HIV is a complicated condition requiring expert care, but how to access that care is another question.
Shifting some of that expertise to the pharmacy would be a boon to ending the epidemic. In November, the Centers for Disease Control and Prevention (CDC) awarded a $2.4 million grant to see if a specific type of pharmacy work can improve medical care for people living with HIV. The CDC leveraged an additional $1 million of in-kind services by partnering with Walgreens Pharmacy.
Specifically, the CDC is looking at the concept of medication therapy management, or MTM.
In MTM, a pharmacist talks with patients to examine all of their medical conditions and needs, including such things as nutrition and exercise, helping to create a treatment plan and then communicating that to the patient and their provider.
Which regimen, for example, might be best across different disease states for the patient? Not a minor concern as people with HIV live longer and develop other medical conditions, sometimes seeing providers who don't communicate with one another.
"MTM is the most comprehensive service we could provide if we had all the time and resources we need," said principal investigator Patrick Clay, PharmD and professor of pharmacotherapy at the University of North Texas Health Science Center (UNTHSC).
Dr. Clay has dedicated his career to HIV care, but he and his staff know the statistics: more and more HIV patients with fewer and fewer HIV specialists.
"There's not a huge influx of HIV care providers coming in," he said. "They're retiring and fewer are taking up the slack. At the same time, the complexity of treating HIV is greater than other diseases and the reimbursement is less, and won't cover what it takes to treat.
"Instead of creating HIV physicians out of thin air," Dr. Clay continued, "why not look to the pharmacist to take some of the less complicated work involved -- that to me is the exciting part, showing the capability and the quality of the pharmacy."
"Pharmacists are underused health providers and we live in the community," said Glen Pietrandoni, RPh, AAHIVP, senior manager in virology for Walgreens Pharmacy.
"Data from the American Pharmacists Association shows that 90% of Americans live within three miles of a pharmacy," added Dr. Clay, "and you can't say that about any other health profession."
Moreover, Walgreens estimates that 90% of people with HIV have access to one of their HIV-specialty pharmacists.
Dr. Clay also hopes the in-depth conversations with patients will help keep them in care, overcoming a significant problem in the U.S. epidemic today.
Like other experts, he believes HIV can now be a lifelong, chronic condition, but only if patients can tolerate and adhere to "arguably the most complex drug regimen ever used in medicine." That, he says, requires harmony among many different parts, including the medical providers involved.
Included in Dr. Clay's team are HIV and MTM experts, healthcare economists, and capacity building specialists from HealthHIV and the Universities of Kentucky, Minnesota, and Nebraska and Northwestern University. This group, working with Walgreens and the CDC, will identify 10 sites and 1,000 patients around the country to take part in this project.
The CDC had approached Walgreens about a private/public partnership in 2012. "They knew of our interest in working with organizations," Pietrandoni said. "We have worked with the Kaiser Family Foundation, with AIDS United." (Not to mention longtime sponsorship of Positively Aware's annual HIV drug chart and donating editorial support, including articles and reviews of the drug guide itself.)
"CDC knows about Walgreens' commitment to end AIDS. Pharmacists can do a whole lot more than just dispense medications. We started an immunization program five years ago and we probably now do more immunizations than clinics," Pietrandoni said. HIV, however, requires much more extra training, "like learning to speak a foreign language, the language of HIV, so to speak."
"We're using the project to really embellish our MTM program, especially in underserved and minority communities, including rural patients [making up at least 10 percent of the patients participating in the program]," he said. "We have a program that looks at patients holistically and not just their medications, but the patient's whole health."
An MTM pharmacist also stays on top of a patient's care, following the patient's response to medical treatment, watching out for opportunistic infections, and so forth. The project will include an evaluation of communication patterns between patients and their physicians and pharmacists.
"With this program, we delve deeper into HIV: blood pressure, diabetes, smoking, and so on, all in the context of HIV," said Pietrandoni. "We do HIV work every day. I don't know of anyone else [as a commercial pharmacy] who does that."