A New Era: Pharmacists Transforming HIV Outcomes in Community Pharmacies

Michelle J. Sherman, RPh, APh, FASCP, FACA, AAHIVP

MichRx Pharmacist Consulting Services, Inc.
Dana Point, California

Michelle J. Sherman, RPh, APh, FASCP, FACA, AAHIVP, has disclosed that she has served as a speaker for Gilead Sciences and Janssen.

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Released: August 20, 2019

It is a new dawn in the pharmacy profession. The days of the local pharmacy as simply a prescription filling hub are over, and the pharmacist’s role no longer revolves solely around dispensing medication through sticking labels, filling bottles, and billing. Legislation in many states throughout the United States recognizes pharmacists as healthcare providers, finally acknowledging the broader clinical roles of the pharmacist beyond dispensing medication. For example, California enacted a law in October 2013 recognizing pharmacists as healthcare providers. As a result, the California State Board of Pharmacy created the advanced practice pharmacist license. Similarly, Montana and North Carolina license clinical pharmacist practitioners, and New Mexico licenses pharmacist clinicians. These licenses allow for the pharmacist provider to order and interpret tests related to drug therapy and initiate or modify medications under a collaborative practice agreement.

How Can Pharmacy Providers Improve HIV Care?
The role of the community HIV specialist pharmacist is an essential key to maximizing patient outcomes in our often disjointed healthcare system. As pharmacists go through this metamorphosis in healthcare and in pharmacy scope of practice, opportunities for improving HIV care abound. As experts in drug–drug interactions, adherence management, benefits navigation, Medication Therapy Management, and Chronic Care Management, we are able to improve patient outcomes, improve quality of life, and decrease healthcare costs.

The Substantial Impact of Nonadherence to Treatment
Increasing access to pharmacist healthcare providers with expertise in adherence management could have a profound effect on HIV ART adherence. Several studies demonstrate that a 95% adherence rate to ART is required to achieve maximal viral suppression. However, adherence remains suboptimal in the United States, ranging between 27% and 80% across multiple studies. Medication adherence is traditionally lower in patients with chronic illness vs those with acute conditions, resulting in increased healthcare costs. In the United States, the estimated direct and indirect cost of medication nonadherence is approximately $337 billion annually. It is estimated that each nonadherent patient requires 3 extra medical visits per year, leading to $2000 in additional annual treatment costs. Poor medication adherence is also responsible for 33% to 69% of all medication-related hospital admissions, at a total cost of approximately $100 billion per year. Nonadherence does not only come at a monetary price. Approximately 125,000 people in the United States die annually due to poor medication adherence.

Studies in recent years have firmly established the role of HIV treatment-as-prevention by demonstrating that individuals living with HIV who maintain an undetectable viral load do not transmit HIV to others, leading to the informational slogan “U = U” or “undetectable = untransmittable.” Consistent adherence to HIV treatment is necessary to maintain an undetectable viral load, underscoring additional public health benefits of adherence support services provided by pharmacists. Adhering to treatment prevents onward HIV transmission, limiting the burden of disease not only for the individual, but also among the population as a whole.

The Role of Effective Medication Management in HIV Clinical Outcomes
What outcomes could HIV pharmacist providers monitor in their HIV patient populations and how can we, as pharmacists, make a difference to improve those outcomes? The opportunities are plentiful, with a range of clinical outcomes that pharmacists can have a direct impact on through the effective management of a patient’s medication regimen, including treatments for HIV and other comorbidities as well as over-the-counter drugs, vitamins, supplements, and illicit drugs the patient may be taking. An integrated approach to patient care by pharmacist providers can have a profound effect on the following outcomes for patients living with HIV:

  • Viral suppression
  • CD4+ cell count
  • ARV resistance
  • Monitoring and management of adverse reactions
  • Drug–drug interaction management
  • Cardiovascular risk assessment
  • Lipid management
  • Hypertension management
  • Diabetes management
  • Smoking cessation
  • Vaccinations

Pharmacist Provider Role in HIV Prevention
Community pharmacist healthcare providers are perfectly positioned to be key players in the United States’ goal of getting to zero new HIV infections by providing HIV testing and pre-exposure prophylaxis (PrEP) services under collaborative practice agreements. Successful community and independent pharmacy PrEP programs have been implemented in several cities, including Seattle, St Louis, Denver, and San Francisco. These model programs provide examples of the impact community pharmacies can have by increasing local PrEP accessibility and uptake. The provision of PrEP by trained community pharmacists is so important that a bill introduced by California State Senator Scott Wiener proposes allowing pharmacists to furnish PrEP and postexposure prophylaxis without a prescription.

Overall, the specific expertise of pharmacists in managing complex medication regimens can be of great use in improving the health of persons living with HIV and in the fight to reduce new infections. Community pharmacist healthcare providers can have a broad impact on a variety of aspects related to HIV care and prevention, and increasing their integration into HIV care could expand access to care for many persons living with HIV and individuals at high risk of acquiring HIV infection.

Your Thoughts
Which of your specific skills as a pharmacist make you an effective healthcare provider for persons living with HIV? What clinical outcomes do you monitor and track for your patients living with HIV? Please join the conversation and share your experiences in the comments box below.

Provided by the Annenberg Center for Health Sciences at Eisenhower

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