Effect of pharmacist care on clinical outcomes among people living with HIV/AIDS: A systematic review and meta-analysis

Pharmacist-Driven Rapid Initiation of Antiretroviral Therapy Decreases Time to Viral Suppression in People With HIV

Background

Rapid initiation of antiretroviral therapy (rapid ART) improves clinical outcomes in people with HIV and is endorsed by clinical guidelines. However, logistical challenges limit widespread implementation. We describe an innovative rapid ART model led by pharmacists and its impact on clinical outcomes, including time to viral suppression (TVS).

Methods

On 1 January 2019, we implemented Pharmacist-Driven Rapid ART (PHARM-D RAPID ART), including rapid ART initiation by pharmacists. Our retrospective cohort study compared TVS, using a Cox proportional hazards model, and clinical outcomes among individuals with a new HIV diagnosis before (1 January 2017 to 31 December 2017) and after (1 January 2019 to 31 December 2019) implementation.

Results

A total of 108 individuals were included. TVS was significantly shorter (P < .001) for the PHARM-D RAPID ART group (n = 51) compared with the preimplementation group (n = 57) (median: 30 days and 66 days, respectively). Those in the PHARM-D RAPID ART group were significantly more likely to achieve VS at any given time during the study period (adjusted hazard ratio: 3.47 [95% confidence interval, 2.25-5.33]). A total of 94.1% (48/51) of patients in the PHARM-D RAPID ART group were retained in care at 1 year. With a median follow-up of 2.4 years in the PHARM-D RAPID ART group, 98% remained suppressed at last recorded viral load.

Conclusions

A pharmacist-driven model for rapid ART delivery decreases TVS with high rates of retention in care and durable VS. This model could improve clinical outcomes and increase program feasibility and sustainability.

Cost-Effectiveness Analysis of Pharmacist Adherence Interventions in People Living with HIV/AIDS in Pakistan

Background: Evidence has shown the positive impact of pharmacist involvement on the adherence and health outcomes of people living with HIV/AIDS. However, whether such intervention provides value for money remains unclear. This study aims to fill this gap by assessing the cost-effectiveness of pharmacist interventions in HIV care in Pakistan. Methods: A Markov decision analytic model was constructed, considering clinical inputs, utility data, and cost data obtained from a randomized controlled trial and an HIV cohort of Pakistani origin. The analysis was conducted from a healthcare perspective, and the incremental cost-effectiveness ratio (ICER) was calculated and presented for the year 2023. Additionally, a series of sensitivity analyses were performed to assess the robustness of the results. Results: Pharmacist intervention resulted in higher quality-adjusted life years (4.05 vs. 2.93) and likewise higher annual intervention costs than usual care (1979 USD vs. 429 USD) (532,894 PKR vs. 115,518 PKR). This yielded the ICER of 1383 USD/quality-adjusted life years (QALY) (372,406 PKR/QALY), which is well below the willingness-to-pay threshold of 1658 USD (446,456 PKR/QALY) recommended by the World Health Organization Choosing Interventions that are Cost-Effective. Probabilistic sensitivity analysis reported that more than 68% of iterations were below the lower limit of threshold. Sensitivity analysis reported intervention cost is the most important parameter influencing the ICER the most. Conclusion: The study suggests that involving pharmacists in HIV care could be a cost-effective approach. These findings could help shape healthcare policies and plans, possibly making pharmacist interventions a regular part of care for people with HIV in Pakistan.

Cost-Effectiveness of Anti-retroviral Adherence Interventions for People Living with HIV: A Systematic Review of Decision Analytical Models

BACKGROUND

Although safe and effective anti-retrovirals (ARVs) are readily available, non-adherence to ARVs is highly prevalent among people living with human immunodeficiency virus/acquired immunodeficiency syndrome (PLWHA). Different adherence-improving interventions have been developed and examined through decision analytic model-based health technology assessments. This systematic review aimed to review and appraise the decision analytical economic models developed to assess ARV adherence-improvement interventions.

METHODS

The review protocol was registered on PROSPERO (CRD42022270039), and reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Relevant studies were identified through searches in six generic and specialized bibliographic databases, i.e. PubMed, Embase, NHS Economic Evaluation Database, PsycINFO, Health Economic Evaluations Database, tufts CEA registry and EconLit, from their inception to 23 October 2022. The cost-effectiveness of adherence interventions is represented by the incremental cost-effectiveness ratio (ICER). The quality of studies was assessed using the quality of the health economics studies (QHES) instrument. Data were narratively synthesized in the form of tables and texts. Due to the heterogeneity of the data, a permutation matrix was used for quantitative data synthesis rather than a meta-analysis.

