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.
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.
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- 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.
- 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.