July 21, 2025 • 35 mins
HIV treatment has evolved significantly, offering streamlined regimens and improved patient outcomes. This episode will discuss the latest antiretroviral therapy (ART) guidelines, highlighting preferred regimens, key pharmacologic considerations, and practical counseling strategies for pharmacists. Tune in to enhance your clinical knowledge and play a pivotal role in optimizing care for individuals living with HIV.
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact
Rachel Maynard, PharmD
Lead Editor
Pyrls
Joshua Davis Kinsey and Rachel Maynard have no relevant financial relationships to disclose.
BONUS: With this episode, you also get exclusive, FREE access to beautifully designed clinical charts and practice resources from our friends at Pyrls, that you can use in your everyday practice. Click the links below to access these practical tools:
Pharmacist Members, REDEEM YOUR CPE HERE!
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CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Identify current guideline-recommended antiretroviral therapy (ART) regimens and their key components.
2. Describe important counseling points for pharmacists supporting patients on HIV treatment, including adherence, side effects, and drug interactions.
0.05 CEU/0.5 Hr
UAN: 0107-0000-25-245-H02-P
Initial release date: 7/21/2025
Expiration date: 7/21/2026
Additional CPE details can be found here.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:07):
Hey, ce Impact subscribers, Welcome to the Game
Changers Clinical Conversationspodcast.
I'm your host, josh Kinsey, andas always, I'm excited about
our conversation today.
As a reminder, we've launched aspecial pilot series in
collaboration with our friendsat PEARLS, a modern drug
information resource and app.
These crossover episodes,called Game Changing PEARLS,
(00:28):
combine PEARLS' trusted,evidence-based clinical tools
with CE Impact's expertise inpharmacy education and
accreditation, bringing youtimely, actionable content that
supports both your practice andyour professional development.
It's a privilege to workalongside the PEARLS team and
we're excited to continue thispilot series with today's
episode focused on HIV treatment.
(00:49):
Hiv treatment continues toevolve, offering simpler
regimens, improved tolerabilityand life-changing outcomes for
patients.
In today's episode, we'll coverwhat pharmacists need to know
about current antiretroviraltherapy, key counseling points
and how to support patientsthrough every step of their
treatment journey.
And it's so great to haveRachel Maynard back as our guest
(01:10):
for today's episode Rachelwelcome.
Speaker 2 (01:12):
Thank you so much for having me back.
Speaker 1 (01:14):
Yeah, and as a reminder, rachel joined us for a
previous episode on asthma, butfor some of those listeners
that may not have had a chanceto listen to that, rachel, if
you'll take just a minute or twoto introduce yourself and tell
us a little bit about yourposition at Pearls and anything
else you want to share, Sure,yeah, Thanks, Josh.
Speaker 2 (01:33):
So I am a clinical lead at Pearls.
As you mentioned, we're a druginformation resource and some of
our most popular features aresome of our charts and key
counseling points at ClinicalPearls so the name is apt.
But my prior background?
I worked for over a decade inthe drug information education
space and before that I was acommunity pharmacist.
(01:54):
I did a community pharmacyresidency and then was a staff
pharmacist and managed clinicalprograms for a region of a
grocery store chain.
So really I'm here and excitedtoday, passionate about
educating healthcare providersto optimize care for patients in
the best way possible, usingtools and resources to make
their work efficient andeffective.
(02:14):
So very, very happy to be hereand to be chatting about this
very important topic.
Speaker 1 (02:18):
Yeah, yeah, absolutely.
And you know, like I said inthe segue, this is this topic.
It just I feel like it's one ofthe ones that is just ever
changing, like new stuff all thetime, different regimens and
and which is great, it's justwonderful, but it's one of those
that we really have to workhard at keeping up to date with.
So thank you so much forjoining us and and giving us
(02:40):
some actionable insights fortoday.
So, as I always like to do,start off the episode with just
a foundational refresh to makesure everybody's on the same
page.
So, if you don't mind, let'sjust recap exactly what HIV is
and, just a little maybe, somefacts about it and so forth.
So we'll start with that.
Speaker 2 (02:58):
Sure.
So yeah, hiv it stands forhuman immunodeficiency virus.
It is a retrovirus that targetsthe immune system, and so some
of the metrics you might heararound that are CD4 count, which
is a type of white blood cell,and also viral load.
So how much virus isessentially in the blood for
(03:18):
patients to know how well theircondition is being managed?
But ultimately it can lead toif unmanaged, can lead to a
weakening of the immune system,and the most advanced stage of
an HIV infection would be AIDS,acquired immunodeficiency
syndrome.
So without treatment, the lifeexpectancy for people with AIDS
(03:42):
is actually about three years,and even less if they were to
develop an opportunisticinfection.
So if you think about that,that life expectancy for for
AIDS, versus where we are now intreating HIV and getting
patients treated sooner andmanaging the condition, like you
say, it's come a really longway in the 40 years or so since
(04:04):
it was sort of at the height ofthe epidemic.
Speaker 1 (04:07):
Yeah, absolutely, and you know, again reiterating
that this is no longer not to befrank, but no longer a death
sentence, right?
Speaker 2 (04:15):
Absolutely.
Speaker 1 (04:16):
Yeah, it's a manageable condition.
Early diagnosis is key, alsomaking sure that the right
regimen and treatment is key.
But yeah, totally manageabledisease and patients can live a
normal, healthy life.
Speaker 2 (04:29):
Yeah, what we're seeing is that, you know, more
guidelines are coming out.
We have our guidelines focusedon HIV treatment, but we're also
seeing more guidelines focusedon managing chronic
comorbidities in people livingwith HIV, because their life
expectancy is now as good assomebody who doesn't have HIV.
So, yeah, more likecardiovascular management and
(04:53):
guidelines tailored to patientswith HIV, but focusing on these
other comorbidities that theymight be living with, just like
any other patient who's living along life would expect to have.
Speaker 1 (05:03):
Exactly yeah, because back in the 80s, when it was at
the forefront of everything,those patients weren't living
long enough to develop diabetesor heart disease or things like
that.
So, yeah, it's a great point.
So one of the things that we'regoing to talk about, obviously,
is the therapy and thedifferent regimens, and so I
mentioned earlier it'santiretroviral therapy, which
(05:23):
we'll just refer to throughoutas ART.
We talked about that's amouthful, so we're going to go
ahead and just say that we'regoing to just refer to that as
ART throughout the rest of theepisode today.
But let's talk just brieflyabout what are some of those
regimens, and I'd also like tointroduce undetectable, and I'd
(05:43):
also like to introduceundetectable.
That's something that you'regoing to hear in treatment and
maybe exactly if you can explainwhat that means and what we're
trying to reach with that yeah.
Speaker 2 (05:51):
So antiretroviral therapy ART since that is a
mouthful that is the idea ofusing multiple drugs to suppress
HIV replication and that wasreally sort of, as you say,
brought about in the early 90sand sort of revolutionized the
treatment of HIV, the idea beingthat we have a multi-drug
(06:13):
regimen that targets variouspoints of the HIV life cycle to
help manage the condition.
And so one of the key goals oftherapy is not only to, you know
, protect and preserve theimmune system, but also, through
that viral suppression, butalso to help prevent
transmission to people who don'thave HIV.
So, as you said, thisundetectable and a really easy
(06:36):
way to remember this, and what Ithink is getting a lot of press
recently, is this U equals U,so U, the letter U equals U, so
undetectable equalsuntransmittable, and the idea
that this sustained viralsuppression can help prevent
sexual transmission of HIV.
So, again, a really sort ofrevolutionizing opportunity for
(06:57):
people to understand that takingHIV antiretroviral therapy, it
doesn't mean just helping theirown condition, but also helps
prevent transmission to others,and that's a really, I think,
powerful point for people tounderstand.
Speaker 1 (07:11):
Absolutely, absolutely, and it's important
for us, as pharmacists, tounderstand the terminology
that's associated with it, andif our patients mention
something like that, we need tobe in the know as to what
everything means.
So with that perfectintroduction to what is the role
of the pharmacist, so where aresome of the things that some of
the opportunities that we have?