RESULTS

Fifteen studies, mostly conducted in North America (8/15 studies), were included in the review. The time horizon ranged from a year to a lifetime. Ten out of 15 studies used a micro-simulation, 4/15 studies employed Markov and 1/15 employed a dynamic model. The most commonly used interventions reported include technology based (5/15), nurse involved (2/15), directly observed therapy (2/15), case manager involved (1/15) and others that involved multi-component interventions (5/15). In 1/15 studies, interventions gained higher quality-adjusted life years (QALYs) with cost savings. The interventions in 14/15 studies were more effective but at a higher cost, and the overall ICER was well below the acceptable threshold mentioned in each study, indicating the interventions could potentially be implemented after careful interpretation. The studies were graded as high quality (13/15) or fair quality (2/15), with some methodological inconsistencies reported.

CONCLUSION

Counselling and smartphone-based interventions are cost-effective, and they have the potential to reduce the chronic adherence problem significantly. The quality of decision models can be improved by addressing inconsistencies in model selection, data inputs incorporated into models and uncertainty assessment methods.

Clinical, economic and humanistic outcomes of medication therapy management services: A systematic review and meta-analysis

Background: Medication therapy management (MTM) services is a method that can effectively improve patients’ conditions, but the efficacy of economic and humanistic outcomes remain unclear. This systematic review and meta-analysis aim to use economic, clinical and humanistic outcomes to evaluate the multi-benefits of MTM services.

Method: A systematic review and meta-analysis was conducted by retrieving PubMed, EMBASE, the Cochrane Library and ClinicalTrial.gov from the inception to April 2022. There were two reviewers screening the records, extracting the data, and assessing the quality of studies independently.

Results: A total of 81 studies with 60,753 participants were included. MTM services were more effective in clinical outcomes with decreasing the rate of readmission (OR: 0.78; 95% CI: 0.73 to 0.83; I2 = 56%), emergency department visit (OR: 0.88; 95% CI: 0.81 to 0.96; I2 = 32%), adverse drug events (All-cause: OR: 0.68; 95% CI: 0.56 to 0.84; I2 = 61%; SAE: OR: 0.51; 95% CI: 0.33 to 0.79; I2 = 35%) and drug-related problems (MD: −1.37; 95% CI: −2.24 to −0.5; I2 = 95%), reducing the length of stay in hospital (MD: −0.74; 95% CI: −1.37 to −0.13; I2 = 70%), while the economic and humanistic outcomes were less effective.

Conclusion: Our systematic review and meta-analysis demonstrated that MTM services had great ability to improve patients’ clinical conditions while the efficacy of economic and humanistic outcomes, with some of the outcomes showing high degree of heterogeneity and possible publication bias, required more future studies to provide stronger evidence.

Systematic Review Registration: [https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=349050], identifier [CRD42022349050].

Pharmacist-Involved Antiretroviral Stewardship Programs in People Living with HIV/AIDS: A Systematic Review

People living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS; PLWHA) frequently encounter antiretroviral (ARV) therapy-related problems. Clinical pharmacists with specialized training in ARV stewardship play an important role in managing these problems. However, there is a paucity of evidence to clarify the impact of clinical pharmacists' interventions on managing ARV therapy-related problems in PLWHA. Therefore, we aim to systematically review the literature to determine the nature and impact of pharmacists' interventions on managing medication-related problems in PLWHA. The review protocol was registered on International Prospective Register of Systematic Reviews (PROSPERO; CRD42020173078). Relevant records were identified from six electronic bibliographic databases (PubMed, Embase, EBSCOhost, ProQuest, Scopus, and the Cochrane Central Register) from their inception until September 2022. We included all randomized and nonrandomized interventional studies that were published in English. After the abstract and full-text screening, data were extracted from the selected studies, and the quality of the studies was assessed. The electronic database search and citation tracking identified two thousand and three citations. The review included 21 of these studies, involving 2998 PLWHA, published between 2014 and 2022. Pharmacists' interventions, working alone or in a multi-disciplinary team, comprised ARV medication review, management of adverse drug reactions (ADRs), therapeutic drug monitoring, prevention of drug interactions, and provision of drug information to PLWHA or the health care team. The pharmacist-involved interventions significantly reduced incorrect/incomplete ARV regimens, drug interactions, incorrect dosages, duplicate therapy, polypharmacy, administration errors, missing medication, wrong formulation, ADRs, and prescribing errors. Most studies reported that physicians usually accept more than 90% of the pharmacists' recommendations. ARV medication-related problems remain highly prevalent in PLWHA. Pharmacist-led interventions and stewardship significantly reduce ARV therapy-related problems in PLWHA and are widely accepted by physicians. Dedicated pharmacists with specialized training and credentialing in infectious diseases or HIV/AIDS have a great potential to improve health outcomes in PLWHA.

