Get the content you want anytime you want.
REGISTER NOW | SIGN IN
ARTICLE

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

MAR 07, 2017 | BETTY VU, PHARMD AND DREW HALBUR, BSPHARM, BCACP, AAHIVP

Cascade of Care 

Beyond poor engagement in HIV treatment, providers and HIV-infected individuals may face obstacles when disruption occurs along the HIV care continuum, also known as the Cascade of Care.15 This model—defined in 2011 by Edward M. Gardner, MD, and colleagues—outlines five sequential steps of HIV medical intervention including: diagnosis, linkage to care, retention in care, acquisition of ART, and achievement of viral suppression.15 Frequently, HIV-infected patients who face psychosocial or economic barriers are at risk of lost to care. Pharmacists, as part of antiretroviral stewardships, can assist with strengthening the continuum of HIV care by ensuring linkage to care after hospital discharge or outpatient.
 
The Cascade of Care has become such a significant model that former President Barack Obama prioritized efforts in addressing this model through executive order of the HIV Care Continuum Initiative in 2013.16 This step-in implementation of the national HIV/AIDS strategy focuses efforts on increasing the proportion of patients in each stage of the continuum by increasing access to HIV testing, care, and treatment.
 
Within institutional care of HIV-infected patients, one major stage of the Cascade of Care that is affected is initiation of ART during hospitalization, particularly in those with late entry into medical care when concomitantly diagnosed with HIV/AIDS and opportunistic infection or active seroconversion. Pharmacists involved with the care of these individuals play an important role as patient advocates by facilitating appropriate and timely initiation of ART where added benefit has been previously seen.17 Additionally, appropriate transition into outpatient care is a key intervention to ensure patients are linked with and engaged in care with health care providers, including pharmacists with special training in HIV ART. This ultimately leads to viral suppression and optimized HIV treatment outcomes.
 

Future Directions 

There is still much left to be done even with the great progress that has been made over the recent years with the reduction in HIV diagnoses and improved viral suppression. The medication error rate in ART regimens reported in hospitalized patients is alarming, but it is also a great opportunity for pharmacists to optimize and improve the medication use process, as the results of published studies have already demonstrated. Further direction with impact of ART stewardship in the ambulatory setting and with guidance on appropriate therapeutic interchange within hospital formularies are needed. With a variety of methods to reduce medication errors, such as use of computerized order entry sets, provider education, and prospective feedback, pharmacists can continue to work to make an impact in advancing HIV patient care and supporting the continuum of care.
 
Acknowledgements: The authors would like to acknowledge the contribution and guidance of Milena McLaughlin, PharmD, MSc, BCPS-AQ ID, AAHIVP.
 
Feature Image Source: ScienceSource/Francis Sheehan
 
Drew Halbur, BSPharm, AAHIVP, BCACP, is a clinical pharmacist at a Walgreens local specialty pharmacy as a part of the Howard Brown Health Center, the largest LGBTQ health organization in the Midwest. He completed his pharmacy degree at Drake University in Des Moines, IA, and has worked in HIV primary care for almost 20 years. 
 
Betty Vu, PharmD, is a PGY2 infectious disease pharmacy resident at the Department of Pharmacy at Midwestern University, Chicago College of Pharmacy. She completed her PGY1 pharmacy residency at Montefiore Medical Center in Bronx, NY, and her Doctor of Pharmacy degree at the University at Buffalo. She is an active member of ACCP, IDSA, and SIDP. 
 
References
  1. Centers for Disease Control and Prevention. HIV in the United States at a glance. CDC website.  http://www.cdc.gov/hiv/statistics/overview/ataglance.html. Accessed November 15, 2016. Updated December 2, 2016.
  2. U.S. Food and Drug Administration. Antiretroviral drugs used in the treatment of HIV infection. FDA website http://www.fda.gov/forpatients/illness/hivaids/treatment/ucm118915.htm. Accessed November 15, 2016. Updated August, 9, 2016.
  3. Centers for Disease Control and Prevention. Division of HIV/AIDS Prevention Annual Report 2015. Atlanta, Georgia: CDC; 2016. https://www.cdc.gov/hiv/pdf/policies/cdc-hiv-2015-dhap-annual-report.pdf.
  4. Lundgren JD, Babiker AG, Gordin F, et al; INISGHT START Study Group. Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J Med. 2015;373(9):795-807.
  5. Danel C, Moh R, Gabillard D, et al; TEMPRANO ANRS 12136 Study Group. A trial of early antiretroviral and isoniazid preventive therapy in Africa. N Engl J Med. 2015;373(9):808-822.
  6. Cohen MS, Chen YQ, McCauley M, et al; HPTN 052 Study Team. Prevention of HIV-1 infection with early antiretroviral therapy. N Eng J Med. 2011;365(6):493-505.
  7. Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. AIDSinfo website. http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed November 15, 2016.
  8. Pastakia SD, Corbett AH, Raasch RH, Napravnik S, Correll TA. Frequency of HIV-related medication errors and associated risk factors in hospitalized patients. Ann Pharmacother. 2008;42(4):491-497.
  9. Daniels LM, Raasch RH, Corbett AH. Implementation of targeted interventions to decrease antiretroviral-related errors in hospitalized patients. Am J Health Syst Pharm. 2012;69(5):422-430.
  10. Garey KW, Teichner P. Pharmacist intervention program for hospitalized patients with HIV infection. Am J Health Syst Pharm. 2000;57(24):2283-2284.
  11. Billedo JA, Berkowitz, LB, Cha A. Evaluating the impact of a pharmacist-led antiretroviral stewardship program on reducing drug interactions in HIV-infected patients. J Int Assoc Provid AIDS Care. 2016;15(1):84-88.
  12. Sanders J, Pallotta A, Bauer S, et al. Antimicrobial stewardship program to reduce antiretroviral medication errors in hospitalized patients with human immunodeficiency virus infection. Infect Control Hosp Epidemiol. 2014;35(3):272-277.
  13. Zucker J, Mittal J, Jen SP, Cheng L, Cennimo D. Impact of stewardship interventions on antiretroviral medication errors in an urban medical center: a 3-year, multiphase study. Pharmacother. 2016;36(3):245-251.
  14. Guo Y, Chung P, Weiss C, et al. Customized order-entry sets can prevent antiretroviral prescribing errors: a novel opportunity for antimicrobial stewardship. P T. 2015;40(5):353-360.
  15. Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum of engagement of HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52(6):793-800.
  16. AIDS.gov. HIV Care Continuum Initiative. AIDS.gov website. https://www.aids.gov/federal-resources/national-hiv-aids-strategy/strategy-implementation/federal-implementation/#continuum. Accessed December 12, 2016. Revised January 20, 2017.
  17. Department of Health and Human Services Panel on Opportunistic Infections in HIV-infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. AIDSinfo website. http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf. Accessed December 12, 2016.


Advocacy and Research Foundation Partners