And we're going to dig intothose deeper.
(07:32):
But obviously we're themedication experts, right?
So we are the ones that shouldknow everything about the
regimens, the medications,helping to select those.
If we're working in acollaborative effort with other
providers of our patients withHIV, we can obviously help with
adherence support, we can helpwith counseling and all of those
sorts of things and thenmanaging any side effects.
(07:55):
So, unfortunately, ARTs don'tcome with no side effects, Just
like any other medications.
There are a lot of side effectsthere, and one of the things
that I really want to touch onlater is you know, these
medications are somewhat highlyinteractive with other meds and
with other things.
So we want to be sure that weas pharmacists are in the know
about that as well.
(08:16):
Anything to add there before wejump into each of those kind of
individually and greater yeah,there's a lot to tackle.
Speaker 2 (08:23):
So, yeah, let's let's break that up into bite sized
chunks.
Speaker 1 (08:26):
Perfect, perfect, okay.
So one of the first things, asan opportunity for pharmacists,
let's talk about the guidelines,the guideline based care, the
pharmacotherapy that's out there, and the the importance of
ensuring that our patients areon the right therapy, first line
, so that we're not running outof options or that they're not
(08:47):
reaching undetectable statusquickly.
Speaker 2 (08:50):
Yep.
So the guidelines are from theUS Department of Health and
Human Services and the websiteis clinicalinfohivgov, so it's
very easy to find.
And again, there are guidelinesspecifically for antiretroviral
therapy for adults andadolescents, as well as more
tailored guidelines forperinatal care for pediatric
(09:11):
patients for opportunisticinfections.
So there's a whole host ofguidelines on the website, but
very easy to digest and readthrough and they have executive
summaries and very easy to sortof get the information you need
quickly.
So it's a good resource to beaware of and those are updated
on a rolling basis as newevidence comes out.
(09:31):
So the last time theseguidelines were updated was last
September and there was apretty big shift in sort of this
initial treatment for HIVbecause one of the previous
regimens that was recommended asoriginal initial treatment was
sort of swapped out with adifferent regimen, and so I can
(09:52):
chat a little bit about that ifwe're at a good place to do that
, yeah, let's do it.
Okay, sure.
So basically you can sort ofthink of the treatment of HIV as
typically requiring two orthree drugs in the regimen.
So typically we'll see twonucleoside reverse transcriptase
(10:12):
inhibitors, nrtis, plus a thirddrug from one of these other
classes which might be anintegrase transfer inhibitor, an
integrase inhibitor I'll callit an NNRTI non-nucleoside
reverse transcriptase inhibitoror a protease inhibitor with a
pharmacokinetic booster.
So I know that's a lot and Iknow.
(10:34):
For me, learning about HIV inschool and then like trying to
remember it was always veryoverwhelming.
But there are, like I said,lots of resources to help.
The guidelines are great AtPearls.
We also have a pharmacotherapyreview chart, cheat sheet, which
outlines the first lineregimens for many patients with
(10:54):
HIV and I know you show thathere, josh.
So what we see now is thatinitial ART for most people
living with HIV is, as you said,very streamlined and
straightforward compared to whatit was even a few years ago.
So one of the first lineoptions is a complete regimen.
(11:15):
That's one tablet taken oncedaily with or without food, very
straightforward.
So it has three drugs.
It has big Tegravir, tenofovir,alafenamide and emtricitabine.
So again, an integraseinhibitor with two NRTIs.
So it matches up with that sortof general combination we need
to be thinking about, but it's avery simplified regimen for
(11:37):
patients.
So that's one option.
There are other three drugcombos that again the chart
shows and the guidelines have.
But basically it means that formost people they can have a two
pill regimen and much easierfor two pill, you know, starting
out at the most, and sometimesjust one.
So again, very, verystreamlined.
(11:58):
And the side effects youmentioned can be problematic.
But for these initial therapiesthe toxicity and side effect
concern is actually much, muchless than it was with our older
regimens.
So again, that's another longway that I think we've we've
come with HIV treatment is notonly the simplicity but also
helping to mitigate some ofthose side effects of some of
the newer regimens.
Speaker 1 (12:20):
And have a better quality of life for the patient
as they're taking themedications.
Speaker 2 (12:24):
Yeah, and to help improve adherence right, Because
we know, adherence, as you said, is such an important part of
HIV treatment.
So if we can have meds that arebetter tolerated, that's
obviously going to innatelyimprove adherence, just by, yeah
, the matter of having bettertolerated meds, absolutely.
Speaker 1 (12:38):
Yep, yeah, and this chart for those of you that are
just listening, I am showing achart right now from Pearls and
it is their pharmacotherapyreview HIV pharmacotherapy
review chart and it's just it'sI was telling Rachel early it's
so good, it's so detailed, ithas so much great information on
here and it's just a reallygreat resource for the pharmacy
teams to ensure that patientsare starting out on the right
(13:01):
thing and if there is anopportunity for you know if they
have to change therapy, this isa great resource to look at to
see what are the other optionsfor your patients.
Rachel, is there anything elseyou wanted to share on this
particular chart here?
Speaker 2 (13:15):
No, I would just say again, I always felt like HIV
treatment was very overwhelmingand I think this just helps to
exemplify the fact that itdoesn't need to be.
And for all of us aspharmacists, I think we can
really just sort of remembersome simple strategies, like the
fact that you know it's twoNRTIs, usually with one of these
other classes, and there arethese complete regimens
(13:37):
available that have all threedrugs in one pill.
So we have again it'sstreamlined and simplified,
hopefully from what many of usmay have been taught in school.
Speaker 1 (13:54):
Yeah, exactly, I mean , it was 20 years ago for me,
when I was more than 20.
Yeah, so it definitely is muchmore streamlined and I feel like
much more manageable from thatprovider perspective, like it's
easier for us as pharmacists tohelp manage this process.
So you mentioned adherencesupport and I think that's huge.
So let's talk about that.
That's another opportunity.
Obviously, as pharmacists,we're the medication experts,
(14:15):
but we also you know that's oneof our roles is making sure that
patients understand theimportance of staying adherent.
So, if we can speak to that forjust a couple minutes as well,
yeah, yeah, absolutely.
Speaker 2 (14:26):
And I think, just like with any adherence
consideration in working withour patients, it's not a one
size fits all approach and anyconcerns about adherence are
going to be very patient,specific.
So finding out what might be apotential barrier for that
patient or where a gap inunderstanding might be, and
helping the patient get thatbuy-in for whatever is important
(14:48):
to them.
So you know, if it is a concernabout number of pills, number of
daily doses, as I said, thereare one pill, one daily dose,
you know, with or without food,that can be very straightforward
.
So hopefully that is less of aconcern than it maybe was before
.
But also helping peopleunderstand the importance of
(15:10):
taking the medicine in thiscondition versus other
conditions they might be takingmedicines for.
It's a similar sort of thingwhere they might not have any
symptoms or any visible effectsfrom the condition, just like
with heart disease, diabetesthey might not have anything
that they feel, but theimportance of suppressing that
viral load and maintaining thatin order to not only improve
(15:31):
their own health but also that Uequals U right.
So preventing transmission toothers and especially with HIV
treatment, the concern aboutresistance and so helping them
understand if the regimen isn'ttaken as prescribed, then it
might increase the risk ofresistance and then that can
lead to the treatment notworking as well and then they
(15:52):
might need a different regimenthat maybe isn't as easy to take
or isn't tolerated as well, andso, again, getting that
understanding and buy-in earlyon, I think can just go a long
way, but really helping themunderstand working with the
patient.
As I say, if it's concernedabout side effects, again, side
effects are much more easilynavigated than they might have
been in the past.
(16:13):
With any regimen.
It's going to vary by regimenand there are still a lot of
regimens, so it's going to varybut we can let them know that.
You know, common side effectsinclude things like fatigue,
nausea, sleep problems, butthose typically are mild and go
away with time.
I think, in terms of sideeffects, the point I would
really want to bring home isthat if they are having anything
(16:35):
they feel is a side effect,just be sure to report it to me,
like I would rather have youcome to me and tell me that
you're concerned, rather thanhaving you try to adjust your
regimen or stop the regimenbecause of those issues with
resistance and then not havingthat viral load suppressed.
