sample, accounting for adherence and do so in the era of HAART.

Psychosocial factors predict CD4 and viral load change in men and women with human immunodeficiency virus in the era of highly active antiretroviral treatment

OBJECTIVE

Most previous longitudinal studies demonstrating relationships between psychosocial variables and human immunodeficiency virus (HIV) disease progression utilized samples of gay men accrued before the era of highly active antiretroviral treatment (HAART), without including viral load (VL) as an indicator of disease progression or assessing the impact of medication adherence. This study sought to determine whether psychosocial variables would predict both CD4 and VL changes in a diverse sample assessed entirely during the era of HAART and accounting for adherence effects.

METHODS

This longitudinal study assessed a multiethnic HIV+ sample (n = 177) of men and women in the midrange of illness (CD4 number between 150 and 500; no previous acquired immunodeficiency syndrome [AIDS]-defining symptom) every 6 months for 2 years. Hierarchical linear modeling was used to model change in CD4 and VL controlling for sociodemographics (age, gender, ethnicity, education) and medical variables (baseline CD4/VL, antiretroviral medications at each time point, adherence).

RESULTS

Baseline depression, hopelessness, and education predicted the slope of CD4 and VL. Avoidant coping and life event stress predicted VL change. Cumulative variables produced stronger relationships (depression, avoidant coping, and hopelessness with CD4/VL slope and life events stress with VL slope). High cumulative depression and avoidant coping were associated with approximately twice the rate of decline in CD4 as low scorers and greater relative increases in VL. Social support was not significantly related to CD4 or VL slope.

CONCLUSIONS

Psychosocial factors contribute significantly to the variance in HIV disease progression (assessed through CD4 number and VL) in a diverse sample, accounting for adherence and do so in the era of HAART.