THE EXPANDING ROLE OF PHARMACISTS

Supporting Sustainable Adherence to HIV Prevention, Care & TreatmentICAP Technical WorkshopOctober 19-22, 2009Kigali, Rwanda

Angela G Giovanniello, Pharm.D.

Aby Leonard, Cote d’Ivoire

Gideon Chelule, Kenya

Kidwell Matshotyana, South Africa

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”

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

Potential Role of an HIV Pharmacist

Traditional Role

Dispensing

InventoryStock Management

PredictionsTracking

Approp. Drug Selection

Potency Lack of interaction

Compatible with patient

Pre-therapy Counseling

Show & TellDrug/food restrictions

Side Effects Adherence

Follow-up

AdherenceTolerance/Toxicity

HIV Pharmacist

Adherence

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

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.

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

Adherence Tools

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?

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

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?

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

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?

Change in Dynamic

Provider

Patient

RPH

Patient Provider

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?

ICAP Country Examples: Pharmacy Support for Adherence

Cote d’Ivoire – Role of Pharmacy in Patient Education

Kenya – Integrated Appointment and Adherence Assessment

South Africa – Development of VAS and Task Shifting

Cote d’Ivoire Traditional Overview Role of Pharmacy

1.Ensure the availability of drugs and laboratory

reagents (firstly)

2.Ensure drugs management and dispensing.

3.Ensure adherence to treatment through

advices and treatment explanation

4.Ensure the pharmacological monitoring of the

treatments introduced (Ensure the

prescription conformity)

5.Implement pharmacy database

6.Pharmacovigilance

Cote d’IvoirePharmacy and Peer Educator Collaboration

1. Peer Educator is the continuation of the pharmacist in

the community

2. Pharmacist reinforce and deepen the Peer Educator

knowledge on ART treatment.

• Pharmacist and PE share information on patients

(diary, dispensing register, etc.)

3. Pharmacist encourages patients to see the PE after

each ART dispensing to reinforce adherence

4. Strengthen communication between Pharmacist, data

officer and PE

• Share information to allow verification of

appointments, lost to follow up, deaths and other

information

Cote d’IvoirePharmacy and Support Group Linkages

1. Pharmacist informs and reminds patients

of the available support group

2. Pharmacist should lead some sessions

on adherence at the support group on site

3. Discussion of the benefit of adherence to

treatment, pharmacovigilance, and

provide advice which can help with

adherence.

Kenya

Pill count done at pharmacy An integrated diary able to book

appointment and record pill count was developed.

A formulae was integrated into the diary

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

System

Kenya

Task shifting to peer educators stationed at pharmacy was done

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

Patients asked to return pill balances at every visit

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

Adherence is then assessedImplementing Integrated Appointment and Adherence Assessment

System

DiarySCHEDULED VISITS: ART

Ser.no.Attended

(√) Unique ID Name Sex (M/F)

A=

Pills prescribed

B=

PillsDispensed

C=

Pills Returned

% Adherence

=

(B-C) * 100 A

1 □              

2 □              

UNSCHEDULED VISITS: ART

Ser.no.  Attended

(√) Unique ID NameSex (M/F)

A=

Pills Should have taken

B=

PillsDispensed

C=

Pills Returned

% Adherence

=

(B-C) * 100 A

1 □              

2 □              

South Africa Overview Role of Pharmacy in South Africa Care

and Treatment Aim of pharmacy support is to provide a

comprehensive pharmaceutical service at all ICAP supported sites

Quality of care is at the centre Monitoring treatment outcomes through

pharmacovigilance and adherence monitoring systems

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

Compliance with minimum standards of pharmacy practice – legal requirement

South Africa Development and Use of VAS… Various methods used in assessing adherence :

pill counts, appointment schedule, patient interviews / checklists, Pill boxes, alarm clocks, treatment diaries,

treatment buddy There is no one effective system in monitoring

and assessing adherence Adult Patient Adherence Record and Monitoring

Form Owned by the National DOH Consists of: Pill Identification test, medication

pick-up dates, Pill counts, Visual Analogue Scale, patient self reporting

A comprehensive system to improve adherence

Time consuming on the user but very effective in developing a stepped-up adherence plan

South Africa Opportunities for Task Shifting to PEs….

PE tend to understand local languages They interact with the patients in the

community and in the local HIV support group (PLHIV support group)

Clinicians do not have enough time The large number of patients at each sites Some clinics have 3 PE and 1 PN, no

pharmacy personnel, PE can do pill counts, VAS, Pill identification Clinicians – Patient self-reporting & interviewing

then developing a plan to improve adherence.