So yeah, just encouraging thatopen communication so patients
(16:57):
feel comfortable coming to uswith those concerns.
Speaker 1 (16:59):
Absolutely, and that's something that we talk
about all the time aspharmacists.
That's our role is to to havethat, that relationship with a
patient, so that they do feelcomfortable telling us
everything you know.
I think it's really important,too, to to point out that not
only is this like a like a oneone pill wonder, where you know
all three are in one pill, butit's just once daily as well,
(17:20):
like it's just it's one pillonce daily, taking the same time
each day, you know, and so Ithink that's really important
too.
I think you think about, andeven again, back when I was in
school, I felt like the regimensweren't that simplified, like
there was even, you know,multiple times a day, or two or
three pills a day, or whatever,and so I, you know, just really
(17:40):
focusing on this is simple, thisis easy.
And if you take it this way andcontinue to do it in this easy
way, then it gets to stay thatway, you know like it's when
you're non-adherent.
That's when we have morecomplex regimens.
Speaker 2 (17:55):
That's when we have difficulties and whatever.
So yeah, and I will say too,there is an injectable treatment
option as well.
And I will say too, there is aninjectable treatment option as
well.
So, for people who are stableand have, you know, a very good
viral suppression, there is aninjectable option that, once
it's initiated, it can be givenevery two months or so.
So that is another option.
(18:17):
If patients are stable anddoing well, it may be a
consideration for them.
If they're having trouble withthat daily dosing, that could be
another injectable option toconsider.
Speaker 1 (18:27):
Yeah, that's a great call out Again.
Just so many advancements inthis space.
You know the fact that thereare injectable options now that
are longer acting.
So one of the other things thatwe'd be remiss if we didn't
talk about is counseling andeducating the patients on
prevention of transmission eventhough you know we reached the
undetectable.
(18:48):
It's not 100%, absolutely notpossible.
It is very, very high, but wewant to be sure that we are
educating our patients with HIVabout, you know, their partners
who might be at risk oftransmission.
So anything you want to add tothat in that space?
Speaker 2 (19:04):
Yeah, so, as you said , pre-exposure prophylaxis.
So PrEP is, I think, a termthat both you know, the public
and healthcare professionals aregetting more and more aware of.
You know, helping preventpeople from being at risk of
getting HIV before they'reexposed.
So, like you say, if somebodyliving with HIV is being treated
(19:26):
with antiretroviral therapy andhas a partner who doesn't have
HIV, if they were to use PrEP,that also would then
substantially reduce their riskof getting HIV.
And so there are oral medicinesagain that people can take on a
daily basis to help preventexposure.
But actually, pretty big news,just last week I don't know if
(19:49):
you saw, but there was a newinjectable option approved for
PrEP.
So lenacapivir is the name ofthe drug and it's the first
option that's actually injectedevery six months for PrEP.
So just twice a year patientscan get an injection for PrEP
and to help prevent exposure.
There was an injectable optionbefore that was given every two
(20:11):
months.
It's still available and thereare still, like I say, oral
medications that can be taken aswell.
But this is another again niceoption to help simplify PrEP too
.
Yeah, and use that in tandem.
Speaker 1 (20:24):
And I wonder you know if, is it good news down the
line that there may be anotherlong-acting injectable option to
treat HIV that is more of asix-month or one year or
something like that, which wouldjust make the regimen that much
simpler for patients.
Just, like a long-acting thingit's interesting to think about
(20:45):
and hopefully that is somethingthat we can see coming down the
pipe.
Speaker 2 (20:49):
So I don't know is something that we can see coming
down the pipe.
So I don't know, yeah, ifactually the the pearls chart
that we have, that hivmedications chart that we have.
So it has, um, like we said, ithas all the complete regimens.
It has the um individual drugclasses so you can see which
drugs are in each class.
Um, it does note the theinjectable options here as well.
(21:11):
There we go, just waiting forthat to pull up, and so, yeah,
if you scroll down just a littlebit, yeah, it shows here these
lenacapavir options, so thatSalenka is also approved for
treatment and Yastigo sorry, isthe brand names for these drugs
that are for PrEP.
So there's both an injectableoption of that same drug for
(21:33):
treatment as well.
So, just again, another it'snot a complete regimen, but it
is a drug option that can beejected, whereas if you look in
the complete regimen categorythere's um again oral, but also
that injectable that I mentioned.
Um, that can be a treatmentoption too.
So just a good way to just sortof have these all side by side
(21:54):
because, again, there are a lotof drugs, it's hard to keep them
straight, but definitely lotsof options available for
patients too, which is great.
Speaker 1 (22:03):
Yeah, yeah, I know this is another great chart.
I love that.
It's just so well organized,and even the icons here let you
know whether it's an oral pillor an injectable, and so, yeah,
just super great charts.
So again, for those of you thatare just listening, I'm showing
the HIV medications chart, aresource from Pearls, so okay.
(22:24):
So one other thing.
I think, actually I think thatmay be all of the opportunities
that we wanted to touch on forpharmacists.
So let's move into some ofthose challenges that we see,
some of those challenges that wemay face as pharmacists with
managing the care for ourpatients, and we've touched on
these and we've talked aboutthem.
But just to kind of reiterate,so let's dig into the drug
(22:45):
interactions first.
So, unfortunately, some ofthese medications do have
interactions with othermedications and so forth.
So let's talk a little bitabout what that looks like and
being sure that that's somethingthat we, as pharmacists, are
helping out with.
Speaker 2 (22:59):
Yeah, and, as you say , it is something that it's a
common concern with several ofthese different drug classes,
and it's also a concern withproducts that people may take
over the counter, which I thinkis the trickier part with that.
You know that often peoplemight not think about OTCs or
vitamins or supplements as beingnecessarily a concern with
(23:21):
interactions, and so they mightknow oh yeah, I need to be aware
of interactions but might notthink about OTCs and vitamins as
an issue.
So I think, again, that I wouldsay is probably one of the most
important points is not onlymaking the person aware that
interactions are something theyshould be talking about each
time they start a new product,but also that it's not just
prescriptions, it's also thestuff they can get over the
(23:41):
counter without talking toanyone if they wanted to.
So, yeah, the ones that I thinkof most often are those that
can affect absorption, and so,with the integrase inhibitors
again, which are often inseveral of these first line
regimens, they can be, they caninteract with divalent cations,
so things like iron, calcium,aluminum, magnesium.
(24:04):
So again, you can find those inantacids and vitamins and
laxatives.
So those can usually be managedby spacing apart, but how you
space.
It depends on the drug.
So it is just important to havethe person be aware of that and
coming to you like, hey, if I'mhaving heartburn I want to take
this antacid.
Just check with me so that youknow how to take it properly
(24:26):
with your other meds.
Acid reducers more broadly, sonot only antacids but also H2
blockers and PPIs Again, theseover-the-counter meds that may
interact are a concern with someother HIV medicines, like
atazanivir and rapilverine.
So just being aware of thoseand then those cytochrome P450
(24:49):
interactions too.
So CYP enzymes can metabolizemany drugs, including various
classes of HIV meds.
So protease inhibitors tend tobe a concern with those.
So, for example, with statins,that's something to be aware of.
Some of these boosters,pharmacokinetic boosters like
(25:09):
ritonavir and cabistostat Ithink a lot of us think of
ritonavir as sort of likeboosters, pharmacokinetic
boosters like ritonavir andcabistostat.
I think a lot of us think ofritonavir as sort of like a
classic, also in the COVIDantiviral right.
And so often something that wethink about with interactions.
So, yeah, definitely some keyconcerns to be aware of, but I
think again, one of the points Iwanna drill home with patients
(25:30):
is the fact that it's not justprescription medicine.
So it's not only important forme to be aware of what you're
getting from other pharmacies,but also what you're taking over
the counter.
Speaker 1 (25:39):
Absolutely, and you know, rachel, I think that goes
back to the point we madeearlier where building that
relationship with the patient,making sure that they feel
comfortable talking to us aboutyou know everything.
