What made you decide to go into HIV care?
As a clinical pharmacist, one area of my training is in drug interactions. Since most of the medications used in the treatment of HIV cause very complicated drug interactions, I find myself interested in understanding them, and the appropriate treatment of HIV and its related complications.
Can you describe your clinic and what you do there?
We are a multidisciplinary clinic with 500 to 600 HIV clients. I see clients one day a week, for a half-day. We do team rounds. We have a big research unit where we have 20 research protocols (mostly our own research projects, but 40 percent are collaborations with the ACTG [AIDS Clinical Trials Group]) that are funded by NIAID (the National Institute of Allergy and Infectious Diseases within the National Institutes of Health [NIH]) or by drug companies. You have to apply to become an ACTG site. You have to have the proper people running the clinic; it isn't a distinction that you can just decide for yourself. We have multiple projects going on at once. There are three half-days a week that we devote to seeing HIV clients. We usually have three infectious diseases faculty, two physician assistants (PAs), a social worker and a clinical pharmacist. We are a teaching clinic, so there are teachers and students rotating throughout the clinic. This is one of the biggest VAs in the country. They really need a Pharm.D. on every team, in every clinic, and having me on the team helps avoid big problems that other people aren't catching. There just is too much to know, and with the level of info coming out these days, it is nearly impossible for physicians to know everything.
How long has it been since you've been preparing medications for people living with HIV?
I am primarily a clinician. I do not prepare or distribute drugs, as most people would think.
Does your most successful work come as a result of working in a team environment?
We have a multidisciplinary team made up of physicians, clinical pharmacists, PAs, research coordinators and social workers. We work very well together because our common goal is to provide the best care possible and we all know what we can each offer. I receive consults from the physicians and they consult me to help them take care of their patients' various disease states. We don't like to refer our clients outside of the infectious disease world because they tend to prescribe things that have interactions with the patients' HIV meds. I manage all of the diseases or illnesses our patients have. I see patients as all physicians would. I prescribe and mirror the practices of a physician. I see my own patients and prescribe my own medicines. I do direct patient care, counsel the patients and reinforce adherence.
Each person can only know so much. With the best interest of the patient in mind, we work as a team to serve the patient. The DHHS (Department of Health and Human Services) Kaiser guidelines recommend that you have a Pharm.D. in-house to watch for drug interactions. Our chief of infectious disease started establishing those practices here. He was educated at the National Institutes of Health, where there was no Pharm.D. I was finishing a residency, which gave me a specialization in pharmacotherapy, and it worked out that I started here. It isn't the typical vision of a pharmacist, where you are very restricted as to the types of services you can provide. A person who doesn't do the next degree level is more of a counselor -- a critical role in the treatment of patients, but far from what I do on a day-to-day basis. This position requires you to do residency training and become a board-certified pharmacotherapy specialist. These are all the credentials for the public that validate my knowledge, but more importantly, we are moving to educate the public about what our clinical pharmacy positions are becoming.
Physicians diagnosis on a specific issue, but they can't know everything. Clinical pharmacists learn diagnosis, but our main focus is understanding how the drugs are used, using the right meds for the right patients. I get consults, and then am responsible for managing the clients when they have received a diagnosis from the physician. We draw on the knowledge and experience of the entire team to come up with the best answer. I document all the consults I make, and I catch some very serious failures of HIV drugs. I understand the drug interactions, and this improves the care of the patient. We avoid giving the patient drugs that could cause illness or death, and also save the system money. Before I arrived, negative drug interactions did happen. There are just certain drugs you can't mix, and no one was paying attention to the bigger picture. You can give a patient a simple drug that is commonly known to help with a certain problem, but it may have a major interaction problem with one of the HIV drugs.
Why do you think people with HIV nominated you as their favorite pharmacist?
I think I've been able to help my patients not only understand their disease, but also the rationale for our approach to its treatment and the complications that may result. In addition to knowing how to treat their HIV, I am also involved in treating many other comorbidities, such as hypertension (HTN), dyslipidemia, diabetes, adrenal insufficiency and pain.
If I were to follow you for a week, what would I observe you doing?
I do rounds with an internal medicine team every morning except Wednesdays and Thursdays. The rounds include all patients who are admitted to the hospital, and I think that it is an asset, because people living with HIV still have other problems. I see patients on all levels: inpatient, acutely ill and outpatient, which are not as serious. We are treating the whole patient, and keeping people alive a lot longer. On Wednesdays, I am in the HIV clinic treating patients. On Thursdays, we have research clinic, where I enroll patients into our studies and help manage them on these studies. I also spend a lot of time writing up my research and other articles.
What is the best thing about your job?
Using the knowledge I have to help others. The information is not mine alone and I see sharing it with others as an act of service.
What is the worst thing about your job?
There is not enough time to do more.
