December 19, 2024 • 11 mins
In this episode, APhA Executive Education Fellows and Katie Meyer will review Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV recently published by National Institutes of Health (NIH).
Each month, APhA will release two, 10 to 15 minute podcast episodes offering a fresh dose of education highlights, practice pearls, and insights to inform your pharmacy practice and advance patient care. Listen to new episodes at your convenience! Both members and nonmembers can log into their APhA Learning Library account to successfully complete a short assessment at the end of each month to earn 0.5 hours of CE credits (.05 CEU).
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:02):
Hello and welcome to the First Filland happy holidays.
This month is HIV AIDS Awareness Month.
So we're highlighting the critical rolepharmacists play in improving outcomes for people
living with HIV, from ensuring accessto the right antiretroviral therapy,
to providing ongoing support and counseling,pharmacists are key in managing HIV care.
Your dedication helps make a differencein the lives of those affected by HIV.
(00:25):
So thank you for all you do.
Before we dive in, I'd like to introducemy guest today, Katie and Nick.
Katie and Nick,Why don't you introduce yourselves?
Thank you, Yara. Hi there, everyone.
This is Katie Meyer.
I serve as the Senior Director of Content Creationhere at APhA
and I'm excited to join ya today.
And hi, everybody. This is Nick Bennet Brush.
(00:46):
I'm one of the education fellows here at APhAfor the 2024, 2025 year.
It's good to be here.
Welcome.
I'm excited to have you both today.
In part one, Katie, Nick and I will discussthe latest updates to the antiretroviral therapy,
also known as ART Guidelinesfor Adults and Adolescents with HIV.
We'll also discuss considerations in older adultsas fortunately we have more effective medication
(01:11):
which allows peopleliving with HIV to live longer.
In part two, we'll hear from Kevin Astle,a clinical pharmacist specialist
who will share practice perilsfor optimizing care for people living with HIV.
Let's dive into the updated ART guidelinesby the US Department of Health and Human Services.
These guidelines, updated September 2024provide essential recommendations
(01:33):
to improve antiretroviraltherapy, management and treatment outcomes.
While we won't have time to cover all the updatestoday, we will focus on the key highlights
and encourage you to review the full guidelinesfor deeper insights at clinicalinfo.HIV.gov.
Katie, can you share with our listenersthe most notable updates to the recommended
(01:53):
initial antiretroviral therapy regimensfor people newly diagnosed with HIV?
Absolutely Yara.
The guidelines were last updatedin 2022 and research has certainly evolved
in terms of initial combinationanti retroviral use for people with HIV.
First, dolutegravir/abacavir/lamivudinewas previously recommended
(02:15):
for most people with HIV, but the guidelinesnow recommend that it only be used for certain
clinical scenariossuch as concern about renal or bone-associated
adverse events in which tenofovir disoproxil (TDF)
or tenofovir alafenamide (TAF)
would be contraindicateddue to the need for HLA-B*5701 testing before
(02:37):
initiating therapy, potential for increase
in the risk of cardiovascular eventsand availability of other safer options.
Second, several antiretroviral regimenswere removed from the list of recommended
initial therapy including elvitegravir/cobicistatand raltegravir-based regimens,
boosted atazanavir-based regimens,efavirenz-based regimens,
(03:01):
and rilpivirine/tenofovirdisoproxil fumarate/emtricitabine regimens.
These changes were due to these regimenshaving higher pill burdens, more adverse
effects or lower barriersto resistance than other antiretroviral regimens.
For people who do not have a history ofusing CAB-LA as PrEP, the guidelines now recommend
either bictegravir/TAF/emtricitabine, dolutegravir
(03:25):
plus TAF or TDF plus emtricitabine or lamivudine
or dolutegravir/lamivudine with some restrictions.
For people who have a history of using CAB-LAas PrEP,
INSTI genotyperesistance testing should be performed.
Darunavir/cobicistator darunavir/ritonavir with TAF or TDF
(03:46):
plus emtricitabine or lamivudine
should be startedpending the results of the genotype test
and then the regimen should be modifiedaccording to the results.