And it's important to also say,like you mentioned, tell me
things that you're taking overthe counter you know like.
And if they're takingsupplements and things like that
(26:00):
, sometimes patients arehesitant to share that because
you know it's not somethingthat's you know like.
Oh, I read this or I heard thison TV and I'm taking this, you
know, as a supplement, and Iknow you may not agree with it
and whatever.
So I think it's reallyimportant for pharmacists to
also be sure that we're in anonjudgmental space and that
we're not just saying like, oh,don't do that, don't ever do
(26:21):
that, or whatever, because thatcould push the patient away from
telling us more.
So we want to be sure thatwe're always keeping the lines
of communication open so thatthey feel comfortable telling us
about it, because that's justreally important, because if
they start taking things andhiding it from us, then we don't
know what they're doing andwhat they're doing.
We can't help manage.
So, yeah, really important.
So another challenge that wehave obviously we touched on it
(26:44):
is, you know, regardless ofadherence, I mean, it's pretty
clear if the patient is adherent, but there are times when
failure, treatments fail andwhen resistance occurs, and so
that is another challenge for usas well is recognizing when the
regimen needs to change or whatalternative needs to be had,
(27:06):
and also being able tocollaborate with other providers
in that space to choosedifferent regimens.
Speaker 2 (27:11):
So, if you can kind of talk briefly about that and
our role as pharmacists in thatspace too, yeah, yeah, and I
think it goes back to this ideaof you know they are checking in
with us often on a regularbasis and so making sure they
are having regular monitoringwith their other health
providers if needed.
The frequency of how often thathappened varies depending on
(27:31):
their status, but usually atleast three to six months they
should be having a check oftheir viral load and making sure
you know if it is suppressed ornot and helping them understand
what that means Again, so theymight be aware of the need for
viral suppression.
There are cases where you knowsometimes there will be a little
blip, which is where a patientyou know they might go up to a
(27:53):
detectable viral load and thengo back down to an undetectable
level without you know.
There could be all kinds ofreasons for that to happen, but
that doesn't necessarily meanthat they've failed or that
they're you know.
It doesn't mean that thetreatment is failing either.
Sometimes that can happen.
The blips are different than avirologic failure, so but seeing
(28:16):
some of those results andunderstanding them also, I think
, can go a long way in helpingpatients understand how that
ties back in with adherence andmaybe interactions are leading
to some of those issues too or,like you say, it could be a
concern with the resistance.
So just helping them keep upwith that, monitoring,
understanding what those levelsmean and taking action if needed
(28:39):
.
But again, it doesn'tnecessarily mean a change is
needed unless they have aconsistent viral load over 200,
that's typically linked toresistance and then in that case
identifying the cause and again, the cause is usually poor
adherence is critical to thenidentify whether a new regimen
is needed and, if so, ifadherence is a concern, being
(29:00):
sure to keep that definitely inmind and simplifying the regimen
if possible.
Speaker 1 (29:04):
Yeah.
So, rachel, in our last coupleof minutes I just want to be
sure I think we'd be remiss ifwe didn't mention, you know, the
stigma that sometimes isassociated with an HIV status
and also the fact you knowmaking sure that we are
navigating those sensitiveconversations that were
obviously ensuringconfidentiality.
But cultural competence is hugeas well.
(29:27):
You know.
We know that certaincommunities LGBTQ communities
specifically is more susceptibleto HIV infection, and so just
understanding that a lot oftimes there's conversations that
will need to be had that thatpatient may not be out to their
work or to their community or totheir family or whatever, and
so just really understanding theneed for confidentiality and
(29:50):
navigating those sensitivediscussions.
So if there's anything you wantto add to that, I know that
that's just a, that's achallenge, but it's also a great
opportunity for pharmacistsbecause you know we can navigate
those situations very easilyand that's something that we can
do well.
Speaker 2 (30:09):
Yeah, I think it goes back to that idea of open
communication, creating a safespace.
So identifying if you need to goto a more private area, you
know, if there's more sensitiveconversation that needs to be
had.
You know, using using terms likeyour medicine instead of your
HIV medicine, things like thatcan be very small steps that can
(30:29):
go a long way in helping toavoid stigma.
But, like you say, just, I thinkit's what we want to do with
all of our patients, right, it'sjust making sure they feel
comfortable and using ourstrategies like active listening
, and avoid assuming you knowwhat their priorities might be.
Um, if they have concerns,acknowledging those and
(30:52):
recognizing those and thesupplement example you gave is a
great example, because we don'twe wouldn't want them to feel
like we would be judging themfor taking a supplement.
So, you know, making sure thatthat safe space is there, both
both in a, you know,communication perspective, but
also from, you know, aninteraction perspective and just
chatting with them.
So not only privacy from a, butalso from an interaction
perspective and just chattingwith them.
So not only privacy fromhearing other people, being able
(31:12):
to hear, but, yeah, just makingthem feel comfortable and
supporting their decision-makingtoo.
So if they do or don't feelcomfortable with one strategy or
another, supporting them downthat road.
Speaker 1 (31:24):
Yeah, no, that's a great point.
So I think we always run out oftime, rachel, we have so much
to talk about.
So I think just as kind of awrap up, so many opportunities
for pharmacists in this space tohelp with adherence and
educating the patients andensuring you know that we're
watching out for any sort ofinteractions or managing side
(31:45):
effects and just really keepingthe lines of communication open
with our patients who have HIVand you know the resources that
we've shared so good that helpwith pharmacotherapy.
They help identify thedifferent medications and the
opportunities that are there forregimens.
What else do you want to addbefore we wrap up?
Anything that you felt like youdidn't get to talk about?
Speaker 2 (32:08):
Well, I would just say, you know, something that
was always in the back of mymind as a community pharmacist
was about vaccination, so I'lljust put in a plug for that as
well.
Immunizations are always a topof mind for all of our patients,
but for patients with HIV it'salso a consideration, not only
with what they may need, butalso, you know, depending on how
(32:31):
well the condition is beingmanaged, if they may not be, but
also, you know, depending onhow well the condition is being
managed, if they may not beeligible for some live vaccines,
for example.
So I'll just put in, I'll throwthat in, as another you know,
thing to be keeping in mind withthese discussions.
But yeah, I think one of thebiggest things that I would take
away from the discussion isthat U equals U concept.
I think that's.
There's a lot of information onthe CDC site regarding this and
(32:53):
I think it's a new concept thatsome of us might not be as
familiar with, but it is such animportant way to help convey
the importance of adherence andhelp patients sort of get
empowered with what they can doto prevent transmission to
others.
Speaker 1 (33:09):
Yeah, that's great.
And to improve their ownquality of life.
Speaker 2 (33:13):
Exactly.
Speaker 1 (33:14):
Yeah, that's great.
Okay, so, as I always do, Ithink you kind of did it just
now, but what would you say?
Is the game changer here.
What would you say is the gamechanger?
Is the game changer you know?
Fully understanding and knowingabout you equals you, or is
you've already done that one, soI'm going to ask you for a
different one.
Speaker 2 (33:34):
Yeah, I think probably one of the most
important considerations withHIV treatment is adherence, and
so you know we talked about lotsof different ways to improve
adherence.
Think about adherence includinginjectables, including
streamlined regimens that are,you know, one pill easy to take,
um, but uh, also thinking aboutthe the person's particular
(33:56):
barriers and any challenges theymight have.
So I would say adherence for somany reasons is important.
And then also again with theseinteractions and the concern
about interactions withover-the-counter products and
vitamins and supplements.
I would say that's just againreinforcing that point of good
communication and encouragingthe patient to come with you
with any questions about whatthey might be taking over the
(34:17):
counter.
Speaker 1 (34:18):
Yep.
So, as is the case with so manyof our conversations on the
podcast, the game changer isthat pharmacists have a very
impactful role in managingpatients with HIV.
So yeah, so many things that weare the experts at doing and
can really improve the qualityof life and outcomes for our
patients with HIV.
(34:38):
So thank you again, rachel.
So good to have you again.
We really appreciate you givingus your time again.
Speaker 2 (34:44):
Thank you so much for having me.