What is the biggest challenge you face as a pharmacist?
Keeping up with all the new literature (not only related to HIV). This profession has so many journals, with new information coming out every day. I teach classes, see patients and then I have a family at home -- my day is very busy. I go to conferences as well, such as the 12th Conference on Retroviruses and Opportunistic Infections, which took place this year in Boston. It is a mostly research-related conference, with about 5,000 people in attendance. I go to it every year. You hear about cutting-edge research with results of recently finished clinical trials. They have to keep developing new drugs, but they aren't approved for market use. We are getting better and better at treating patients, and not just their HIV.
I also feel challenged by risky patient behaviors, like unprotected sex, which has made the rate of hepatitis C rise. I don't think treatment is the final answer; the disease is spreading because of lifestyle behaviors practiced without safety. No one is addressing the situation because of its political nature. People need to understand that viruses are different, and just because one patient has their HIV under control, they can lose that control if they expose themselves to someone else's virus.
What do you think are the biggest problems that people with HIV face today?
There are sicknesses appearing alongside HIV that were not encountered previously. HIV drugs (protease inhibitors) have the tendency to raise cholesterol levels, cause diabetes and cause heart attacks, but patients can't stop taking their HIV medications. You are stuck treating them with what you have, which means more medicine. People dealing with HIV are full just swallowing pills. Everyone requires two or three drugs. In addition to the HIV drugs, there are 13 to 20 other medications many people have to take daily, and they are all necessary.
I counsel patients not to take herbs, because they aren't approved by the FDA (U.S. Food and Drug Administration). This means that the consumer isn't guaranteed that what is on the label is actually in the pill. The comfort of a prescribed drug is that the FDA regulates what is in each pill. Just because a bottle says each pill contains 500 mg of vitamin C doesn't mean that it really is vitamin C. Unknown additional ingredients could interact negatively with their prescribed medications. I see a problem with not knowing what you are getting. Plus there are no clinical studies with data to prove that what is on the label is in the pills. I don't feel that I can tell my patients to use a product if I can't guarantee its safety. A lot of HIV patients look for St. John's wort, which is known for treating depression, and is actually quite good at treating it. But there is also evidence that it increases the metabolic rate of how the body processes other drugs. St. John's wort, for instance, makes protease inhibitors completely worthless, and risks that a patient's HIV becomes resistant to them.
Ninety percent of all the herbs on the market haven't had studies done on their effects. I find the quality of a product questionable when there is a 200 percent profit margin and no regulation. If the patient decides that they still want to take the herbs, they can, but if their HIV gets out of control, then we have to make the decision to cut it out. There are other examples as well. Grapefruit juice has a chemical compound that is an inhibitor to the enzyme that metabolizes the protease inhibitors and causes worsening side effects, or side effects the patient didn't otherwise have with protease inhibitors. We are sometimes able to deliberatively do certain types of drug interactions that result in a therapeutic response. Using a low dose of one drug to boost another drug that most people can't handle at full dosage can cause fewer side effects.
What preparation did you have for pharmacy school?
I minored in biology. I didn't major in biology during undergrad because I wanted to have direct patient care experience. Looking back and knowing many of my colleagues that didn't do this, I am glad I did, because I feel that it is an asset.
If you weren't a pharmacist, what would your profession be?
I'd be a physician.
Who have been the most influential people in your life, professionally and personally?
Jesus Christ, because His compassion and care for those sick and in need of healing inspire me to give compassion and care to others. He stands for truth (and humility), even when it is not popular.
If my patients ask about my faith, I will talk about it, but I don't advertise it or force it on anyone. I usually don't even volunteer any information. It hasn't come up very often -- once or twice -- and we will talk about the subject in a nonthreatening way. My faith changes the way that I do my job. I see my job as a service, and I use my skills to serve people. It is a mind-set that influences the way I treat my patients. I always try to embrace compassion with my patients. It is a lifestyle for me and it influences the way I take care of my patients. I feel like I've been given special training and knowledge that is a gift not to be taken for granted. Jesus gave it to me to serve people; it isn't knowledge just for me, but to be used to help the people around me.
I approach every day doing what is right for patients. I care about their health and getting them better, even if my decision isn't popular. I analyze if I'm really helping people or if my concern is for the welfare of the greater public. New diagnoses come in because HIV-positive people are engaging in risky behavior. I don't want to facilitate their behavior by giving them a drug that does something that allows them to spread the infection. I feel it is out of genuine concern for their health, but most people don't see it that way. I'm concerned for their health, but there are choices to be made. I'm looking out for the safest option and I like to err on the safer side, to always default to the safer side.
When you are able to get some spare time, what are your hobbies?
I spend time with my wife of eight years and my kids: a son, five years old, and a daughter, who is three and a half years old. I also participate in various church-related activities.