Medical experts discuss the significance of pill burden in the HIV treatment pathway.
Adam C. Welch, PharmD: We talked about how it’s important to initiate therapy quickly. We talked about how it’s important to test for resistance ahead of time. We also talked about pill burden. When you’re approaching patient care, what factors are the most important to consider? How do you stratify all of that when you’re taking care of patients?
Shauna Applin, ARNP, CNM, AAHIVS: The guidelines call it out, but I’ll list some of the things we’re thinking about. Clearly, we want something easy for them to take. We want something that doesn’t cause adverse effects. Many of our patients are aging. When we think about what other comorbidities they have, we’re thinking about disease state but also what other medications they’re taking to treat them. Then we can consider drug-drug interactions. Also, we need to know their resistance history because once resistant, always resistant. That’s going to play into the decision we make. But to give the clinical experience and what patients care about, is it easy to take and does it cause adverse effects? I can give you the thorough answer that I’m considering, but it comes down to this: how hard is it for me to take or to remember it? And is it going to make me feel sick?
Adam C. Welch, PharmD: Unless they’re observed, they have to physically swallow the tablet.
Christian B. Ramers, MD, MPH, FIDSA, AAHIVS: I have an anecdote about a patient of mine who was treatment experienced. As we get into second- and third-line regimens, we have to be very creative with many more pills than we’d want to use. Sometimes we get into a situation where the regimen should work on paper, yet the patient comes back and their virus is out of control. It’s an awkward discussion, saying, “I don’t know why it’s not working for you.” Patients are embarrassed. They don’t want to look bad to their providers. A particular patient of mine, after 2 to 3 months of getting to know him, admitted to me that he couldn’t swallow large pills. He’d had a stroke and a central nervous system infection related to AIDS, so his swallowing was not normal. He couldn’t admit that. He couldn’t say to me, as his provider, “I can’t take those giant pills.”
We ended up being very creative and his regimen was Juluca [dolutegravir, rilpivirine]–Descovy [emtricitabine, tenofovir alafenamide]. They are the 2 tiniest pills that we have, the size of Tic Tacs. They wouldn’t show up in any regimen or algorithm, but thank goodness the payer was OK with me doing that. That’s exactly the type of thing Shauna mentioned. We need to take all these factors into consideration, for the human being in front of us. It’s our job as specialists to come up with that regimen that he’s going to take for the rest of his life. Thankfully, he’s biologically suppressed now, and his T cells are above the AIDS range. It was a really nice outcome. But you have to have some flexibility to bring our expertise into the individual patient experience.
Alina Orozco, RN: I want to add that we’ve seen that from the case-management perspective, working with individuals. They’ll tell the case manager—they haven’t said anything to their provider—“Look, the pills are too big, and I can’t take them.” Or they say they’re not adherent because “I live with other people, and I’m concerned they’re going to find my pills. So I don’t take them all the time.” Those are prime candidates for the injectables because they’re concerned about stigma. Those concerns are very real. [This is] where that partnership works, where the case manager can call the provider and say, “I had this conversation with your patient, and this is what they shared. Maybe they’re not comfortable sharing it with you.” Building those collaborative relationships helps address some of those things before they come in 2, 3, or 4 months later. Hopefully this can cement a better rapport all around with everyone and help increase those outcomes to better health.
Adam C. Welch, PharmD: When we’re talking about HIV/AIDS, the investment of that type of conversation is important for the outcomes when we’re talking about a lifetime of burden.
Ann Khalsa, MD, MSEd, FAAFP, AAHIVS: I want 1 more comment about injectables. For example, with Cabenuva [cabotegravir, rilpivirine], you do every-2-month injections after you do an oral lead-in for tolerability—if you do—and then monthly injections in the beginning. We’ve seen data that unfortunately show occasional treatment resistance and treatment failure even with on-time injections. So 1 thing we always do is viral-load testing as part of the ongoing monitoring.
One issue we’ve had at our clinic is that because not many individuals have utilized this medication, for whatever reason, it’s been licensed only to certain pharmacies throughout the country. We have to work with 1 pharmacy to get the oral lead-in, a different pharmacy for the initiation injections, and a different pharmacy for the maintenance injections. We’ve been harping on resistance and how critical that is, but we’ve had 1-, 2-, and 3-week gaps at each junction because of all the prior authorization hoops we have to jump through with insurance to get to each of those different pharmacies. If we want to go to injectable therapy across the system, we’ve got to make this more seamless.
We have other injectables. For my highly treatment-experienced patient, 1 of them is intravenous [IV] injection, either an infusion or an injection. Another 1 is a subcutaneous injection. But is that a medical benefit or a pharmacy benefit? Where do I get the medicine, and who’s going to administer it? Can I do it in my clinic with my nurses, or do they have to go to an infusion center? If they’re on Ryan White [HIV/AIDS Program] coverage, will they pay for that? There are all these other payer hurdles that create our barriers. Back in the day, in the 1980s and ’90s, we did blood transfusions and chemotherapy in the hallways of the clinic. We were there focused on serving the patient. We’ve got all these rules and regulations, but it’s going to come back to bite us a little, especially with these injectables.
Adam C. Welch, PharmD: It sounds as if optimizing this antiretroviral therapy in patients is complicated. It takes the providers and payers to be on the same pages for the patient’s best interest.
Transcript edited for clarity.