It was great to be here.
Speaker 1 (34:47):
So, before we wrap up , here's a quick tip.
Through our partnership withPearls, you now have access to
the clinical charts and practicetools that we talked about and
that I shared during thisepisode.
The resources are designed toenhance your workflow and
support patient care.
You'll find all the links anddetails in the show notes, so be
sure to check those out.
If you're a CE plan subscriber,be sure to claim your CE credit
(35:07):
for this episode of GameChangers by logging in at
CEimpactcom.
And, as always, have a greatweek and keep learning.
I can't wait to dig intoanother game-changing topic with
you all next week.
Hey, ce Impact subscribers, Welcome to the Game
Changers Clinical Conversationspodcast.
I'm your host, josh Kinsey, andas always, I'm excited about
our conversation today.
As a reminder, we've launched aspecial pilot series in
collaboration with our friendsat PEARLS, a modern drug
information resource and app.
These crossover episodes,called Game Changing PEARLS,
(00:28):
combine PEARLS' trusted,evidence-based clinical tools
with CE Impact's expertise inpharmacy education and
accreditation, bringing youtimely, actionable content that
supports both your practice andyour professional development.
It's a privilege to workalongside the PEARLS team and
we're excited to continue thispilot series with today's
episode focused on HIV treatment.
(00:49):
Hiv treatment continues toevolve, offering simpler
regimens, improved tolerabilityand life-changing outcomes for
patients.
In today's episode, we'll coverwhat pharmacists need to know
about current antiretroviraltherapy, key counseling points
and how to support patientsthrough every step of their
treatment journey.
And it's so great to haveRachel Maynard back as our guest
(01:10):
for today's episode Rachelwelcome.
Speaker 2 (01:12):
Thank you so much for having me back.
Speaker 1 (01:14):
Yeah, and as a reminder, rachel joined us for a
previous episode on asthma, butfor some of those listeners
that may not have had a chanceto listen to that, rachel, if
you'll take just a minute or twoto introduce yourself and tell
us a little bit about yourposition at Pearls and anything
else you want to share, Sure,yeah, Thanks, Josh.
Speaker 2 (01:33):
So I am a clinical lead at Pearls.
As you mentioned, we're a druginformation resource and some of
our most popular features aresome of our charts and key
counseling points at ClinicalPearls so the name is apt.
But my prior background?
I worked for over a decade inthe drug information education
space and before that I was acommunity pharmacist.
(01:54):
I did a community pharmacyresidency and then was a staff
pharmacist and managed clinicalprograms for a region of a
grocery store chain.
So really I'm here and excitedtoday, passionate about
educating healthcare providersto optimize care for patients in
the best way possible, usingtools and resources to make
their work efficient andeffective.
(02:14):
So very, very happy to be hereand to be chatting about this
very important topic.
Speaker 1 (02:18):
Yeah, yeah, absolutely.
And you know, like I said inthe segue, this is this topic.
It just I feel like it's one ofthe ones that is just ever
changing, like new stuff all thetime, different regimens and
and which is great, it's justwonderful, but it's one of those
that we really have to workhard at keeping up to date with.
So thank you so much forjoining us and and giving us
(02:40):
some actionable insights fortoday.
So, as I always like to do,start off the episode with just
a foundational refresh to makesure everybody's on the same
page.
So, if you don't mind, let'sjust recap exactly what HIV is
and, just a little maybe, somefacts about it and so forth.
So we'll start with that.
Speaker 2 (02:58):
Sure.
So yeah, hiv it stands forhuman immunodeficiency virus.
It is a retrovirus that targetsthe immune system, and so some
of the metrics you might heararound that are CD4 count, which
is a type of white blood cell,and also viral load.
So how much virus isessentially in the blood for
(03:18):
patients to know how well theircondition is being managed?
But ultimately it can lead toif unmanaged, can lead to a
weakening of the immune system,and the most advanced stage of
an HIV infection would be AIDS,acquired immunodeficiency
syndrome.
So without treatment, the lifeexpectancy for people with AIDS
(03:42):
is actually about three years,and even less if they were to
develop an opportunisticinfection.
So if you think about that,that life expectancy for for
AIDS, versus where we are now intreating HIV and getting
patients treated sooner andmanaging the condition, like you
say, it's come a really longway in the 40 years or so since
(04:04):
it was sort of at the height ofthe epidemic.
Speaker 1 (04:07):
Yeah, absolutely, and you know, again reiterating
that this is no longer not to befrank, but no longer a death
sentence, right?
Speaker 2 (04:15):
Absolutely.
Speaker 1 (04:16):
Yeah, it's a manageable condition.
Early diagnosis is key, alsomaking sure that the right
regimen and treatment is key.
But yeah, totally manageabledisease and patients can live a
normal, healthy life.
Speaker 2 (04:29):
Yeah, what we're seeing is that, you know, more
guidelines are coming out.
We have our guidelines focusedon HIV treatment, but we're also
seeing more guidelines focusedon managing chronic
comorbidities in people livingwith HIV, because their life
expectancy is now as good assomebody who doesn't have HIV.
So, yeah, more likecardiovascular management and
(04:53):
guidelines tailored to patientswith HIV, but focusing on these
other comorbidities that theymight be living with, just like
any other patient who's living along life would expect to have.
Speaker 1 (05:03):
Exactly yeah, because back in the 80s, when it was at
the forefront of everything,those patients weren't living
long enough to develop diabetesor heart disease or things like
that.
So, yeah, it's a great point.
So one of the things that we'regoing to talk about, obviously,
is the therapy and thedifferent regimens, and so I
mentioned earlier it'santiretroviral therapy, which
(05:23):
we'll just refer to throughoutas ART.
We talked about that's amouthful, so we're going to go
ahead and just say that we'regoing to just refer to that as
ART throughout the rest of theepisode today.
But let's talk just brieflyabout what are some of those
regimens, and I'd also like tointroduce undetectable, and I'd
(05:43):
also like to introduceundetectable.
That's something that you'regoing to hear in treatment and
maybe exactly if you can explainwhat that means and what we're
trying to reach with that yeah.
Speaker 2 (05:51):
So antiretroviral therapy ART since that is a
mouthful that is the idea ofusing multiple drugs to suppress
HIV replication and that wasreally sort of, as you say,
brought about in the early 90sand sort of revolutionized the
treatment of HIV, the idea beingthat we have a multi-drug
(06:13):
regimen that targets variouspoints of the HIV life cycle to
help manage the condition.
And so one of the key goals oftherapy is not only to, you know
, protect and preserve theimmune system, but also, through
that viral suppression, butalso to help prevent
transmission to people who don'thave HIV.
So, as you said, thisundetectable and a really easy
(06:36):
way to remember this, and what Ithink is getting a lot of press
recently, is this U equals U,so U, the letter U equals U, so
undetectable equalsuntransmittable, and the idea
that this sustained viralsuppression can help prevent
sexual transmission of HIV.
So, again, a really sort ofrevolutionizing opportunity for
(06:57):
people to understand that takingHIV antiretroviral therapy, it
doesn't mean just helping theirown condition, but also helps
prevent transmission to others,and that's a really, I think,
powerful point for people tounderstand.
Speaker 1 (07:11):
Absolutely, absolutely, and it's important
for us, as pharmacists, tounderstand the terminology
that's associated with it, andif our patients mention
something like that, we need tobe in the know as to what
everything means.
So with that perfectintroduction to what is the role
of the pharmacist, so where aresome of the things that some of
the opportunities that we have?
And we're going to dig intothose deeper.
(07:32):
But obviously we're themedication experts, right?
So we are the ones that shouldknow everything about the
regimens, the medications,helping to select those.
If we're working in acollaborative effort with other
providers of our patients withHIV, we can obviously help with
adherence support, we can helpwith counseling and all of those
sorts of things and thenmanaging any side effects.
(07:55):
So, unfortunately, ARTs don'tcome with no side effects, Just
like any other medications.
There are a lot of side effectsthere, and one of the things
that I really want to touch onlater is you know, these
medications are somewhat highlyinteractive with other meds and
with other things.
