This document discusses the expanding role of pharmacists in supporting HIV treatment adherence. It provides examples of how pharmacists in Cote d'Ivoire, Kenya, and South Africa work to enhance adherence through patient education, integrated appointment and pill count systems, visual analogue scales to assess adherence, and task-shifting some responsibilities to peer educators. The document also presents case studies demonstrating pharmacist interventions around medication counseling, drug interactions, pediatric dosing, and adherence barriers.

1. The Expanding Role of Pharmacists Supporting Sustainable Adherence to HIV Prevention, Care & Treatment ICAP Technical Workshop October 19-22, 2009Kigali, Rwanda Angela G Giovanniello, Pharm.D. Aby Leonard, Cote d’Ivoire GideonChelule, Kenya KidwellMatshotyana, South Africa

2. Background Suboptimal treatment exposure result in the failure of available regimens Adherence is key to achieving successful treatment Requires everyone to play a part Regimens are complex and have little pharmacologic “forgiveness”

3. Pharmacist Role The care of the HIV-infected individual presents special challenges that warrant the need for a pharmacists intervention Large number of drug interactions Prescribed/ Herbal / Food The need for poly-pharmacy for effective treatment Medication pick-up ultimately last stop in the clinic Provide time to recap or address any unmet issues Disclosure issues Barriers to family support or help Incorporate family health to strengthen the family unit Part of the multidisciplinary team Referring when needed to counselors, clinicians, and lab personnel

4. Potential Role of an HIV Pharmacist Traditional Role Dispensing Inventory Stock Management Predictions Tracking Adherence HIV Pharmacist Approp. Drug Selection Potency Lack of interaction Compatible with patient Pre-therapy Counseling Show & Tell Drug/food restrictions Side Effects Adherence Follow-up Adherence Tolerance/Toxicity

5. Opportunity for Intervention Frequent patient interactions (monthly medication pick-up ) Allowing for engagement Side effect/ toxicity identification Quickly detect any adherence problems Verify appropriate dosing and administration schedules

6. Case 1 AK is a 39 yo female Started on HAART 2 months ago coming for her first medication refill She has missed her medical follow-up appointment Prompt a discussion about the timing of her medication pick-up AK reveals she has a lot of diarrhea on the days she takes her medication and can not take her medications on the days she has to be out of the house.

7. Adherence Measures 3 day recall In the past 3 days how many doses have you missed? 7 day recall When was the last dose you missed? What would make your regimen easier? Pill count Refill dates

8. Adherence Tools

9. Adherence Tools Pillboxes Alarms Cellphones Blister packaging Peers – social supports MEMS caps

10. Barriers to Adherence Lack of education Adherence goals most pt do not know that > 95% is the goal If missing more then 1 day per month under 95% Resistance Evaluate barriers to adherence Create a rapport – include family when possible Depression Side Effects/ Drug toxicity Active substance abuse Literacy

11. Case 2 EH is a 16 yo pregnant female coming to the clinic for prenatal care Started on HAART consisting of NVP/3TC/d4T Experiencing continued vomiting over the past 2 days due to the pregnancy and has been unable to continue the prescribed treatment Based on the pharmacokinetic properties of her medications can she just stop all her medications?

12. NNRTI PK Problems Prolonged half-life with a greater risk of developing regimen crippling mutations Possible utility of continuing NRTI’s of the regimen to prevent this occurrence Recommendations vary from 7 to 14 days of continued NRTI treatment after the discontinuation of the NNRTI Others have recommended swapping NNRTI’s to LPV/r for 1 month then discontinuation of all agents

13. Case 3 MM a patient doing well on a regimen AZT/3TC/NVP * 6 months Diagnosed with TB and placed on Isoniazid/Rifampin/Pyrazinamide/Ethambutol Comes to the pharmacy for the additional treatment What discussion occurs?

14. Key Drug-Drug Interactions Rifampicin – potent CYP isoenzyme inducer Alters drug concentrations of most ARV’s significantly Changes to alternate ARV’s possible option NVP  EFV

15. Case 4 ZR a 1 yo male comes for a monthly medication d4T/3TC/NVP The baby is healthy and developing well Tolerating all medications No present issues with adherence to liquids Doses have remained the same for the past 3 months Is this alarming?

16. Patient Provider Change in Dynamic Patient Provider RPH

17. Key Points Small steps incorporate 2 steps to each prescription. Check refill dates Check log and see if dates make sense Ask simple questions about tolerability of ARV’s Have you been having any problems that have made taking your medications difficult? Any nausea/vomiting? Any rash developments? CNS SE of efavirenz?

20. Kenya – Integrated Appointment and Adherence Assessment

24. An integrated diary able to book appointment and record pill count was developed.

25. A formulae was integrated into the diary

26. Integrated Diary was then stationed at the pharmacyDeveloping Integrated Appointment and Adherence Assessment System

28. Adherence assessment (including pill count) integrated in APS training curriculum

29. Patients asked to return pill balances at every visit

30. Patients collect their repeat medication on scheduled dates of appointment (28 day cycle pick-up)

31. Adherence is then assessedImplementing Integrated Appointment and Adherence Assessment System

32. Diary

34. Aim of pharmacy support is to provide a comprehensive pharmaceutical service at all ICAP supported sites

35. Quality of care is at the centre

36. Monitoring treatment outcomes through pharmacovigilance and adherence monitoring systems

37. Monitor & support drug availability – all essential drugs in the program (anti-TB/ARV/OI)

39. Various methods used in assessing adherence : pill counts, appointment schedule, patient interviews / checklists,

40. Pill boxes, alarm clocks, treatment diaries, treatment buddy

41. There is no one effective system in monitoring and assessing adherence

42. Adult Patient Adherence Record and Monitoring Form

43. Owned by the National DOH

44. Consists of: Pill Identification test, medication pick-up dates, Pill counts, Visual Analogue Scale, patient self reporting

45. A comprehensive system to improve adherence

47. PE tend to understand local languages

48. They interact with the patients in the community and in the local HIV support group (PLHIV support group)

49. Clinicians do not have enough time

50. The large number of patients at each sites

51. Some clinics have 3 PE and 1 PN, no pharmacy personnel,

52. PE can do pill counts, VAS, Pill identification

53. Clinicians – Patient self-reporting & interviewing then developing a plan to improve adherence.