Rapid initiation of antiretroviral therapy (ART) has been shown to significantly reduce the rate of loss to follow-up and improve clinical outcomes among people living with HIV. The PHARM-D RAPID ART program used pharmacists to provide an HIV care appointment on the day a person received their diagnosis, supporting immediate access to ART. Results showed a significant decrease in the time from clinic intake to viral suppression (<200 copies/ml) in the PHARM-D RAPID ART program compared with a pre-implementation program (30 days versus 66 days).
Program description
Before the PHARM-D RAPID ART program was implemented (i.e., pre-implementation), clients had an initial nursing evaluation that included collecting patient sociodemographic information and providing education. If needed, clients also had a social worker evaluation that included an assessment of their need for referrals to community services. At a later time, clients had an appointment with a provider (i.e., medical doctor) where ART could be initiated.
The PHARM-D RAPID ART program offered ART initiation on the same day a person received their HIV diagnosis to reduce dropout rates and improve clinical outcomes for people living with HIV. Clinical pharmacists were used to provide same-day ART because of their accessibility to clients and their ability to facilitate access to ART. The program had two dedicated pharmacists with specialized training and credentials in HIV pharmacotherapy and infectious diseases. The PHARM-D RAPID ART program also included a nursing evaluation, and patients could also be connected to a social worker as needed during their initial visit (as in the pre-implementation program).
In the PHARM-D RAPID ART program, in-clinic pharmacists provided clinical evaluation using a documented algorithm and process list, which included initiating ART as part of a multidisciplinary intake process. The clinical evaluation conducted by the pharmacists centred around five key areas:
- ordering baseline laboratory tests (e.g., HIV viral load)
- assessing appropriateness of rapid ART (e.g., patient readiness, and potential barriers to adherence)
- providing patient counselling and education (e.g., disease state education, and medication counselling)
- ensuring medication access (e.g., assessing insurance)
- initiating personalized pharmacotherapy (e.g., considerations of drug–drug interactions, resistance potential)
Clients with the required insurance had their prescriptions were filled and delivered before the end of their initial appointment. Pharmacists continued to support them with a follow-up call one week after initiation of ART. On this call, they gave counselling, provided support for treatment adherence and assessed patients’ toleration of their medication. Further visits could occur until the patient achieved an undetectable viral load and had two provider visits.
Results
A total of 108 people with HIV were included in the analysis; 51 of them received a new diagnosis between January 1 and December 31, 2019, as part of the PHARM-D RAPID ART program. This group was compared with the pre-implementation group of 57 people who received their diagnosis between January 1 and December 31, 2017. All people included in the study were 18 years of age or older, were enrolling in care with a new HIV diagnosis and had not previously received ART.
The two groups had similar characteristics:
- average age 35 years
- 55% were men who have sex with men
- 52% reported having current or previous substance use disorder or mental health disorder
- 28% were uninsured
- 15% reported having unstable housing
- 85% were assigned male at birth, 15% were assigned female at birth
The primary outcome was time to viral suppression (<200 copies/ml). Results indicate that the clients in the PHARM-D RAPID ART program had a significantly shorter time from clinic intake to viral suppression (30 days) than those in the pre-implementation group (66 days).
The analysis of the secondary outcomes included the following results:
- Median time from the intake visit to ART initiation was significantly shorter in the PHARM-D RAPID ART group (0 days) than in the pre-implementation group (9 days).
- Median time from the intake visit to a visit with a provider was significantly longer in the PHARM-D RAPID ART group (20 days) than in the pre-implementation group (9 days).
- Median number of encounters with the healthcare team was significantly higher in the PHARM-D RAPID ART group (15 encounters) than in the pre-implementation group (9 encounters).
There were no significant differences between the PHARM-D RAPID ART group and the pre-implementation group in terms of retention in care at 1 year after their intake visit, viral suppression rates 1 year after their intake visit and viral suppression rates at the time of their last recorded viral load test.
Adverse effects that led to increased monitoring or discontinuation of treatment were rare for all participants. One member of the PHARM-D RAPID ART group was supported by the pharmacist, who adjusted their ART. Twenty-one percent of all participants experienced mild to moderate adverse effects, the most common of which was gastrointestinal upset.
What does this mean for service providers?
The study shows that pharmacist-driven rapid initiation of ART can significantly improve clinical outcomes for people living with HIV. Use of pharmacists for rapid ART initiation overcame some of the barriers associated with other approaches such as long wait times for first provider appointments and lack of ability to provide same-day ART initiation because of limited availability of providers and a lack of clinic resources.
The main benefit of the PHARM-D RAPID ART program was the use of pharmacists as they have the necessary clinical expertise but can have more flexible schedules and can be more accessible than medical doctors. Additionally, pharmacists can support clients with follow-up, they have knowledge of co-pay models and they can work with community partners to support sustained access to treatment.
Related resources
Linkage to HIV care: Falling behind and getting ahead – Prevention in Focus article
A pharmacist, physician and patient navigator collaborative care model for hepatitis C treatment – evidence brief
Pharmacy-based HIV point-of-care testing – evidence brief
Reference
Brotherton AL, Coroniti AM, Ayuninjam DK et al. Pharmacist-driven rapid initiation of antiretroviral therapy decreases time to viral suppression in people with HIV. Open Forum Infectious Diseases. 2024;11(5):ofae237.