So we want to be sure that weas pharmacists are in the know
about that as well.
(08:16):
Anything to add there before wejump into each of those kind of
individually and greater yeah,there's a lot to tackle.
Speaker 2 (08:23):
So, yeah, let's let's break that up into bite sized
chunks.
Speaker 1 (08:26):
Perfect, perfect, okay.
So one of the first things, asan opportunity for pharmacists,
let's talk about the guidelines,the guideline based care, the
pharmacotherapy that's out there, and the the importance of
ensuring that our patients areon the right therapy, first line
, so that we're not running outof options or that they're not
(08:47):
reaching undetectable statusquickly.
Speaker 2 (08:50):
Yep.
So the guidelines are from theUS Department of Health and
Human Services and the websiteis clinicalinfohivgov, so it's
very easy to find.
And again, there are guidelinesspecifically for antiretroviral
therapy for adults andadolescents, as well as more
tailored guidelines forperinatal care for pediatric
(09:11):
patients for opportunisticinfections.
So there's a whole host ofguidelines on the website, but
very easy to digest and readthrough and they have executive
summaries and very easy to sortof get the information you need
quickly.
So it's a good resource to beaware of and those are updated
on a rolling basis as newevidence comes out.
(09:31):
So the last time theseguidelines were updated was last
September and there was apretty big shift in sort of this
initial treatment for HIVbecause one of the previous
regimens that was recommended asoriginal initial treatment was
sort of swapped out with adifferent regimen, and so I can
(09:52):
chat a little bit about that ifwe're at a good place to do that
, yeah, let's do it.
Okay, sure.
So basically you can sort ofthink of the treatment of HIV as
typically requiring two orthree drugs in the regimen.
So typically we'll see twonucleoside reverse transcriptase
(10:12):
inhibitors, nrtis, plus a thirddrug from one of these other
classes which might be anintegrase transfer inhibitor, an
integrase inhibitor I'll callit an NNRTI non-nucleoside
reverse transcriptase inhibitoror a protease inhibitor with a
pharmacokinetic booster.
So I know that's a lot and Iknow.
(10:34):
For me, learning about HIV inschool and then like trying to
remember it was always veryoverwhelming.
But there are, like I said,lots of resources to help.
The guidelines are great AtPearls.
We also have a pharmacotherapyreview chart, cheat sheet, which
outlines the first lineregimens for many patients with
(10:54):
HIV and I know you show thathere, josh.
So what we see now is thatinitial ART for most people
living with HIV is, as you said,very streamlined and
straightforward compared to whatit was even a few years ago.
So one of the first lineoptions is a complete regimen.
(11:15):
That's one tablet taken oncedaily with or without food, very
straightforward.
So it has three drugs.
It has big Tegravir, tenofovir,alafenamide and emtricitabine.
So again, an integraseinhibitor with two NRTIs.
So it matches up with that sortof general combination we need
to be thinking about, but it's avery simplified regimen for
(11:37):
patients.
So that's one option.
There are other three drugcombos that again the chart
shows and the guidelines have.
But basically it means that formost people they can have a two
pill regimen and much easierfor two pill, you know, starting
out at the most, and sometimesjust one.
So again, very, verystreamlined.
(11:58):
And the side effects youmentioned can be problematic.
But for these initial therapiesthe toxicity and side effect
concern is actually much, muchless than it was with our older
regimens.
So again, that's another longway that I think we've we've
come with HIV treatment is notonly the simplicity but also
helping to mitigate some ofthose side effects of some of
the newer regimens.
Speaker 1 (12:20):
And have a better quality of life for the patient
as they're taking themedications.
Speaker 2 (12:24):
Yeah, and to help improve adherence right, Because
we know, adherence, as you said, is such an important part of
HIV treatment.
So if we can have meds that arebetter tolerated, that's
obviously going to innatelyimprove adherence, just by, yeah
, the matter of having bettertolerated meds, absolutely.
Speaker 1 (12:38):
Yep, yeah, and this chart for those of you that are
just listening, I am showing achart right now from Pearls and
it is their pharmacotherapyreview HIV pharmacotherapy
review chart and it's just it'sI was telling Rachel early it's
so good, it's so detailed, ithas so much great information on
here and it's just a reallygreat resource for the pharmacy
teams to ensure that patientsare starting out on the right
(13:01):
thing and if there is anopportunity for you know if they
have to change therapy, this isa great resource to look at to
see what are the other optionsfor your patients.
Rachel, is there anything elseyou wanted to share on this
particular chart here?
Speaker 2 (13:15):
No, I would just say again, I always felt like HIV
treatment was very overwhelmingand I think this just helps to
exemplify the fact that itdoesn't need to be.
And for all of us aspharmacists, I think we can
really just sort of remembersome simple strategies, like the
fact that you know it's twoNRTIs, usually with one of these
other classes, and there arethese complete regimens
(13:37):
available that have all threedrugs in one pill.
So we have again it'sstreamlined and simplified,
hopefully from what many of usmay have been taught in school.
Speaker 1 (13:54):
Yeah, exactly, I mean , it was 20 years ago for me,
when I was more than 20.
Yeah, so it definitely is muchmore streamlined and I feel like
much more manageable from thatprovider perspective, like it's
easier for us as pharmacists tohelp manage this process.
So you mentioned adherencesupport and I think that's huge.
So let's talk about that.
That's another opportunity.
Obviously, as pharmacists,we're the medication experts,
(14:15):
but we also you know that's oneof our roles is making sure that
patients understand theimportance of staying adherent.
So, if we can speak to that forjust a couple minutes as well,
yeah, yeah, absolutely.
Speaker 2 (14:26):
And I think, just like with any adherence
consideration in working withour patients, it's not a one
size fits all approach and anyconcerns about adherence are
going to be very patient,specific.
So finding out what might be apotential barrier for that
patient or where a gap inunderstanding might be, and
helping the patient get thatbuy-in for whatever is important
(14:48):
to them.
So you know, if it is a concernabout number of pills, number of
daily doses, as I said, thereare one pill, one daily dose,
you know, with or without food,that can be very straightforward
.
So hopefully that is less of aconcern than it maybe was before
.
But also helping peopleunderstand the importance of
(15:10):
taking the medicine in thiscondition versus other
conditions they might be takingmedicines for.
It's a similar sort of thingwhere they might not have any
symptoms or any visible effectsfrom the condition, just like
with heart disease, diabetesthey might not have anything
that they feel, but theimportance of suppressing that
viral load and maintaining thatin order to not only improve
(15:31):
their own health but also that Uequals U right.
So preventing transmission toothers and especially with HIV
treatment, the concern aboutresistance and so helping them
understand if the regimen isn'ttaken as prescribed, then it
might increase the risk ofresistance and then that can
lead to the treatment notworking as well and then they
(15:52):
might need a different regimenthat maybe isn't as easy to take
or isn't tolerated as well, andso, again, getting that
understanding and buy-in earlyon, I think can just go a long
way, but really helping themunderstand working with the
patient.
As I say, if it's concernedabout side effects, again, side
effects are much more easilynavigated than they might have
been in the past.
(16:13):
With any regimen.
It's going to vary by regimenand there are still a lot of
regimens, so it's going to varybut we can let them know that.
You know, common side effectsinclude things like fatigue,
nausea, sleep problems, butthose typically are mild and go
away with time.
I think, in terms of sideeffects, the point I would
really want to bring home isthat if they are having anything
(16:35):
they feel is a side effect,just be sure to report it to me,
like I would rather have youcome to me and tell me that
you're concerned, rather thanhaving you try to adjust your
regimen or stop the regimenbecause of those issues with
resistance and then not havingthat viral load suppressed.
So yeah, just encouraging thatopen communication so patients
(16:57):
feel comfortable coming to uswith those concerns.
Speaker 1 (16:59):
Absolutely, and that's something that we talk
about all the time aspharmacists.
That's our role is to to havethat, that relationship with a
patient, so that they do feelcomfortable telling us
everything you know.
I think it's really important,too, to to point out that not
only is this like a like a oneone pill wonder, where you know
all three are in one pill, butit's just once daily as well,
(17:20):
like it's just it's one pillonce daily, taking the same time
each day, you know, and so Ithink that's really important
too.
