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ARTICLE

A Pharmacist's Role in HIV Antiretroviral Stewardship in the Hospital

MAR 07, 2017 | BETTY VU, PHARMD AND DREW HALBUR, BSPHARM, BCACP, AAHIVP
Nationally, over 1.2 million Americans are living with HIV, of which 13% are unaware of their infection.1 The management of HIV infection has drastically changed over the last 10 years with the development and enhancement of more than 14 antiretroviral medications, including better formulations and various combination pills approved by the Food and Drug Administration.2 Since entering the decade of enhanced formulations of antiretrovirals and the initiation of pre-exposure prophylaxis in 2014, there has been both a significant reduction in HIV-related illnesses and an increase in proportion of patients with viral suppression—with a more than 19% decline in new HIV diagnoses over the last decade.3
 
Other significant factors that have contributed to this positive impact include early initiation of antiretroviral therapy (ART) and the use of this therapy for reducing the risk of HIV transmission. Both the START and TEMPRANO studies were landmark randomized controlled trials published in 2015 that provide the highest level of evidence to support the use of early initiation of ART, regardless of CD4 cell count, for benefit in boosting immune recovery and preventing clinical events.4,5 The treatment-as-prevention model is a method studied in the HIV Prevention Trials Network (HPTN 052) study that demonstrated a reduction of sexual transmission of HIV among heterosexual couples, with full viral suppression from ART.6
 
The Department of Health and Human Services (DHHS) recommends triple combination therapy for treating HIV, with dual nucleoside reverse transcriptase inhibitors and either an integrase strand transfer inhibitor or protease inhibitor in combination with a pharmacokinetic enhancer agent (ie, ritonavir or cobicistat) for HIV treatment-naïve patients.7 These regimens are often complex and have clinically significant drug-drug interactions; without appropriate monitoring, there is a high risk for medication errors and unwanted adverse effects, especially in those with multiple comorbidities. The incidence of medication errors related to antiretroviral agents in hospitalized patients has ranged between 21% and 72%.8-10 Errors were observed in all major antiretroviral drug classes and include medication omission, inappropriate scheduling of drug administration, drug interactions, and incorrect dosing.
 
Pharmacists play vital roles in optimizing HIV treatment outcomes in multiple ways and in all medical settings, such as ensuring patients are taking a complete and appropriate regimen, recommending alternative therapy, dose or formulation adjustments, mitigating drug-drug interactions, and modifying drug schedules to optimize absorption. In order to improve the quality of care in HIV-infected patients, more institutions are partaking in several forms of ART stewardship, often composed of a team led by pharmacists specialized in infectious diseases and/or HIV.
 

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