Y4 MPharm lecture - The role of the HIV pharmacist

The Role of an HIV Specialist Pharmacist

Jacob Smiles, Highly Specialist HIV and Sexual Health Pharmacist at The Hathersage Centre

Intended Learning Outcomes

  • Describe ways in which the pharmacist contributes to quality patient care and improves outcomes for patients with infections: Pharmacists play a crucial role in managing medication therapy, counseling patients on adherence, and providing education on infections and preventive measures.

  • Demonstrate understanding of decision-making related to own attitudes and behaviours: Understanding personal biases and how they affect interactions with patients is essential in providing equitable care and respecting patient autonomy.

  • Discuss evidence-based management strategies for HIV and viral hepatitis: This includes identifying the most effective therapies based on current guidelines and individual patient needs, while considering drug interactions and side effects.

  • Apply principles of evidence-based practice addressing actual and potential problems with individual patients’ therapy; advice on appropriate drug therapy for infection: Pharmacists assess patients' symptoms, lab results, and medications to optimize therapy and prevent complications.

  • Understand how infectious diseases spread within populations; utilize epidemiology in controlling spread: Knowledge of epidemiological principles can aid pharmacists in advising on public health measures, vaccination, and harm reduction strategies.

  • Use digital resources (e.g., decision aids) to facilitate evidence-based clinical decision-making, referral, and signposting: Familiarity with digital tools enables pharmacists to enhance patient engagement and improve clinical outcomes.

Terms / Abbreviations Commonly Used in HIV Care

  • HIV: Human Immunodeficiency Virus (subtypes HIV-1 and HIV-2)

  • AIDS: Acquired ImmunoDeficiency Syndrome

  • OI: Opportunistic Infection (infections from organisms that don't affect healthy immune systems)

  • ARVs: AntiRetroVirals (refers to the medicines themselves)

  • ART: AntiRetroviral Therapy (using ARVs in treatment regimens)

  • HAART: Highly Active AntiRetroviral Therapy (term less commonly used)

  • PEP: Post Exposure Prophylaxis (ARVs taken after potential HIV exposure)

  • PrEP: Pre-Exposure Prophylaxis (ARVs prescribed before potential exposure)

  • MTCT: Mother-To-Child Transmission

  • PMTCT: Prevention of Mother-To-Child Transmission

  • MSM: Men Who Have Sex With Men

Evolution of HIV Care

  • Pathophysiology of HIV: HIV attacks and depletes the immune system, particularly targeting CD4 T cells, which are crucial for immune defense.

  • Progression to AIDS: If untreated, HIV can lead to AIDS, where harmless microbes can turn into life-threatening infections due to a severely compromised immune system.

  • Treatment History: Early treatment regimens in the '80s and '90s were often ineffective, leading to rapid progression to AIDS and death within 1-2 years. However, significant advancements have been made since then.

  • Current Treatment Success: Today's antiretroviral treatments (ART) allow for early diagnosis and initiation of therapy, drastically improving the life expectancy and quality of life for those infected with HIV. The advent of new drugs has transformed the HIV landscape, enabling patients to live long, healthy lives.

  • Noteworthy Milestones: Major events include:

    • 1982: Terrence Higgins dies of AIDS; his death prompted the formation of the Terrence Higgins Trust for HIV support and education.

    • 1996: The introduction of Highly Active Antiretroviral Therapy (HAART) marked a paradigm shift in HIV treatment, combining multiple drugs for better viral suppression.

    • 2001: The first rapid HIV test was approved, promoting earlier diagnosis and linkage to care.

  • Recent Statistics: Reports have shown a significant increase in survival rates and life expectancy among individuals living with HIV due to advances in medication and healthcare access.

Antiretroviral Therapy for HIV Infection

  • Historical Context: Treatment regimens during the 1990s required patients to take multiple pills at varying times throughout the day, complicating adherence.

  • Current Advances: Modern regimens may include just one pill per day that combines multiple medications, enhancing adherence and patient convenience.

Patient Assessment

  • Key Measurements:

    • Viral Load (VL): This assesses the level of virus in the bloodstream, which indicates how effective the treatment is.

    • CD4 Count: A critical marker that measures the number of CD4 T cells, indicating the health of the immune system.

    • U = U (Undetectable = Untransmittable): Based on studies (PARTNER 1 and PARTNER 2), effective treatment can maintain an undetectable viral load, meaning no HIV transmission occurs during condomless sex.

Reducing HIV Stigma and Improving Quality of Life

  • Importance of Reducing Stigma: Reducing stigma is key to achieving UNAIDS 2025 targets and the global goal of ending HIV transmission by 2030. Stigma affects individuals’ ability to seek care and adhere to treatment, influencing overall health outcomes.

  • Addressing Stigma: Almost 1 in 8 individuals do not disclose their HIV status beyond healthcare professionals, contributing to feelings of loneliness and isolation.

  • Transforming Language: Shifting from stigmatizing language to person-centered language, such as using "person living with HIV (PLWHIV)" rather than "HIV positive," can foster acceptance and support.

Tasks of an HIV Pharmacist

  • Clinical Role: Responsibilities include clinical checking of prescriptions for ART, participating in Multi-Disciplinary Team Meetings (MDTs), active involvement in HIV clinic activities, and responding to medication queries from both patients and healthcare providers.

Common Drug Names and Classifications

  • NRTIs: Nucleotide Reverse Transcriptase Inhibitors, include medications such as Lamivudine, Zidovudine (AZT), and Tenofovir.

  • NNRTIs: Non-Nucleoside Reverse Transcriptase Inhibitors such as Nevirapine and Efavirenz.

  • Integrase Inhibitors: Include Dolutegravir and Raltegravir.

  • Protease Inhibitors: Include Darunavir and Lopinavir.

Factors Influencing Adherence

  • Comprehensive Consideration: Factors influencing adherence to therapy include mental health, socioeconomic status, physical health, beliefs, and past experiences. Emphasizing the need for person-centered care ensures a holistic approach to treatment.

Long-acting Injectable Therapy

  • Recent Developments: Introduced in the UK in 2022, this includes Cabotegravir and Rilpivirine, which require only 2 injections every 2 months, suitable for patients facing adherence challenges.

  • Side Effects: Main side effects often include injection site reactions, with careful monitoring required.

REPRIEVE Trial

  • Significance: The largest Randomized Controlled Trial (RCT) involving individuals living with HIV (PLWHIV) demonstrated a significant reduction in major adverse cardiovascular events associated with Pitavastatin treatment.

  • Recommendations: Strong recommendations indicate that statins should be offered to all PLWHIV over 40 years of age to support cardiovascular health.

Testing in Emergency Departments

  • Implementation: Testing for HIV in emergency departments has been operational since September 2022, leading to numerous new HIV diagnoses.

  • Ethics: Ethical considerations regarding testing in emergencies include mechanisms for notional consent being established to ensure patient rights and confidentiality.

Resources

  • E-Learning: Tackling HIV Stigma and Discrimination e-learning program is available for further education at e-Ifh.org.uk.