Thanks Katie.
Let's shift towards key considerations
and recommendationswhen caring for older people with HIV.
Nick, how do the updated guidelines addressmanaging antiretroviral therapy in older adults,
(04:09):
particularly considering polypharmacyand age related comorbidities?
Great question, Yara.
These updated guidelinesemphasize patient specific antiretroviral therapy
to address challenges like polypharmacyand related health conditions.
Polypharmacy is a pretty major concernbecause many older adults already
take one medication or more than one medicationfor other health conditions like heart disease.
(04:33):
With antiretroviral therapies,there is a greater risk of drug-drug interaction.
Thus, the guidelines recommend medicationreviews regularly to minimize the risks.
In terms of age related co-morbidities,we actually see
that older adults with HIVare at a higher risk of cardiovascular disease
developing at about ten yearsearlier than the general population.
The Reprieve trial supportsthat and use for primary prevention,
(04:55):
even in those with low cardiovascularrisk, are particularly
in those between ages 40 and 75
when ten year ASCVDrisk estimates are between five and 20%.
The recommendationto start a moderate intensity statin
like pitavastatin 4 mg oncedaily is pretty strong.
We also need to be aware of chronic kidney diseasein this population.
(05:17):
Regular monitoring and adjustments in ARTmight be necessary
to decrease risk of worsening CKD for example,tenofovir
alafenamide is preferred over tenofovirdisoproxil fumarate in renally impaired patients.
Another condition to consider is bone health.
HIV patients have a 1.5 foldhigher risk of fragility
(05:37):
related fractureand a four fold higher risk of hip fractures.
While this is not entirely explainedby differences in bone mineral density,
some ART regimens,such as those containing TDF or boosted
protease inhibitors are detrimentalto bone mineral density.
In short, the guidelines recommendmonitoring for polypharmacy
and focusing on medication regimensthat treat age related non
(05:59):
HIV related illnessesthat may be impacted by HIV regimens.
Thanks, Nick.
This was insightful.
Katie, the updated ARTguidelinesalso talk about optimizing ART
in the setting of viral suppression.
What considerations do the guidelineshighlight for managing ART in people
who have achieved viral suppression?
Yeah, sure, Yara.
(06:20):
Before I dive into the guidelines themselves,I want to first level set
in terms of exactlywhat the term viral suppression means.
So essentially, viral suppression occurswhen antiretroviral
therapy reduces a person'sviral load to an undetectable level.
So this doesn't mean the person is cured.
And if the ART was discontinued, the viral load
(06:40):
would likely return to detectable level.
So considering that,because we now better understand HIV
drug resistance,there are circumstances where it may be possible
to consider switching a personto an alternative regimen that still maintains
viral suppressionwithout jeopardizing future treatment options.
Reasons why we want to considerswitching to an effective regimen includes
(07:04):
maybe the patient experiencing adverse events,or there's drug, drug or drug food interactions.
The patient becomespregnant, cost, convenience, or
they simply have the desireto simplify their regimen.
Traditionally, people living with HIV
who have no history of drug resistance orvirologic failure can likely switch to any regimen
(07:26):
that has been shown to be highly effectivein people who are antiretroviral naive.
One update made to the guidelineshowever was due to evidence that found
that more people living withHIV are switched to regimens that do not include
nucleoside reverse transcriptase inhibitors(or NRTI) or
only lamivudine.
Because of this, the panel expanded the guidanceto emphasize the importance of keeping regimens
(07:50):
that contain hepatitis B active drugsfor people with hepatitis B/HIV co-infection.
As evidencesupporting use of long-acting cabotegravir
plus rilpivirine has evolved, the guidelines nowalso offer that as an option based on data
from switch studies and people who have challengeswith adherence to oral antiretroviral therapy.
(08:12):
So major takeaways when considering switching
antiretroviral regimen for a personwho's achieved viral suppression,
it's important to personalizethe decision based on what's best for their needs.
And you should definitely screen for hepatitisB infection before
considering an NRTI sparing regimen.
