HOSPITAL PHARMACISTS: MAXIMIZING OUTCOMES IN PATIENTS WITH HIV INFECTION IN THE 21st CENTURY
Camille Thornton, PharmD, BCPS*
Having seen what HIV and AIDS looked like in the 1980s, it is quite amazing how, not even 30 years later, we are fortunate enough to be living in a time when the abundance of antiretroviral agents has turned HIV from an inevitable death sentence to a chronic illness—not much different from diabetes. During the mid-to-late 1990s, treatment advances slowed the progression of HIV infection to AIDS, led to dramatic decreases in AIDS-related deaths, and lowered the number of persons in the United States living with AIDS.1 Unlike the patients of the past, who fought a losing battle with some of the most gruesome AIDS-related opportunistic infections, today's patients face issues related to longevity, such as long-term adverse effects of antiretroviral therapy. Although managing side effects is more feasible than fending off HIV with AZT (zidovudine) alone, there is still much progress that needs to be made to beat this unrelenting infectious disease.
Clinicians must still contend with a rising incidence of HIV infection and considerable HIV-related morbidity, which is, in part, because of the progression of comorbid diseases and adverse effects of antiretroviral therapy.2 The extended survival of patients being treated with antiretroviral therapies introduces new comorbidities, such as diseases of the liver, malignancies, hyperlipidemia, and diabetes mellitus. One increasingly common complication that poses a real health threat to patients is the antiretroviral-associated lipodystrophy syndrome, which is characterized by hyperlipidemia, insulin resistance, hyperglycemia, peripheral fat wasting, and central obesity.2 In managing this disorder, clinicians must now consider how antihyperlipidemic, hypoglycemic, and cardiovascular agents will interact with antiretroviral drugs. Another challenge is finding therapies for treatment-experienced patients. Nothing is more frustrating than having an abundance of drugs but not finding any that are active for drug-resistant HIV. Although HIV is commonly referred to as a chronic illness, that is only true for a subset of patients—many still struggle to find treatments that are active for their strain of virus. Managing these patients requires intricate knowledge of atypical antiretroviral regimens and the ever-changing strategies for managing opportunistic infections. These issues, along with the inherent complexities of HIV therapy, have increased the need for clinicians with broad knowledge of and experience in managing HIV infection and its concomitant diseases. With medications being such a focal point in HIV treatment, pharmacists are the ideal healthcare providers to optimize the care of patients infected with HIV.
In an effort to involve more pharmacists in the management of HIV, this issue of University of Tennessee Advanced Studies in Pharmacy focuses on the role of these healthcare providers in the many aspects of HIV management. Christopher W. James, PharmD, a clinical pharmacy specialist at a community HIV program, offers a portrait of the different settings within integrated health systems where pharmacists have become extensively involved in HIV care, including inpatient and outpatient centers. Dr James highlights the activities of several HIV pharmacy practices, which include participation in multidisciplinary medical rounds; providing drug information, medication counseling, and compliance education; monitoring drug therapy; and identification of drug-related problems. He also reviews common barriers to medication adherence and discusses various medication adherence programs that reach treatment-naive and treatment-experienced patients. Dr James talks about programs where pharmacists utilize various adherence tools, such as medication "maps," beepers that remind patients to take medications on time, pill planners, and close follow-up. Patients attend several sessions, in which pharmacists develop therapy goals, provide education and counseling on HIV treatment, individualize highly active antiretroviral therapy regimens, assess adherence with ongoing treatment, and suggest ways of managing adverse effects. Also included in this article are practical tips that pharmacists can use in educating patients about HIV medications, in addition to explaining the pharmacist's role as a liaison between the pharmacy service and other healthcare providers.
John J. Faragon, PharmD, assistant professor of pharmacy practice at the Albany College of Pharmacy, continues the discussion with ways that pharmacists can help minimize HIV-related medication errors. Using examples that are specific to HIV treatment, Dr Faragon offers an explanation of the different types of medication errors, including incorrect drugs, wrong doses, incorrect dosing frequency, and drug interaction problems. He also addresses the use of abbreviations for HIV medications, soundalike drugs, prescriptions that are devoid of dietary restrictions, and findings indicating that 82% of HIV-related prescribing errors involve underdoses or overdoses. In discussing dosing frequency errors, Dr Faragon addresses the increasingly common use of once-daily dosing regimens, which can place patients who are not consistent in taking medications on the same schedule each day at risk for subtherapeutic drug levels. Also included in this article are strategies for identifying and preventing medication errors, such as the use of standardized, preprinted order sheets that list the common dosages of antiretroviral therapy, updated references including online databases, and healthcare-provider-targeted education.
Christopher Miller, PharmD, BCPS, assistant professor of pharmacy practice at the Albany College of Pharmacy, participates in a clinician interview in which he responds to questions regarding the challenges of managing HIV and opportunistic infections in a hospital setting. Dr Miller addresses changes to the recently released US Department of Health and Human Services Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents. He also discusses issues such as management of treatment-experienced patients with drug-resistant HIV, raising awareness to prevent opportunistic infections, and the types of clinical interventions that hospital pharmacists perform in managing HIV.
The value of the pharmacist in providing services well beyond those related to dispensing medications is increasingly being recognized. Not only are pharmacists offering comprehensive pharmaceutical care, they are also vigilant in documenting their activities and their impact on patient outcomes. This progression in the profession has facilitated the acceptance of pharmacy services by other healthcare providers. There are now great opportunities to become fully engaged in this 21st century way of practicing pharmacy by getting involved in managing HIV, a demanding disease that requires a tremendous amount of drug expertise and clinical dedication.
1. CDC. HIV/AIDS Surveillance Report, 2004. Vol. 16. Atlanta: US Department of Health and Human Services, CDC; 2005:1-46.
2. ASHP statement on the pharmacist's role in the care of patients with HIV infection. Am J Health Syst Pharm. 2003;60:1998-2003.
*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, 208 Johnson Building, 847 Monroe Avenue, Memphis, TN 38163.
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 contents.