Clarissa Chan, PharmD
Antiretroviral therapy (ART) recommendations from the International Antiviral Society from December 2022 highlight novel long-acting injectables for PrEP and HIV treatment. These HIV therapies, which have advanced considerably, provide many patients convenience, improved adherence, and reduced stigma.
“Long-acting injectable cabotegravir for PrEP and cabotegravir/rilpivirine for treatment are game changers. They help reduce pill burden and decrease stigma associated with taking daily oral agents,” said Anna Staudt, PharmD, AAHIVP, allied health manager and lead pharmacist at Heart of Ohio Family Health in Columbus, OH, who did not contribute to the recommendations.
The long-acting injectable cabotegravir/rilpivirine (Cabenuva–Viiv Healthcare) offers a non-oral option for patients with HIV who have no previous treatment failure history and no known resistance to either drug component. Cabenuva offers patients an option to receive an intragluteal injection every 1 or 2 months, said Maksida Sabackic, PharmD, AAHIVP, pharmacy operations regional director at AIDS Healthcare Foundation in Los Angeles, who was also not involved with the new recommendations.
“Although treatment failure risk is low, it is still possible with Cabenuva, especially with 2-month dosing intervals. All patients should be informed of this risk prior to initiating treatment,” she said.
Switching to Cabenuva creates an important adherence challenge: ensuring scheduled appointments are not missed. “Many patients with jobs may have difficulty taking time off for regular injection appointments,” said Sabackic. “Pharmacists can be a solution by receiving training in intragluteal injection technique and providing injections outside of provider office hours when patients have more availability.”
Novel PrEP therapy
Like Cabenuva, cabotegravir (Apretude–Viiv Healthcare) is an injectable option approved for PrEP and may be considered for patients with adherence challenges.
“In certain states, pharmacists have the ability to furnish PrEP independent of a medical provider, increasing access to PrEP,” said Sabackic. “Communities with disproportionately high HIV incidence rates need more PrEP-related resources and guidance.”
Pharmacists can help prevent HIV transmission by advocating for and educating patients on best practices and providing available resources to increase access to treatment and reduce barriers to care.
ART accessibility and adherence advancements
Despite the options, some patients may not have access to HIV therapies due to socioeconomic or environmental factors. Since patients with HIV are among the most vulnerable populations, providing ongoing monitoring and support will promote adherence, said Sabackic.
“I have many patients with or at risk for HIV [who] struggle with medication access, transportation, and stable housing,” said Staudt. “It’s a necessity to assess [SDOH] and offer assistance and linkage to resources to improve care and outcomes.”
Accessibility and maintaining adherence to ART in patients who are at risk of HIV has historically been a challenge for providers. “When we assess a patient, we must look at the complete picture,” said Sabackic. “What is the lifestyle of my patient? Where do they live and sleep at night? How often do they have access to meals? These questions and others are needed for deciding appropriate ART regimens.”
Pharmacists can promote adherence by providing pill boxes, medication packs, and prescription delivery; helping patients set calendar reminders; helping patients apply for assistance programs to reduce drug costs; understanding community resources available for housing, food, insecurity, and social work; and providing ongoing compassionate care with stigma-free support, Sabackic said.
Influence of substance use disorders
Screening for substance use disorders can be easily overlooked during appointments.
“Pharmacists have a significant role in the patient’s overall wellbeing by understanding risks and drug–drug interactions with opioids and other illicit substances, and being able to counsel and offer stigma-free support to patients who are willing to open up about their substance misuse,” said Sabackic. “Pharmacists also have the ability to furnish naloxone within all 50 states.”
Although stigma still exists surrounding patients purchasing clean needles from pharmacies, it is important to understand the public health perspective on syringes to prevent diseases like HIV from spreading that may occur with sharing needles, said Sabackic.
Pharmacists may provide community resources to help patients seek out addiction treatment clinics and licensed practitioners in their area, she said. ■