Great. Thanks, Katie.
And for our last topic discussion today, Nick,why don't you discuss how pharmacies
(08:34):
can play a key role in implementing
these updates, particularlyfor populations with unique clinical needs?
Yeah, sure.
So pharmacists are incrediblywell positioned to optimize treatment
regimens by tailoring ART to our patientsindividual needs.
We can review that regimen for potential DDIsmonitor for side effects, monitor
renal or hepatic impairmentand help with co-infections like Hep B or TB.
(08:58):
We also play a unique role in providingeducating patients on the importance of adherence.
We educate healthcare providers about regimensand we help in reduce the risk
of virologic failure by providing counselingto our patients and to those healthcare providers.
By working within a multidisciplinaryteam, pharmacists can develop comprehensive care
plans for patients that can managecomplex cases like those we see in HIV infected
(09:21):
older adults to ensure they receivepersonalized treatment for their disease.
Awesome.
Thank you, Katie and Nick, for providing
such valuable insightsinto the recent HIV treatment guideline updates.
These updates underscore the essential rolepharmacists play in optimizing care
for people living with HIV.
In part two will focus on the unique challengesfaced by special populations
(09:41):
such as older adultsand those with complex medical conditions.
So stay tuned.
All right, Let's summarizemajor takeaways from our time here today.
One, special populations such as older adultsand people with viral suppression,
require careful consideration of co-morbiditiesand drug interaction.
And our second major takeaway pharmaciesplay a pivotal role
(10:03):
in optimizing outcomes through counseling,education and adherence monitoring.
All right, folks,that's all the time we have for today.
Look out for part
two of this month's First Fill podcastthat will release next Thursday, December 26th.
Teaser, We'll be speaking with Kevin Astle,a clinical pharmacy specialist dedicated
to improving care for patients and fosteringa stigma free health care environment.
(10:26):
Don't miss it.
For any HIV credentialed pharmacists,check out a recently released webinar
titled Ending with HIV Epidemic PharmacistsExpanding Role in Impact
and our HIV PEP/PrEP Certificate Learning programthat you'll find both in our learning library.
And last but not least, don'tforget to head over to the Learning Library
(10:47):
at learn.pharmacist.comto earn your see for this month's podcast.
We'd love to hear your feedback on how you likethe new set up.
Take care and good bye.
Hello and welcome to the First Filland happy holidays.
This month is HIV AIDS Awareness Month.
So we're highlighting the critical rolepharmacists play in improving outcomes for people
living with HIV, from ensuring accessto the right antiretroviral therapy,
to providing ongoing support and counseling,pharmacists are key in managing HIV care.
Your dedication helps make a differencein the lives of those affected by HIV.
(00:25):
So thank you for all you do.
Before we dive in, I'd like to introducemy guest today, Katie and Nick.
Katie and Nick,Why don't you introduce yourselves?
Thank you, Yara. Hi there, everyone.
This is Katie Meyer.
I serve as the Senior Director of Content Creationhere at APhA
and I'm excited to join ya today.
And hi, everybody. This is Nick Bennet Brush.
(00:46):
I'm one of the education fellows here at APhAfor the 2024, 2025 year.
It's good to be here.
Welcome.
I'm excited to have you both today.
In part one, Katie, Nick and I will discussthe latest updates to the antiretroviral therapy,
also known as ART Guidelinesfor Adults and Adolescents with HIV.
We'll also discuss considerations in older adultsas fortunately we have more effective medication
(01:11):
which allows peopleliving with HIV to live longer.
In part two, we'll hear from Kevin Astle,a clinical pharmacist specialist
who will share practice perilsfor optimizing care for people living with HIV.
Let's dive into the updated ART guidelinesby the US Department of Health and Human Services.
These guidelines, updated September 2024provide essential recommendations
(01:33):
to improve antiretroviraltherapy, management and treatment outcomes.
While we won't have time to cover all the updatestoday, we will focus on the key highlights
and encourage you to review the full guidelinesfor deeper insights at clinicalinfo.HIV.gov.