Patient Experience Evaluation of the CMO-Based Pharmaceutical Care Model vs Usual Care in People Living with HIV

Objective

To compare patient experience in a real-life population of people living with HIV (PLWH) who received pharmaceutical care (PC) based on the Capacity-Motivation-Opportunity (CMO) model versus the traditional model.

Methods

Prospective cohort study in PLWH receiving either CMO-based PC or traditional PC in Spain between October 2019 and June 2021 (24 weeks), performed by the pharmacy department of 14 Spanish hospitals. Participants were adult patients with a clinical diagnosis of HIV treated with antiretrovirals who had been monitored in the participating hospital pharmacies for >1 year. Patient experience (IEXPAC questionnaire), clinical outcomes (cholesterol, triglycerides, HDL, glycated haemoglobin, and blood pressure), adherence to treatment, virologic control and patient satisfaction were determined.

Results

Patient experience in the CMO group at week 24 was significantly better (7.6 vs 6.9) than in the traditional group, with a higher mean improvement. Adherence was better in the CMO group, particularly with regard to concomitant medications (53.2% to 91.7%, p<0.001); no changes were observed in the traditional group. Patient satisfaction improved in the CMO group vs the traditional group (48 vs 44, p<0.001).

Conclusion

To our knowledge, this is the first study to compare CMO vs traditional methodology. The CMO model showed an overall improvement in real-life patient experience, satisfaction, and adherence to treatment compared to the traditional methodology.

A qualitative inquiry into the patient-related barriers to linkage and retention in HIV care within the community setting

Background

People with the Human Immunodeficiency Virus (PWH) experience barriers to care within the community that impedes their progress from when they discover that they are HIV positive to becoming virally suppressed. For individuals with HIV to achieve sustained viral suppression, they must be linked to care to start receiving anti-retroviral therapy and remain retained in care for continuous treatment. However, HIV surveillance data shows that many PWH are not linked to care and become lost to continuous follow-up care. Although pharmacists, PWH, and social workers interact with one another and are aware of their roles in HIV care, their perspectives on barriers to linkage and retention in care have not been investigated collectively.

Objectives

Explore the perspectives of PWH, pharmacists, and social workers on barriers to linkage and retention of HIV care within the community setting.

Methods

Convenience sampling was used to recruit 15 stakeholders (five PWH, five community pharmacists, and five social workers) who participated in 1-h, semi-structured interviews based on three domains of the Patient-centered Medical Home Model including (1) experiences (individual and system-level barriers to care experienced by PWH), (2) activities (social workers and pharmacists initiatives that impact adherence to care)and (3) interventions (critical issues pharmacists can address in the community to engage PWH in their HIV care). We conducted a directed content analysis based on deductive coding. To establish rigor, we focused on Lincoln and Guba's criteria of rigorous qualitative methodology: credibility, dependability, confirmability, and transferability. Similarities and divergences of themes were discussed during data analysis and agreement was reached before interpretation.

Results

Emergent themes uncovered barriers to linkage and retention in HIV care as HIV-related stigma, having mental health illnesses including a history of substance abuse and social determinants of health such as homelessness, food insecurity, and insurance issues.

Conclusion

The perspectives of pharmacists, social workers, and PWH can provide insight into barriers that should be identified and addressed in people living with HIV to enhance their linkage and retention in care.

Advances in Pharmacy Practice: A Look towards the Future

This review looks at the factors that may influence practice in the future. Transformation could occur at 3 levels. Firstly, the traditional profession of the pharmacist as a dispenser of medicines is expanding. Secondly, the pharmacist’s activities are progressing into new healthcare fields. Thirdly, other changes are stimulated by global developments. This review may be helpful for pharmacy and healthcare leaders looking at the future configuration and aims of their pharmacy services.

