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Internal Medicine, Infectious Diseases & Tropical Medicine
University Hospital of Antwerp
Eric Florence, MD, PhD: researcher (paid to institution): Gilead Sciences, Merck Sharpe and Dohme, ViiV Healthcare; consultant/advisor/speaker (paid to institution): Gilead Sciences, ViiV Healthcare; other/travel grant: ViiV Healthcare.
The approval and commercial availability of long-acting (LA) injectable antiretroviral therapy (ART) for HIV have been paradigm changing but require clinics to make adaptations in their infrastructure and staff training. Below, I describe what I view as necessary for the successful implementation of LA ART in clinical practice after having done so within my own clinic in Belgium.
Optimal Clinic Infrastructure
I think the clinic infrastructure most essential for the successful implementation of LA ART is a dedicated room in which to prepare and administer the injections. The room should have enough space to accommodate injections while a patient is lying down or standing up and optimal lighting for the preparation of the drug. Clinics also should maintain ready access to injection materials. It also is helpful to the patient if painkillers and other means to alleviate pain from injections are available immediately after injection.
Where allowable, clinics also should decide whether they want to manage the drug supply and distribution for their patients or whether patients should bring their own medication on injection days. Given the temperature requirements of LA cabotegravir + rilpivirine, the amount of space available for refrigerators is a limiting factor in this decision, and some countries or regions may not yet allow for the drug to be distributed directly to patients.
Regardless of what clinics decide, a small supply of extra medication should be kept in case of unforeseen circumstances such as a broken vial, cold chain disruption, or expired medication. All refrigerators holding LA ART should have temperature monitoring with an alarm system in case of cold chain disruption.
Although changes in clinic infrastructure are an important part of the successful integration of LA ART, well-trained staff also are critical. For patients to successfully adhere to the regimen and receive each dose on time, I have found that extra staffing is necessary to answer patient questions, plan follow-up visits far in advance, and follow up with patients who have missed an injection appointment.
A good agenda and schedule planning tool is the first key to success in implementing LA injectable ART. Upcoming injections need to be planned far in advance in collaboration with the patient, taking account of times when patients will be traveling and unable to come to the clinic.
A reminder system also should be in place to remind patients of their appointments a few days in advance. It is paramount for the administrative staff answering the phones and scheduling these appointments to know basic information about the regimens to ensure that doses are scheduled at appropriate intervals and that patient calls are directed to appropriate staff members.
The most critical staff members are nurses, who should be very skilled in injection techniques to minimize patient discomfort. Nurses need thorough knowledge of the drugs to provide accurate information to patients. Other medical staff also should be familiar with the treatment and able to discuss it with patients during consultations and answer questions when on call outside business hours. To ensure continuity of care during holidays or in case of sick leave, at least 2 staff members should be available to answer patient questions about their LA ART.
How has your clinic implemented LA ART, or how does your clinic plan to implement LA ART for people with HIV? Join the discussion by posting a comment.