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Expert Panel: Access to Multiple Treatment Options Is Needed to Continue the Fight Against HIV
Jerry Cade, MD; Jeff Dunn, PharmD, MBA; Holly Kilness-Packett, MA; Glen Pietrandoni, RPh, AAHIVP; Carl Schmid, MBA

Expert Panel: Access to Multiple Treatment Options Is Needed to Continue the Fight Against HIV

Jerry Cade, MD; Jeff Dunn, PharmD, MBA; Holly Kilness-Packett, MA; Glen Pietrandoni, RPh, AAHIVP; Carl Schmid, MBA
A multidisciplinary panel of HIV experts gathered in October 2016 to discuss the current state of HIV care and develop critical recommendations for Pharmacy and Therapeutics (P&T) committee members to consider when developing policies affecting their member populations who are living with HIV. This paper presents the panel’s discussion, consensus opinion, and conclusions.

Market Dynamics Will Impact HIV Management in the Future
A variety of factors pose challenges to continued progress towards HIV population management goals. These include evolving HIV population demographics, suboptimal adherence to drug regimens, risk of ARV resistance, and increases in spending for HIV treatment.

Today, approximately 1.2 million people are living with HIV in the United States, with as many as 1 in 8 not knowing they are infected. The majority of people newly diagnosed with HIV are <50 years old. In 2015, the distribution of cases diagnosed according to age was as follows: 4% aged 13-19, 61% aged 20-39, 29% aged 40-59, and 5% aged 60 and over.10

HIV/AIDS has impacted the lives of people of every race, religion, and sex; however, men who have sex with men are disproportionately affected, accounting for an estimated 82% of HIV diagnoses among males and 67% of all diagnoses according to 2015 statistics. Within this subpopulation, black men who have sex with men accounted for the largest number of HIV diagnoses, followed by white men who have  sex  with  men.  Among  Hispanic/Latino men who have sex with men, diagnoses rose by 24% from 2005-2014. Women accounted for an estimated 19% of HIV diagnoses.10

Geographic incidence varies widely across the United States: The rates (per 100,000 people) of HIV diagnoses in 2015 were 16.8 in the South, 11.6 in the Northeast, 9.8 in the West, and 7.6 in the Midwest.10

Socioeconomic factors can contribute to disparities in care. Prevalence of HIV and other sexually transmitted diseases  (STDs) in a community, higher rates of undiagnosed/ untreated STDs, language barriers, poverty, discrimination, and higher rates of incarceration among men all present significant challenges to the management of the disease.9
“Each patient should be approached/ considered  differently  because  of the significant obstacles they face in addition to their HIV—factors such as mental health conditions, substance abuse issues, poverty, homelessness, etc.”—Jerry Cade, Medical Director, Viral Specialty Treatment Service, University Medical Center

Suboptimal adherence and risk of resistance

UNAIDS and the NHAS 2020 have both established separate adherence targets  of ≥80% for people living with HIV in order to support community viral suppression—a goal that is unmet in the United States, according to CDC surveillance data.7,12 In fact, in one meta- analysis of over 17,500 patients in the United States living with HIV, 45% did not maintain≥80% adherence.13

Difficulties with adherence can arise from a number of issues, including, but not limited to, complex medication regimens; patient-related factors, such as comorbidities, the experience of adverse effects, or substance abuse; and health system issues, such as interruptions in patient access to medication and inadequate education  and support.4

The result of suboptimal adherence can be reduced treatment response or even treatment failure and resultant emergence of drug- resistant viral mutations that may compromise the patient’s future treatment options.4 Resistance may also be transmitted to patients who are ARV treatment-naïve. This means ARV class options could already be limited for treatment-naïve patients. In all of these cases, panel members point out that resistance is permanent and can limit future treatment options.

For example, evidence suggests that the chance of developing HIV  drug resistance increases with length of time on therapy, meaning that patients may require treatment with different ARV regimens over the course of their lives to maintain viral suppression.14 Panel members highlighted that a long-term view on the risk of resistance, as well as suboptimal adherence considerations, point to the importance of individualized treatment.
The importance of addressing adherence is highlighted when considering that additional instances of managing resistance can be costly. An example is demonstrated in a Canadian study by Krentz et al, aimed to measure and compare the direct costs of HIV-related care in patients with HIV drug resistance vs no resistance. The researchers found that secondary resistance increased per-person-per- month costs by 22%.15

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