Interventions and Impact of Pharmacist-Delivered Services for People Infected with COVID-19: A Systematic Review

Pharmacists are essential members of the healthcare team. The emergence of the novel coronavirus disease 2019 (COVID-19) pandemic has led pharmacists to undertake additional clinical roles. We aim to conduct a systematic review on the interventions and impact of pharmacist-delivered services in managing COVID-19 patients. We searched PubMed, Embase, Scopus, CINAHL plus, International Pharmaceutical Abstracts, and Web of Science from 1 December 2019 (the first case of COVID-19 emerged) to 13 January 2022 to retrieve the articles. Cochrane handbook and PRISMA guidelines were followed respectively to perform and report the review. The pharmacist-led interventions were reported following the Descriptive Elements of Pharmacist Intervention Characterization Tool (DEPICT) version 2. The protocol of systematic review was registered on PROSPERO (CRD42021277128). Studies quality was assessed with the modified NOS scale. In total, 7 observational studies were identified from 10,838 studies. Identification of dosage errors (n = 6 studies), regimen modifications (n = 5), removal of obsolete/duplicate medications (n = 5), identification and management of adverse drug reactions (n = 4), drug interactions prevention (n = 2), and physicians acceptance rate (n = 3) of therapy-related services delivered in-person or via tele-pharmacy were among the pharmacist-delivered services. Common interventions delivered by pharmacists also included optimizing the use of antibacterial, antivirals, and anticoagulants in COVID-19 infected patients. The acceptance of pharmacist-delivered services by physicians was high (88.5–95.5%). Included studies have described pharmacists’ beneficial role in managing patients with COVID-19 including detection, resolution, and prevention of medication-related problems, with physicians demonstrating high trust in pharmacists’ advice. Future research should assess the feasibility and scalability of such roles in real-world settings.

Barriers and Enablers for Adherence to Antiretroviral Therapy Among People Living With HIV/AIDS in the Era of COVID-19: A Qualitative Study From Pakistan

Background: With the increased availability of safe antiretroviral therapy (ART) in recent years, achieving optimal adherence and patient retention is becoming the biggest challenge for people living with HIV (PLWH). Care retention is influenced by several socioeconomic, socio-cultural, and government policies during the COVID-19 pandemic. Therefore, we aim to explore barriers and facilitators to adherence to ART among PLWH in Pakistan in general and COVID-19 pandemic related in particular.

Methods: Semi-structured interviews were conducted among 25 PLWH from December 2020 to April 2021 in the local language (Urdu) at the ART centre of Pakistan Institute of Medical Sciences, Islamabad, Pakistan. Interviews were audio-recorded in the local Urdu language, and bilingual expert (English, Urdu) transcribed verbatim, coded for themes and sub-themes, and analyzed using a phenomenological approach for thematic content analysis.

Results: Stigma and discrimination, fear of HIV disclosure, economic constraints, forgetfulness, religion (Ramadan, spiritual healing), adverse drug reactions, lack of social support, alternative therapies, and COVID-19-related lock-down and fear of lesser COVID-19 care due to HIV associated stigma were identified as barriers affecting the retention in HIV care. At the same time, positive social support, family responsibilities, use of reminders, the beneficial impact of ART, and initiation of telephone consultations, courier delivery, and long-term delivery of antiretrovirals during COVID-19 were identified as facilitators of HIV retention.

Conclusion: Improving adherence and retention is even more challenging due to COVID-19; therefore, it requires the integration of enhanced access to treatment with improved employment and social support. HIV care providers must understand these reported factors comprehensively and treat patients accordingly to ensure the continuum of HIV care. A coordinated approach including different stakeholders is required to facilitate patient retention in HIV care and consequently improve the clinical outcomes of PLWH.

