Hiv management in saskatchewan m.stuber
- 1. HIV Management in Saskatchewan April 30, 2016 Mike Stuber, BSP Clinical Pharmacist - HIV
- 2. Disclosures ■ I have received honoraria from the following companies: ◻ Gilead Sciences, Bristol Myers Squibb, ViiV, Janssen ■ If you detect any commercial bias, please let me know ◻ Phone: 306.766.0717 ◻ Email: Michael.Stuber@rqhealth.ca
- 3. Outline ■ What’s going on with HIV in Saskatchewan? ■ The HIV Care Cascade and the role of ART ■ Barriers and Challenges to Effective ART in Saskatchewan ■ The role of the pharmacist in improving HIV care ■ Next Steps
- 4. Perceptions of HIV/AIDS ■ Who is the “face of HIV” to you?
- 5. Crystal ■ 27 year old First Nations woman from Regina ◻ HIV+ diagnosis in Jan 2014 ■ VL = 1.45 mill copies/mL ■ CD4+ = 38 (9%) cells/mm3 ■ History of IDU and heterosexual contact ■ Mother of 3 ■ Unemployed ■ Lives with her mother and children in NC Regina ■ Seen by RQHR IDC team in March, 2014
- 6. HIV and AIDS in Saskatchewan, 2014
- 7. HIV and AIDS in Saskatchewan, 2014
- 8. 112 199 HIV and AIDS in Saskatchewan, 2014
- 9. By The Numbers - Africa on the Prairies ■ 9.8 new HIV infections/100k vs 5.8/100k in Canada ■ ~2x national rate (down from 3x in 2009) ■ 71% new HIV cases in Aboriginal peoples ◻ 84% of women were Aboriginal ◻ ~15% of SK population Aboriginal (~171,000) ■ rate of infection = 51/100k HIV and AIDS in Saskatchewan, 2014
- 10. By The Numbers - Africa on the Prairies ■ 56% new HIV cases report IDU ■ 5% prevalence rate of HIV in Regina (A-Track Pilot Survey) ◻ Sub-Saharan Africa ~4.7% prevalence rate ◻ 46% unaware of HIV + status HIV and AIDS in Saskatchewan, 2014
- 11. Cascade of Care
- 12. Crystal ■ Where is she in the cascade? What can we learn? ◻ Late diagnosis ■ What went right? What went wrong? ■ Ongoing barriers to retain/engage in care?
- 14. HIV - A Natural History
- 15. Crystal ■ Rx for Stribild™ (EVG/c/TDF/FTC) + Reyataz™ (ATV) - Feb/14 ■ Ongoing addictions and trauma ■ Community support ■ Opioid Substitution Therapy ◻ 75mg/day
- 16. HIV and Drug Targets
- 17. Benefits of ART ■ Effective ART: ◻ Suppresses Viral Replication ■ “undetectable” viral load ■ Improves Immune Systems ■ Improved CD4+ counts ■ Avoidance of OIs and AIDS defining illnesses ■ Prevention of death ■ Reduces Inflammation ◻ End-organ damage, cancers
- 18. Benefits of ART ■ Individual ◻ Longer lifespan than pre-HAART era ■ Near normal ■ Reduced morbidity and mortality ◻ Associated hospitalizations ■ Reduced incidence of non-AIDS comborbidities ◻ CVD, DM, CKD, non-AIDS cancers ◻ Still higher than HIV- cohorts
- 19. Benefits of ART ■ Societal: ◻ ZERO TRANSMISSIONS (practically) ■ Treatment as Prevention (TasP) ■ 90-90-90 Approach ◻ Reduced health care costs ■ Improved productivity
- 20. We Can End HIV Epidemic
- 21. Anti-RetroVirals
- 22. Adherence ■ ART only works if taken on a regular, daily basis ◻ “90%” rule ■ Poor Adherence = Treatment Failure = Resistance ◻ Viral replication in the presence of drug ■ Emergence of drug resistant variants ■ Class wide
- 23. Barriers to Adherence ■ Pill burden ■ Adverse Effects ■ Treatment fatigue ■ Relative regimen complexity ■ Navigation of health care system ■ Drug Costs ■ Swallowing difficulty
- 24. Barriers to Adherence ■ Cultural differences ■ Housing Stability/Transiency ■ Social chaos ■ Addictions/Mental Health ■ Access to Food
- 25. Stigma ■ Diabetes vs HIV? ■ Both chronic illnesses ◻ DM outcomes ◻ HIV outcomes ■ Stigma ◻ Nature of disease ◻ Characteristics of HIV+ people
- 26. Crystal ■ Lab work July, 2014; didn’t attend clinic ◻ VL = 849 c/mL ◻ CD4+ = 75 (20%) cells/mm3 ◻ Weight = 53 kg ■ Adherence improved ◻ Switch to pharmacist administered methadone maintenance program ■ Daily administered ART ■ “Enhanced Adherence”
- 27. Drug Interactions ■ Pharmacokinetic ■ Pharmacodynamic ■ May impact ART success ■ May impact patient health
- 28. Crystal ■ Admitted to hospital October, 2014 x 6/52 ◻ SCr 189 umol/L on admission (prev 65); hit 410 umol/L ◻ D/C ART regimen/OI proph ◻ Isentress™ (RAL) BID + Kivexa™ (ABC/3TC) ◻ SCr decreased ■ Pancytopenia, malaise, diarrhea, weight loss ◻ Weight = 48.2kg