I think you think about, andeven again, back when I was in
school, I felt like the regimensweren't that simplified, like
there was even, you know,multiple times a day, or two or
three pills a day, or whatever,and so I, you know, just really
(17:40):
focusing on this is simple, thisis easy.
And if you take it this way andcontinue to do it in this easy
way, then it gets to stay thatway, you know like it's when
you're non-adherent.
That's when we have morecomplex regimens.
Speaker 2 (17:55):
That's when we have difficulties and whatever.
So yeah, and I will say too,there is an injectable treatment
option as well.
And I will say too, there is aninjectable treatment option as
well.
So, for people who are stableand have, you know, a very good
viral suppression, there is aninjectable option that, once
it's initiated, it can be givenevery two months or so.
So that is another option.
(18:17):
If patients are stable anddoing well, it may be a
consideration for them.
If they're having trouble withthat daily dosing, that could be
another injectable option toconsider.
Speaker 1 (18:27):
Yeah, that's a great call out Again.
Just so many advancements inthis space.
You know the fact that thereare injectable options now that
are longer acting.
So one of the other things thatwe'd be remiss if we didn't
talk about is counseling andeducating the patients on
prevention of transmission eventhough you know we reached the
undetectable.
(18:48):
It's not 100%, absolutely notpossible.
It is very, very high, but wewant to be sure that we are
educating our patients with HIVabout, you know, their partners
who might be at risk oftransmission.
So anything you want to add tothat in that space?
Speaker 2 (19:04):
Yeah, so, as you said , pre-exposure prophylaxis.
So PrEP is, I think, a termthat both you know, the public
and healthcare professionals aregetting more and more aware of.
You know, helping preventpeople from being at risk of
getting HIV before they'reexposed.
So, like you say, if somebodyliving with HIV is being treated
(19:26):
with antiretroviral therapy andhas a partner who doesn't have
HIV, if they were to use PrEP,that also would then
substantially reduce their riskof getting HIV.
And so there are oral medicinesagain that people can take on a
daily basis to help preventexposure.
But actually, pretty big news,just last week I don't know if
(19:49):
you saw, but there was a newinjectable option approved for
PrEP.
So lenacapivir is the name ofthe drug and it's the first
option that's actually injectedevery six months for PrEP.
So just twice a year patientscan get an injection for PrEP
and to help prevent exposure.
There was an injectable optionbefore that was given every two
(20:11):
months.
It's still available and thereare still, like I say, oral
medications that can be taken aswell.
But this is another again niceoption to help simplify PrEP too
.
Yeah, and use that in tandem.
Speaker 1 (20:24):
And I wonder you know if, is it good news down the
line that there may be anotherlong-acting injectable option to
treat HIV that is more of asix-month or one year or
something like that, which wouldjust make the regimen that much
simpler for patients.
Just, like a long-acting thingit's interesting to think about
(20:45):
and hopefully that is somethingthat we can see coming down the
pipe.
Speaker 2 (20:49):
So I don't know is something that we can see coming
down the pipe.
So I don't know, yeah, ifactually the the pearls chart
that we have, that hivmedications chart that we have.
So it has, um, like we said, ithas all the complete regimens.
It has the um individual drugclasses so you can see which
drugs are in each class.
Um, it does note the theinjectable options here as well.
(21:11):
There we go, just waiting forthat to pull up, and so, yeah,
if you scroll down just a littlebit, yeah, it shows here these
lenacapavir options, so thatSalenka is also approved for
treatment and Yastigo sorry, isthe brand names for these drugs
that are for PrEP.
So there's both an injectableoption of that same drug for
(21:33):
treatment as well.
So, just again, another it'snot a complete regimen, but it
is a drug option that can beejected, whereas if you look in
the complete regimen categorythere's um again oral, but also
that injectable that I mentioned.
Um, that can be a treatmentoption too.
So just a good way to just sortof have these all side by side
(21:54):
because, again, there are a lotof drugs, it's hard to keep them
straight, but definitely lotsof options available for
patients too, which is great.
Speaker 1 (22:03):
Yeah, yeah, I know this is another great chart.
I love that.
It's just so well organized,and even the icons here let you
know whether it's an oral pillor an injectable, and so, yeah,
just super great charts.
So again, for those of you thatare just listening, I'm showing
the HIV medications chart, aresource from Pearls, so okay.
(22:24):
So one other thing.
I think, actually I think thatmay be all of the opportunities
that we wanted to touch on forpharmacists.
So let's move into some ofthose challenges that we see,
some of those challenges that wemay face as pharmacists with
managing the care for ourpatients, and we've touched on
these and we've talked aboutthem.
But just to kind of reiterate,so let's dig into the drug
(22:45):
interactions first.
So, unfortunately, some ofthese medications do have
interactions with othermedications and so forth.
So let's talk a little bitabout what that looks like and
being sure that that's somethingthat we, as pharmacists, are
helping out with.
Speaker 2 (22:59):
Yeah, and, as you say , it is something that it's a
common concern with several ofthese different drug classes,
and it's also a concern withproducts that people may take
over the counter, which I thinkis the trickier part with that.
You know that often peoplemight not think about OTCs or
vitamins or supplements as beingnecessarily a concern with
(23:21):
interactions, and so they mightknow oh yeah, I need to be aware
of interactions but might notthink about OTCs and vitamins as
an issue.
So I think, again, that I wouldsay is probably one of the most
important points is not onlymaking the person aware that
interactions are something theyshould be talking about each
time they start a new product,but also that it's not just
prescriptions, it's also thestuff they can get over the
(23:41):
counter without talking toanyone if they wanted to.
So, yeah, the ones that I thinkof most often are those that
can affect absorption, and so,with the integrase inhibitors
again, which are often inseveral of these first line
regimens, they can be, they caninteract with divalent cations,
so things like iron, calcium,aluminum, magnesium.
(24:04):
So again, you can find those inantacids and vitamins and
laxatives.
So those can usually be managedby spacing apart, but how you
space.
It depends on the drug.
So it is just important to havethe person be aware of that and
coming to you like, hey, if I'mhaving heartburn I want to take
this antacid.
Just check with me so that youknow how to take it properly
(24:26):
with your other meds.
Acid reducers more broadly, sonot only antacids but also H2
blockers and PPIs Again, theseover-the-counter meds that may
interact are a concern with someother HIV medicines, like
atazanivir and rapilverine.
So just being aware of thoseand then those cytochrome P450
(24:49):
interactions too.
So CYP enzymes can metabolizemany drugs, including various
classes of HIV meds.
So protease inhibitors tend tobe a concern with those.
So, for example, with statins,that's something to be aware of.
Some of these boosters,pharmacokinetic boosters like
(25:09):
ritonavir and cabistostat Ithink a lot of us think of
ritonavir as sort of likeboosters, pharmacokinetic
boosters like ritonavir andcabistostat.
I think a lot of us think ofritonavir as sort of like a
classic, also in the COVIDantiviral right.
And so often something that wethink about with interactions.
So, yeah, definitely some keyconcerns to be aware of, but I
think again, one of the points Iwanna drill home with patients
(25:30):
is the fact that it's not justprescription medicine.
So it's not only important forme to be aware of what you're
getting from other pharmacies,but also what you're taking over
the counter.
Speaker 1 (25:39):
Absolutely, and you know, rachel, I think that goes
back to the point we madeearlier where building that
relationship with the patient,making sure that they feel
comfortable talking to us aboutyou know everything.
And it's important to also say,like you mentioned, tell me
things that you're taking overthe counter you know like.
And if they're takingsupplements and things like that
(26:00):
, sometimes patients arehesitant to share that because
you know it's not somethingthat's you know like.
Oh, I read this or I heard thison TV and I'm taking this, you
know, as a supplement, and Iknow you may not agree with it
and whatever.
So I think it's reallyimportant for pharmacists to
also be sure that we're in anonjudgmental space and that
we're not just saying like, oh,don't do that, don't ever do
(26:21):
that, or whatever, because thatcould push the patient away from
telling us more.
