December 17, 2016
Frank Romanelli, PharmD, MPH, BCPA, AAHIVP, a professor and clinical specialist in HIV and AIDs at the University of Kentucky College of Pharmacy, has studied the link between recreational drug use and high-risk sexual practices, and how the party drugs that impede adherence to antiretroviral therapies can also cause potentially fatal drug-drug interactions with HIV therapies. Dr. Romanelli also works in an HIV clinic where he cares for a wide range of patients, from IV drug users to buttoned-up businessmen, who are on complex drug regimens or relatively straightforward therapies. He recently discussed the difficulties providers often face in getting HIV patients from all walks of life to comply with life-saving therapies. He also touched on the promise of Truvada — the only approved drug currently shown to decrease risk of sexual HIV transmission — and the significant social and financial challenges HIV-positive patients face.
Why is it difficult to care for HIV patients?
Social factors are often especially challenging to manage. HIV patients tend to be minorities, underserved, or on the fringes of society, so no matter their disease state, it requires a lot of attention to get them to attend follow-up appointments and take prescribed therapies as directed. It’s best for HIV patients to enroll in a clinic that’s a one-stop-shop for care. The clinic where I work has primary care physicians, case managers, HIV physicians, nutritionists, and pharmacists, so when patients arrive we can deliver as much care as possible.
How have treatment options for HIV patients changed in recent years?
The adverse effects of the drugs and number of possible drug-drug interactions have decreased, but antiretroviral drugs can still cause side effects such as nausea, GI upset, malaise, fatigue, and high cholesterol. Those conditions require treatment with additional drugs. Infected patients are also living longer now, so they require therapies for treating other chronic diseases such as diabetes. That means the volume of medications that HIV patients need tends to add up. Still, the number of antiretroviral tablets that patients have to take isn’t as voluminous as it used to be, so the overall pill burden has come down. Twenty years ago, it wasn’t unheard of for patients to take up to 23 pills a day. Now there are six daily single-tablet option on the market, so patients have to take only one antiretroviral pill a day.
What are your thoughts on Truvada?
As someone who takes care of patients with the disease, I think it’s great. The pre-exposure prophylaxis drug was very controversial when it was first approved, but it’s become a hot development in HIV prevention efforts. It’s currently in high demand because it’s very efficacious. At-risk individuals who adhere to the therapy and take it properly significantly reduce their risk of acquiring the disease. There are opponents who don’t want to give the drug to people without the disease and wonder about what kind of message that sends about risky sexual activities. Well, what better idea do they have to reduce the risk of transmission? Nothing so far, including condoms and safe sex initiatives, has put as much of a dent in slowing the spread of the disease.
What role do pharmacists play in the care of these patients?
There are numerous antiretroviral agents with various side effects, so pharmacists serve as drug information resources. The other big role they play is helping to guide the care of complicated patients, such as those who develop drug resistance or difficulties swallowing. Pharmacists can ensure optimal therapies are prescribed by consulting with individual patients or making recommendations with providers. They can also conduct one-month follow-ups to check lab reports and make sure patients are talking prescribed therapies as directed. Involving pharmacists in the care of HIV patients eases the burden on other providers and helps decompress healthcare systems.
What do providers need to be more aware of when working with HIV-positive patients?
They need to be very sensitive and aware of maintaining a patient’s confidentiality, because the disease still carries a stigma in society. Some providers also underestimate the significant burdens of the disease. Patients now have access to single-tablet regimens, but adhering to therapies can still be difficult. The medications are also very expensive. Co-pays can run $600 to $700 a month, even for patients with good insurance. How many people can afford that? It’s a big financial weight to carry around.