Boosting Adherence and Managing Antiretroviral Drug Adverse Events: The Role of the Community Pharmacist
Camille Thornton, PharmD*
For many patients living with HIV, these appear to be the best times, and in some regards, the most careless of times. The availability of more than 20 approved antiretroviral drugs and the abundance of research on HIV and the immune system have had a tremendous impact on the course of this disease. Far fewer people are progressing to AIDS, hospital AIDS wards have practically emptied, and the age-adjusted death rate from HIV/AIDS has declined by more than 70%.1 Other than perhaps historical film images, many of the younger patients with HIV infection have fortunately never personally witnessed the ravages of rapidly progressing, end-stage AIDS. For some of these individuals, HIV exists only as a chronic condition requiring strict compliance with "a whole lot of pills." Although this perception may, in some ways, be regarded as progress, the implications of dismissing a potentially lethal disease as a mere annoyance are concerningÑadherence is the single most important determinant for viral suppression. Unfortunately, nonadherence remains common, and its consequences are evidenced in studies demonstrating that although the rates of viral suppression below the limits of detection are possible in as many as 95% of patients, actual viral suppression rates in community settings are in the range of 40% to 50%.2
Although many factors may be attributed to nonadherence with antiretroviral therapy, one of the contributing causes may be today's laissez-faire attitude toward HIV. Some of the older patients with HIV who may have been rescued from the brink of death with the introduction of protease inhibitors fully grasp the critical necessity for meticulous adherence with antiretroviral therapy. But others who live with HIV positivity without clinical progression may, over time, become falsely reassured by their relatively good health and become increasingly less compliant with lifelong antiretroviral therapy. Indeed, it has been observed that medication adherence wanes over time, especially in the face of increasing life spans and newly emerging long-term adverse effects of antiretroviral therapy. An increasing number of patients must now contend with the cosmetic and health ramifications of antiretroviral-associated lipodystrophy syndrome, which is characterized by hyperlipidemia, insulin resistance, hyperglycemia, peripheral fat wasting, and central obesity. Being further removed from the potential fatality of AIDS, some of these patients begin to question the risk versus benefits of continuing antiretroviral therapy. In some ways, the current challenge of adherence with antiretroviral therapy is analogous to that related to childhood vaccinations. Some mothers oppose vaccinating their children in light of potential vaccine-related adverse effects. But the current generation does not normally encounter polio-stricken children, and thus, fear of the actual vaccine-preventable illness no longer drives adherence.
Healthcare professionals involved in the care of patients with HIV are working harder than ever to try and improve adherence with antiretroviral therapy. Many multidisciplinary programs across the country require newly diagnosed patients with HIV to undergo intense evaluation and counseling sessions in order to most accurately predict and optimize their chances of adherence with antiretroviral therapy. Compliance with the latest evidence-based guidelines, management of drug interactions and adverse effects, simplification of regimens, and ongoing counseling are some of the major activities that pharmacists are involved in within these HIV programs and in the general community setting.
In an effort to offer pharmacists some of the clinical tools necessary to become more involved in today's management of HIV, this issue of University of Tennessee Advanced Studies in Pharmacy offers an update on current treatment recommendations, significant adverse effects and drug interactions, and the current state of adherence. Angela D.M. Kashuba, PharmD, DABCP, reviews the current treatment recommendations for treatment-naïve and treatment-experienced patients from the recently updated Department of Health and Human Services' Antiretroviral Guidelines for Adults and Adolescents. An associate professor of pharmacy at the University of North Carolina-Chapel Hill, Dr Kashuba cites various studies that support currently "preferred" antiretroviral therapy agents and those that are not recommended for use. She also includes a discussion on strategies involved in managing virologic and immunologic failures, in addition to clinical progression.
Jennifer Cocohoba, PharmD, focuses on identification and management of drug interactions involving antiretroviral agents and other medications (eg, antibiotics, oral contraceptives, H2 antagonists, and lipid-lowering agents) commonly used in individuals with HIV. Dr Cocohoba, a health sciences assistant clinical professor of pharmacy at the University of California, San Francisco, also includes a review of short-term and long-term adverse effects associated with antiretroviral therapy, along with commonly employed remedies.
Jean C. Lee, PharmD, BCPS, explores the current state of adherence with regard to assessment techniques, barriers, and counseling strategies. Dr Lee, an HIV/AIDS clinical pharmacist at McAuley Health Center, offers a detailed discussion on the many factors contributing to nonadherence and includes evaluation and counseling strategies that are thought to optimize adherence among patients with HIV.
Like many other complex disease states with no known cure, HIV is ever-changing in regard to how it is treated, its potential for fatality, and ultimately, how it is perceived by afflicted individuals. We, as pharmacists, need to adapt accordingly and use the most recent knowledge base and patient feedback to offer the best care possible.
1. Machtinger EL. Adherence to HIV antiretroviral therapy. HIV InSite Knowledge Base Chapter. Available at: http://hivinsite.ucsf.edu/InSite?page=kb-03-02-09#S6X. Accessed March 18, 2008.
2. Reiter GS, Stewart KE, Wojtusik L. Elements of success in HIV clinical care: multiple interventions that promote adherence. Topics in HIV medicine. Intern AIDS Society - USA. 2000;8:20-30
*Clinical Pharmacist-HIV/AIDS, Associate Professor, University of Tennessee, Memphis, Tennessee.
Address correspondence to: Camille Thornton, PharmD, Adult Special Care Clinic, 880 Madison Avenue, 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 contents.