So we want to be sure thatwe're always keeping the lines
of communication open so thatthey feel comfortable telling us
about it, because that's justreally important, because if
they start taking things andhiding it from us, then we don't
know what they're doing andwhat they're doing.
We can't help manage.
So, yeah, really important.
So another challenge that wehave obviously we touched on it
(26:44):
is, you know, regardless ofadherence, I mean, it's pretty
clear if the patient is adherent, but there are times when
failure, treatments fail andwhen resistance occurs, and so
that is another challenge for usas well is recognizing when the
regimen needs to change or whatalternative needs to be had,
(27:06):
and also being able tocollaborate with other providers
in that space to choosedifferent regimens.
Speaker 2 (27:11):
So, if you can kind of talk briefly about that and
our role as pharmacists in thatspace too, yeah, yeah, and I
think it goes back to this ideaof you know they are checking in
with us often on a regularbasis and so making sure they
are having regular monitoringwith their other health
providers if needed.
The frequency of how often thathappened varies depending on
(27:31):
their status, but usually atleast three to six months they
should be having a check oftheir viral load and making sure
you know if it is suppressed ornot and helping them understand
what that means Again, so theymight be aware of the need for
viral suppression.
There are cases where you knowsometimes there will be a little
blip, which is where a patientyou know they might go up to a
(27:53):
detectable viral load and thengo back down to an undetectable
level without you know.
There could be all kinds ofreasons for that to happen, but
that doesn't necessarily meanthat they've failed or that
they're you know.
It doesn't mean that thetreatment is failing either.
Sometimes that can happen.
The blips are different than avirologic failure, so but seeing
(28:16):
some of those results andunderstanding them also, I think
, can go a long way in helpingpatients understand how that
ties back in with adherence andmaybe interactions are leading
to some of those issues too or,like you say, it could be a
concern with the resistance.
So just helping them keep upwith that, monitoring,
understanding what those levelsmean and taking action if needed
(28:39):
.
But again, it doesn'tnecessarily mean a change is
needed unless they have aconsistent viral load over 200,
that's typically linked toresistance and then in that case
identifying the cause and again, the cause is usually poor
adherence is critical to thenidentify whether a new regimen
is needed and, if so, ifadherence is a concern, being
(29:00):
sure to keep that definitely inmind and simplifying the regimen
if possible.
Speaker 1 (29:04):
Yeah.
So, rachel, in our last coupleof minutes I just want to be
sure I think we'd be remiss ifwe didn't mention, you know, the
stigma that sometimes isassociated with an HIV status
and also the fact you knowmaking sure that we are
navigating those sensitiveconversations that were
obviously ensuringconfidentiality.
But cultural competence is hugeas well.
(29:27):
You know.
We know that certaincommunities LGBTQ communities
specifically is more susceptibleto HIV infection, and so just
understanding that a lot oftimes there's conversations that
will need to be had that thatpatient may not be out to their
work or to their community or totheir family or whatever, and
so just really understanding theneed for confidentiality and
(29:50):
navigating those sensitivediscussions.
So if there's anything you wantto add to that, I know that
that's just a, that's achallenge, but it's also a great
opportunity for pharmacistsbecause you know we can navigate
those situations very easilyand that's something that we can
do well.
Speaker 2 (30:09):
Yeah, I think it goes back to that idea of open
communication, creating a safespace.
So identifying if you need to goto a more private area, you
know, if there's more sensitiveconversation that needs to be
had.
You know, using using terms likeyour medicine instead of your
HIV medicine, things like thatcan be very small steps that can
(30:29):
go a long way in helping toavoid stigma.
But, like you say, just, I thinkit's what we want to do with
all of our patients, right, it'sjust making sure they feel
comfortable and using ourstrategies like active listening
, and avoid assuming you knowwhat their priorities might be.
Um, if they have concerns,acknowledging those and
(30:52):
recognizing those and thesupplement example you gave is a
great example, because we don'twe wouldn't want them to feel
like we would be judging themfor taking a supplement.
So, you know, making sure thatthat safe space is there, both
both in a, you know,communication perspective, but
also from, you know, aninteraction perspective and just
chatting with them.
So not only privacy from a, butalso from an interaction
perspective and just chattingwith them.
So not only privacy fromhearing other people, being able
(31:12):
to hear, but, yeah, just makingthem feel comfortable and
supporting their decision-makingtoo.
So if they do or don't feelcomfortable with one strategy or
another, supporting them downthat road.
Speaker 1 (31:24):
Yeah, no, that's a great point.
So I think we always run out oftime, rachel, we have so much
to talk about.
So I think just as kind of awrap up, so many opportunities
for pharmacists in this space tohelp with adherence and
educating the patients andensuring you know that we're
watching out for any sort ofinteractions or managing side
(31:45):
effects and just really keepingthe lines of communication open
with our patients who have HIVand you know the resources that
we've shared so good that helpwith pharmacotherapy.
They help identify thedifferent medications and the
opportunities that are there forregimens.
What else do you want to addbefore we wrap up?
Anything that you felt like youdidn't get to talk about?
Speaker 2 (32:08):
Well, I would just say, you know, something that
was always in the back of mymind as a community pharmacist
was about vaccination, so I'lljust put in a plug for that as
well.
Immunizations are always a topof mind for all of our patients,
but for patients with HIV it'salso a consideration, not only
with what they may need, butalso, you know, depending on how
(32:31):
well the condition is beingmanaged, if they may not be, but
also, you know, depending onhow well the condition is being
managed, if they may not beeligible for some live vaccines,
for example.
So I'll just put in, I'll throwthat in, as another you know,
thing to be keeping in mind withthese discussions.
But yeah, I think one of thebiggest things that I would take
away from the discussion isthat U equals U concept.
I think that's.
There's a lot of information onthe CDC site regarding this and
(32:53):
I think it's a new concept thatsome of us might not be as
familiar with, but it is such animportant way to help convey
the importance of adherence andhelp patients sort of get
empowered with what they can doto prevent transmission to
others.
Speaker 1 (33:09):
Yeah, that's great.
And to improve their ownquality of life.
Speaker 2 (33:13):
Exactly.
Speaker 1 (33:14):
Yeah, that's great.
Okay, so, as I always do, Ithink you kind of did it just
now, but what would you say?
Is the game changer here.
What would you say is the gamechanger?
Is the game changer you know?
Fully understanding and knowingabout you equals you, or is
you've already done that one, soI'm going to ask you for a
different one.
Speaker 2 (33:34):
Yeah, I think probably one of the most
important considerations withHIV treatment is adherence, and
so you know we talked about lotsof different ways to improve
adherence.
Think about adherence includinginjectables, including
streamlined regimens that are,you know, one pill easy to take,
um, but uh, also thinking aboutthe the person's particular
(33:56):
barriers and any challenges theymight have.
So I would say adherence for somany reasons is important.
And then also again with theseinteractions and the concern
about interactions withover-the-counter products and
vitamins and supplements.
I would say that's just againreinforcing that point of good
communication and encouragingthe patient to come with you
with any questions about whatthey might be taking over the
(34:17):
counter.
Speaker 1 (34:18):
Yep.
So, as is the case with so manyof our conversations on the
podcast, the game changer isthat pharmacists have a very
impactful role in managingpatients with HIV.
So yeah, so many things that weare the experts at doing and
can really improve the qualityof life and outcomes for our
patients with HIV.
(34:38):
So thank you again, rachel.
So good to have you again.
We really appreciate you givingus your time again.
Speaker 2 (34:44):
Thank you so much for having me.
It was great to be here.
Speaker 1 (34:47):
So, before we wrap up , here's a quick tip.
Through our partnership withPearls, you now have access to
the clinical charts and practicetools that we talked about and
that I shared during thisepisode.
The resources are designed toenhance your workflow and
support patient care.
You'll find all the links anddetails in the show notes, so be
sure to check those out.
If you're a CE plan subscriber,be sure to claim your CE credit
(35:07):
for this episode of GameChangers by logging in at
CEimpactcom.
And, as always, have a greatweek and keep learning.
I can't wait to dig intoanother game-changing topic with
you all next week.
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