- 29. Drug Interactions ■ Other ARVs ■ OI medications ■ Prescription ■ Non-prescription ■ Herbals ■ Food ■ Recreational/street
- 30. Crystal ■ Mycobacterium avium complex (MAC) ◻ Initiation of ethambutol/rifabutin/clarithromycin ■ VL not suppressed: ◻ 165c/mL - 86 c/mL ◻ Dec 2015 - 6517 c/mL ■ How to address this? ◻ Patient attended methadone, no dirty screens, no missed doses
- 31. Crystal ■ December, 2015 - Medications changed AGAIN! ◻ Prezcobix™ (DRV/c), Tivicay™ (DTG), Ziagen™ (ABC) ■ Resistance and drug interactions ■ Completed MAC therapy April 7, 2016 ◻ VL = Target Not Detected ■ Happy, healthy weight, no physical complaints
- 32. What Can We Learn? ■ Lots of support needed ◻ Fragmented system ■ Many steps to final steps of Cascade ◻ Not always linear progression ■ ART is the key to getting to ‘viral suppression’ ◻ Pharmacists are experts in drug therapy provision ■ Under/poorly utilized in Saskatchewan ■ Unique opportunities vs other provinces
- 33. Pharmacist Roles ■ Drug therapy experts ◻ Ensure right drug/regimen ◻ DIs ■ Overcoming Adherence Barriers ◻ Coverage ◻ Convenience packaging ◻ Transitions in Care ◻ Creative solutions to barriers in care
- 34. Pharmacist Roles ■ Care coordinators/Intermediaries ◻ Recognizing adverse events ◻ Community support linkage ◻ Appointments ◻ Laboratory tests & monitoring ■ Comorbidity Managers ◻ Cardiovascular, renal, bone, smoking cessation, addictions, gastrointestinal, viral hepatitis
- 35. Pharmacist Roles ■ Health promotion ◻ Testing for HIV/HCV ◻ Harm reduction ■ Creative solutions ◻ Involvement in care ◻ Adherence support ◻ Community involvement
- 36. Success and Failure ■ The “Crystals” ◻ The others ◻ AIDS cases aren’t decreasing ■ 22/28 AIDS cases in 2014 alive ■ Provision of ART to hard to reach populations ◻ Does it go far enough? ■ Reduced HIV incidence ◻ True incidence? ◻ Northern/Remote communities
- 37. HIV and AIDS in Saskatchewan, 2014
- 38. Success and Failure ■ Adherence Supports ◻ DOT/EA approaches ■ Documented success in chaotic populations ■ System barriers to implementation ◻ Home care ◻ Case Management
- 39. Next Steps ■ Integration of community pharmacists into HIV team ◻ Use of EMRs ◻ Lower threshold for feedback to clinic team ■ Improved communications mechanisms ◻ HIV testing and follow up ◻ Care coordination ◻ Case management involvement
- 40. Next Steps ■ Building capacity ◻ Targeted education ◻ Intra/Interdisciplinary collaboration ◻ Strategies for overcoming adherence barriers ■ Research ◻ Data needed ◻ Projects
- 41. Next Steps - Tangibles ■ Pharmacist compensation ■ Community Practice Guidelines ◻ Certifications ◻ Internships ■ 100% ARV reimbursement ■ SK HIV Pharmacists Interest Group/Network ◻ Sharing of information ◻ Collaboration ◻ Data collection
- 42. Resources ■ SK HIV Collaborative ◻ http://www.skhiv.ca/ ■ Canadian HIV/AIDS Pharmacists Group (CHAP) ◻ http://hivclinic.ca/chap/ ■ AIDSInfo Guidelines ◻ https://aidsinfo.nih.gov/guidelines ■ BC Centre for Excellence ◻ http://www.cfenet.ubc.ca/ ■ Drug Interactions ◻ http://hivclinic.ca/main/drugs_interact.html ■ Clinical Pharmacists ◻ Regina - 306.766.0717 ◻ Saskatoon - 306.655.0688
- 43. An HIV Free Saskatchewan
- 44. Conclusions ■ HIV is a chronic illness easily treated with ART ■ Myriad challenges and barriers to effective HIV diagnosis, engagement and treatment in Saskatchewan ◻ Exacerbated by fragmented system ■ As gatekeepers of ARVs and drug therapy experts pharmacists are key players in getting patients to the final steps of HIV Care Cascade
- 45. Conclusions ■ Currently pharmacists are under-utilized members of the HIV care team ■ Active involvement of pharmacists in HIV care results in better outcomes ■ Opportunities exist to increase capacity for pharmacist lead HIV interventions ■ Ongoing educational opportunities and collaboration will produce novel ways of overcoming barriers to HIV care
- 46. Questions? ◻PLEASE FILL OUT THE SURVEY! ◻ Phone: 306.766.0717 ◻ Email: Michael.Stuber@rqhealth.ca