Katie, can you share with our listenersthe most notable updates to the recommended
(01:53):
initial antiretroviral therapy regimensfor people newly diagnosed with HIV?
Absolutely Yara.
The guidelines were last updatedin 2022 and research has certainly evolved
in terms of initial combinationanti retroviral use for people with HIV.
First, dolutegravir/abacavir/lamivudinewas previously recommended
(02:15):
for most people with HIV, but the guidelinesnow recommend that it only be used for certain
clinical scenariossuch as concern about renal or bone-associated
adverse events in which tenofovir disoproxil (TDF)
or tenofovir alafenamide (TAF)
would be contraindicateddue to the need for HLA-B*5701 testing before
(02:37):
initiating therapy, potential for increase
in the risk of cardiovascular eventsand availability of other safer options.
Second, several antiretroviral regimenswere removed from the list of recommended
initial therapy including elvitegravir/cobicistatand raltegravir-based regimens,
boosted atazanavir-based regimens,efavirenz-based regimens,
(03:01):
and rilpivirine/tenofovirdisoproxil fumarate/emtricitabine regimens.
These changes were due to these regimenshaving higher pill burdens, more adverse
effects or lower barriersto resistance than other antiretroviral regimens.
For people who do not have a history ofusing CAB-LA as PrEP, the guidelines now recommend
either bictegravir/TAF/emtricitabine, dolutegravir
(03:25):
plus TAF or TDF plus emtricitabine or lamivudine
or dolutegravir/lamivudine with some restrictions.
For people who have a history of using CAB-LAas PrEP,
INSTI genotyperesistance testing should be performed.
Darunavir/cobicistator darunavir/ritonavir with TAF or TDF
(03:46):
plus emtricitabine or lamivudine
should be startedpending the results of the genotype test
and then the regimen should be modifiedaccording to the results.
Thanks Katie.
Let's shift towards key considerations
and recommendationswhen caring for older people with HIV.
Nick, how do the updated guidelines addressmanaging antiretroviral therapy in older adults,
(04:09):
particularly considering polypharmacyand age related comorbidities?
Great question, Yara.
These updated guidelinesemphasize patient specific antiretroviral therapy
to address challenges like polypharmacyand related health conditions.
Polypharmacy is a pretty major concernbecause many older adults already
take one medication or more than one medicationfor other health conditions like heart disease.
(04:33):
With antiretroviral therapies,there is a greater risk of drug-drug interaction.
Thus, the guidelines recommend medicationreviews regularly to minimize the risks.
In terms of age related co-morbidities,we actually see
that older adults with HIVare at a higher risk of cardiovascular disease
developing at about ten yearsearlier than the general population.
The Reprieve trial supportsthat and use for primary prevention,
(04:55):
even in those with low cardiovascularrisk, are particularly
in those between ages 40 and 75
when ten year ASCVDrisk estimates are between five and 20%.
The recommendationto start a moderate intensity statin
like pitavastatin 4 mg oncedaily is pretty strong.
We also need to be aware of chronic kidney diseasein this population.
(05:17):
Regular monitoring and adjustments in ARTmight be necessary
to decrease risk of worsening CKD for example,tenofovir
alafenamide is preferred over tenofovirdisoproxil fumarate in renally impaired patients.
Another condition to consider is bone health.
HIV patients have a 1.5 foldhigher risk of fragility
(05:37):
related fractureand a four fold higher risk of hip fractures.
While this is not entirely explainedby differences in bone mineral density,
some ART regimens,such as those containing TDF or boosted
protease inhibitors are detrimentalto bone mineral density.
In short, the guidelines recommendmonitoring for polypharmacy
and focusing on medication regimensthat treat age related non
(05:59):
HIV related illnessesthat may be impacted by HIV regimens.
Thanks, Nick.
This was insightful.
Katie, the updated ARTguidelinesalso talk about optimizing ART
in the setting of viral suppression.
What considerations do the guidelineshighlight for managing ART in people
who have achieved viral suppression?
Yeah, sure, Yara.
(06:20):
Before I dive into the guidelines themselves,I want to first level set
in terms of exactlywhat the term viral suppression means.
