The Importance Of Community Pharmacist Intervention In Optimizing Hiv Patient Outcomes
Camille Thornton, PharmD, BCPS
We are now 20+ years into the AIDS epidemic. In the United States, despite the current $2.9 billion in annual research funding from the National Institutes of Health alone, the National Institute of Allergy and Infectious Diseases offers these startling statistics: "As many as 950 000 Americans may be infected with HIV, 25% of whom are unaware of their infection. The epidemic is growing most rapidly among minority populations and is a leading killer of African-American males ages 25 to 44 years. According to the Centers for Disease Control and Prevention (CDC), AIDS affects nearly 7 times more African Americans and 3 times more Hispanics than whites. In recent years, an increasing number of African-American women and children are being affected by HIV/AIDS. In 2003, 66% of US AIDS cases in women and children were among African Americans."1,2
We now have more than 20 medications that comprise highly active antiretroviral therapy (HAART)—the recommended treatment regimen for individuals infected with HIV. It is perhaps a mixed blessing that HAART is now the recommended treatment. It comes at a cost that extends beyond monetary commitments. HAART is a complicated regimen on many levels: pill count, drug interactions, adverse effects, and metabolic consequences. The dosing requirements must also consider food intake, storage, and the availability of combination products. On the other hand, HAART offers the tantalizing benefit of the chance at a longer life than ever before with the potential to reduce viral loads to undetectable levels. However, these outcomes are only achieved with at least 95% adherence levels—a goal far removed from even more mundane and simple treatments. Poor adherence incurs the risk of not only faster progression to AIDS but also the increased risk of developing resistant strains of HIV, which impairs the chances of treatment success and narrows treatment options. Many patients do not realize these risks and continue to practice unsafe sexual behaviors with the mistaken belief that sex with other HIV-infected individuals poses no additional risk. In the United Kingdom, a recent study showing increased rates of HIV resistance to at least 1 drug before even starting therapy suggests that achievements in improved morbidity and mortality with HAART may be negated by a second wave of resistant HIV strains.3
With the ever-changing landscape in HIV treatment, pharmacists must be aware of the myriad issues surrounding HIV management throughout the patient's lifetime, from diagnosis to end-stage AIDS. This issue of University of Tennessee Advanced Studies in Pharmacy was created to provide a comprehensive overview of the current status of HIV treatment for community pharmacists—those most likely to interact with HIV-infected individuals on HAART or considering HAART. The monograph includes 3 in-depth review articles on HAART, in addition to a case study that illustrates the pivotal role of the community pharmacist in HAART education and support.
Frank Romanelli, PharmD, BCPS, provides an overview of the recently updated guidelines on screening and treatment of HIV and its associated opportunistic infections from the US Preventive Services Task Force and the Department of Health and Human Services, respectively.
Jean C. Lee, PharmD, BCPS, extends this discussion further with a frank analysis of the issues with HAART, namely adverse events, metabolic complications (lipodystrophy, alterations in glucose metabolism, dyslipidemia, cardiovascular disease, bone abnormalities, and mitochondrial disorders), common adherence barriers, the importance of healthy lifestyles, and patient education.
Billy R. Brown, PharmD, discusses the screening and management issues of HIV during pregnancy, including the evidence to show rates of mother-to-child transmission of the virus during pregnancy, labor and delivery, or postpartum (including breast-feeding). He also reviews the current guidelines regarding the use of HAART during pregnancy and breast-feeding.
With the growing number of patients taking HAART, and no end in sight to the AIDS epidemic, especially in certain populations, patients need to understand the entire range of risks and benefits associated with these life-saving treatments. Pharmacists are the gateway through which patients and physicians are educated about the smartest and most effective use of these drugs.
1. US Department of Health and Human Services. National Institutes of Health Web site. Estimates of funding for various diseases, conditions, research areas. Available at: http://www.nih.gov/news/fundingresearchareas.htm. Accessed February 15, 2006.
2. National Institute of Allergy and Infectious Diseases Web site. HIV infection and AIDS: an overview. Available at: http://www.niaid.nih.gov/factsheets/hivinf.htm. Accessed February 15, 2006.
3. Cane P, Chrystie I, Dunn D, et al. Time trends in primary resistance to HIV drugs in the United Kingdom: multicentre observational study. BMJ. 2005;331:1368.
*Clinical Pharmacist, HIV-AIDS, Assistant Professor, University of Tennessee, Memphis, Tennessee.
Address correspondence to: Camille Thornton, PharmD, BCPS, Clinical Pharmacist, HIV-AIDS, Assistant Professor, University of Tennessee, Adult Special Care Clinic, 880 Madison, Suite 5B01, Memphis, TN 38103. E-mail: firstname.lastname@example.org.
The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its content.