Stigma, Social Support, Illicit Drug Use, and Other Predictors of Anxiety and Depression Among HIV/AIDS Patients in Pakistan: A Cross-Sectional Study

Introduction: Anxiety and depression in people living with HIV/AIDS (PLWHA) can lead to non-adherence to antiretroviral therapy (ART), morbidity, and mortality. Therefore, assessing the stigma, social support, and other determinants of anxiety and depression in PLWHA are important for developing further interventions. Methods: An institution-based cross-sectional study was conducted in 505 PLWHA, approached through systematic sampling, who paid routine visits to the ART center, Pakistan Institute of Medical Sciences (PIMS), Islamabad. Data was collected by pretested validated hospital anxiety and depression scale (HADS). Version 26 of the SPSS was used to apply Logistic regression analysis to identify determinants, and the 95% confidence interval (CI) adjusted odds ratio (AOR) was calculated to assess the magnitude of the relationships. Results: In PLWHA, the prevalence of co-morbid depression and anxiety was 80%. Separately, 89.9% had depression, and 80.3% had anxiety. Use of illicit drugs [AOR = 1.87, 95% CI (1.01, 3.27)], low social support [AOR = 1.21, 95% CI (1.02, 2.25)], being male [AOR = 2.21, 95% CI (1.11, 5.49)], and HIV related stigma [AOR = 2.48, 95% CI (1.25, 6.02)] were significant predictors of depression. Having detectable viral load [AOR = 3.04, 95% CI (1.04, 8.86)], young age [AOR = 5.31, 95% CI (1.19, 29.39)], no formal education [AOR = 21.78, 95% CI (4.03, 117.62)], low [AOR = 1.70, 95% CI (1.12, 6.93)] or moderate [AOR = 2.20, 95% CI (1.79, 6.09)] social support, illicit drugs addiction [AOR = 1.17, 95% CI (1.03, 2.55)], and HIV stigma [AOR = 54.3, 95% CI (21.20, 139.32)] had a remarkable association with anxiety. Conclusions: Given the high prevalence of anxiety and depression among PLWHA, the Pakistan Ministry of Health should focus more on monitoring mental health, expanding mental health services, and developing interventions based on identified factors to treat depression and anxiety among PLWHA.

The economic impact of pharmacist care for people living with HIV/AIDS: A systematic review

Background and objective

Methods

Results

Conclusions

•

The role of pharmacists in HIV care is expanding, and it is recommended by the World Health Organization and the American Society of Health-System Pharmacists. Therefore, we attempted to find the economic impact of these services.

•

We discovered four such studies, each with minor differences in study intervention, study population, and follow-up duration, making it difficult to generalise their findings.

•

Studies have shown that pharmacist interventions have economic benefits; however, future controlled and real world studies to determine the economic benefits, in the long run, are required to strengthen the evidence.

The impact of clinical pharmacist services on patient health outcomes in Pakistan: a systematic review

BACKGROUND

The pharmacist's role shifts from dispensing to bedside care, resulting in better patient health outcomes. Pharmacists in developed countries ensure rational drug use, improve clinical outcomes, and promote health status by working as part of a multidisciplinary team of healthcare professionals. However, clinical pharmacist services on healthcare utilization in low-and middle-income countries (LMICs) like Pakistan are unclear. As a result, we aim to systematically review pharmacists' clinical roles in improving Pakistani patients' therapeutic, safety, humanistic, and economic outcomes.

METHODS

We searched PubMed, Scopus, EMBASE, CINAHL, and Cochrane Library for relevant articles published from inception to 28th February 2021. All authors were involved in the screening and selection of studies. Original studies investigating the therapeutic, humanistic, safety, and economic impact of clinical pharmacists in Pakistani patients (hospitalised or outpatients) were selected. Two reviewers independently assessed the risk of bias in studies, and discrepancies were resolved through mutual consensus. All of the included studies were descriptively synthesised, and PRISMA reporting guidelines were followed.

RESULTS

The literature search found 751 articles from which nine studies were included; seven were randomized controlled trials (RCTs), and two were observational studies. Three RCTs included were having a low risk of bias (ROB), two RCTs were having an unclear ROB, while two RCTs were having a high ROB. The nature of clinical pharmacist interventions included one or more components such as disease-related education, lifestyle changes, medication adherence counselling, medication therapy management, and discussions with physicians about prescription modification if necessary. Clinical pharmacist interventions reduce medication-related errors, improve therapeutic outcomes such as blood pressure, glycemic control, lipid control, CD4 T lymphocytes, and renal functions, and improve humanistic outcomes such as patient knowledge, adherence, and health-related quality of life. However, no study reported the economic outcomes of interventions.

CONCLUSIONS

The findings of the studies included in this systematic review suggest that clinical pharmacists play important roles in improving patients' health outcomes in Pakistan; however, it should be noted that the majority of the studies have a high risk of bias, and more research with appropriate study designs is needed.