So essentially, viral suppression occurswhen antiretroviral
therapy reduces a person'sviral load to an undetectable level.
So this doesn't mean the person is cured.
And if the ART was discontinued, the viral load
(06:40):
would likely return to detectable level.
So considering that,because we now better understand HIV
drug resistance,there are circumstances where it may be possible
to consider switching a personto an alternative regimen that still maintains
viral suppressionwithout jeopardizing future treatment options.
Reasons why we want to considerswitching to an effective regimen includes
(07:04):
maybe the patient experiencing adverse events,or there's drug, drug or drug food interactions.
The patient becomespregnant, cost, convenience, or
they simply have the desireto simplify their regimen.
Traditionally, people living with HIV
who have no history of drug resistance orvirologic failure can likely switch to any regimen
(07:26):
that has been shown to be highly effectivein people who are antiretroviral naive.
One update made to the guidelineshowever was due to evidence that found
that more people living withHIV are switched to regimens that do not include
nucleoside reverse transcriptase inhibitors(or NRTI) or
only lamivudine.
Because of this, the panel expanded the guidanceto emphasize the importance of keeping regimens
(07:50):
that contain hepatitis B active drugsfor people with hepatitis B/HIV co-infection.
As evidencesupporting use of long-acting cabotegravir
plus rilpivirine has evolved, the guidelines nowalso offer that as an option based on data
from switch studies and people who have challengeswith adherence to oral antiretroviral therapy.
(08:12):
So major takeaways when considering switching
antiretroviral regimen for a personwho's achieved viral suppression,
it's important to personalizethe decision based on what's best for their needs.
And you should definitely screen for hepatitisB infection before
considering an NRTI sparing regimen.
Great. Thanks, Katie.
And for our last topic discussion today, Nick,why don't you discuss how pharmacies
(08:34):
can play a key role in implementing
these updates, particularlyfor populations with unique clinical needs?
Yeah, sure.
So pharmacists are incrediblywell positioned to optimize treatment
regimens by tailoring ART to our patientsindividual needs.
We can review that regimen for potential DDIsmonitor for side effects, monitor
renal or hepatic impairmentand help with co-infections like Hep B or TB.
(08:58):
We also play a unique role in providingeducating patients on the importance of adherence.
We educate healthcare providers about regimensand we help in reduce the risk
of virologic failure by providing counselingto our patients and to those healthcare providers.
By working within a multidisciplinaryteam, pharmacists can develop comprehensive care
plans for patients that can managecomplex cases like those we see in HIV infected
(09:21):
older adults to ensure they receivepersonalized treatment for their disease.
Awesome.
Thank you, Katie and Nick, for providing
such valuable insightsinto the recent HIV treatment guideline updates.
These updates underscore the essential rolepharmacists play in optimizing care
for people living with HIV.
In part two will focus on the unique challengesfaced by special populations
(09:41):
such as older adultsand those with complex medical conditions.
So stay tuned.
All right, Let's summarizemajor takeaways from our time here today.
One, special populations such as older adultsand people with viral suppression,
require careful consideration of co-morbiditiesand drug interaction.
And our second major takeaway pharmaciesplay a pivotal role
(10:03):
in optimizing outcomes through counseling,education and adherence monitoring.
All right, folks,that's all the time we have for today.
Look out for part
two of this month's First Fill podcastthat will release next Thursday, December 26th.
Teaser, We'll be speaking with Kevin Astle,a clinical pharmacy specialist dedicated
to improving care for patients and fosteringa stigma free health care environment.
(10:26):
Don't miss it.
For any HIV credentialed pharmacists,check out a recently released webinar
titled Ending with HIV Epidemic PharmacistsExpanding Role in Impact
and our HIV PEP/PrEP Certificate Learning programthat you'll find both in our learning library.
And last but not least, don'tforget to head over to the Learning Library
(10:47):
at learn.pharmacist.comto earn your see for this month's podcast.
We'd love to hear your feedback on how you likethe new set up.
Take care and good bye.
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