Antiretrovirals for People with HIV on Dialysis.

In the era of widespread use of antiretroviral therapy (ART), people with HIV (PWH) have a near-normal life expectancy. However, PWH have high rates of kidney diseases and progression to end-stage renal disease at a younger age. PWH have multiple risks for developing acute and chronic kidney diseases, including traditional risk factors such as diabetes, hypertension, and HIV-related factors such as HIV-associated nephropathy and increased susceptibility to infections and exposure to nephrotoxic medications. Despite an improvement in access to kidney transplant among PWH, the number of PWH on dialysis continues to increase. The expansion of the number of antiretrovirals (ARVs) and kidney replacement modalities, the absence of pharmacokinetic data, and therapeutic drug monitoring make it very challenging for providers to dose ARVs appropriately leading to medication errors, adverse events, and higher mortality. Most of the recommendations are either based on small sample size studies or extrapolated based on physiochemical characteristics of ART. We aim to review the most available and most current literature on ART in PWH with renal insufficiency and ART dosing recommendations on dialysis to ensure that PWH are provided with the safest and most effective ART regimen.

Experiences to date with the logistical management of long-acting cabotegravir and rilpivirine.

The logistical management of an injectable therapy for the treatment of HIV can be expensive, time consuming, frustrating and riddled with barriers. In this Commentary, we describe our experiences to date with acquiring, storing, handling, administering and billing for long-acting cabotegravir and rilpivirine through four scenarios, each of which have presented their own unique obstacles and learning curves. At the time of writing, we have successfully transitioned four patients from the CUSTOMIZE trial to long-acting cabotegravir and rilpivirine. In doing so, we encountered a variety of barriers to acquiring, handling and administering the medication for both insured and uninsured patients; it is expensive, on a limited number of insurance formularies, and often requires a prior authorization from the provider. Cold-chain handling of the injectable therapy, along with individual patient characteristics, present barriers to management and administration of this therapy. Whilst a seemingly very attractive option for the treatment of HIV-1 infection in adults, long-acting cabotegravir and rilpivirine present a variety of challenges to pharmacists, providers and clinic staff on how to obtain it for and administer it to the patient. We plan to continue documenting our experiences, progress and successes, or lack thereof, in order to fine-tune our process and share with others.

The Unanticipated Benefits of PrEP for Young Black Gay, Bisexual, and Other Men Who Have Sex with Men.

Pre-exposure prophylaxis (PrEP) is effective at reducing new HIV infections among adherent users. However, there are potential benefits of PrEP beyond HIV prevention that remain understudied, particularly among young Black gay, bisexual, and other men who have sex with men (MSM). In 2018, we conducted six focus groups (n = 36) in four midwestern cities: Milwaukee, WI; Minneapolis, MN; Detroit, MI; and Kansas City, MO with current and former PrEP users who identified as Black MSM. The focus groups covered medical care and provider experiences, patterns of PrEP use and adherence, relationships while on PrEP, and PrEP stigma. Results revealed four unanticipated benefits of PrEP for young Black MSM: (1) improved engagement in medical care, (2) reduced sexual and HIV anxiety, (3) increased sexual comfort and freedom, and (4) positive sexual relationships with people living with HIV. Findings from this study fill a gap in our understanding of the potential benefits of PrEP beyond HIV prevention. Public health campaigns and messaging around PrEP should incorporate such benefits to reach young Black MSM who may be motivated by benefits beyond HIV prevention.

Health Literacy and Medication Adherence Among Patients Treated in a Free Health Clinic: A Pilot Study.

BACKGROUND: A patient's health literacy is not routinely assessed during visits with a health care provider. Since low health literacy is a risk factor for poor health outcomes, assessing health literacy should be considered as part of the standard medical workup. OBJECTIVES: To evaluate the health literacy levels and medication adherence of patients treated by pharmacists in both the general medicine and the chronic care clinics at an urban free health clinic. METHODS: Eligible patients from the free health clinic completed the Rapid Estimate of Adult Literacy in Medicine (REALM), a health literacy measurement tool, during their clinic visit in 2011. Medication adherence was self-reported by the patients. RESULTS: A total of 100 patients participated (mean age = 48). The majority of participants were female (56%) and white (55%). Most (64%) of the patients scored at a high school reading level according to REALM. Only 21% of participants read at a seventh- to eighth-grade level. Overall medication adherence rate was 73%. Forgetting to take medication was the most popular reason given for nonadherence. CONCLUSION: Disease state and adherence were significantly related in patients with HIV/AIDS and hypertension. Patient's ethnicity was significantly associated with literacy levels (P < .05). Although patients' literacy levels were not significantly associated with self-reported adherence in this population, availability of a patient's baseline health literacy level as a part of the medical record may help clinicians to individualize their interaction based on the patient's health literacy level in order to achieve better health outcomes, including improved medication adherence, especially for underserved populations.

Expanding the role of a pharmacist as a sexually transmitted infection provider in the setting of an urban free health clinic.

BACKGROUND: This study was designed to explore patient perceptions of sexually transmitted infection (STI) screening and treatment provided by a pharmacist in an urban free health clinic. With health care reform on the horizon, the role of a pharmacist is quickly evolving, making it necessary for pharmacists to sharpen their clinical skills to accurately serve their patients. One in 4 American adolescents is infected with an STI, placing pharmacists in a position to help decrease STI transmission and complications. METHODS: To assess patient attitudes toward pharmacists as STI providers, a convenience sample of patients who presented to an urban free health clinic in 2009 for STI testing were given a confidential survey of 12 statements relating to STI testing and the acceptability of a pharmacist-provider. RESULTS: Patients expressed overwhelming support of a pharmacist as their STI treatment provider (79.9%). The services they were comfortable with a pharmacist performing included running a urine screen (95.1%), performing a physical examination (81.1%), treating STIs (98.2%), and discussing STI test results (93.9%). Patients also approved of pharmacists working under a collaborative practice agreement with a physician (97.6%). CONCLUSIONS: Acceptance by patients of a pharmacist-provider for STI screening may lead to the adoption of pharmacists as providers in STI screening clinics. This would decrease barriers to treatment (eg, stigma and lack of access), increase accessibility to care, and greatly improve the identification of those infected with STIs, ultimately leading to a decrease in the spread and long-term sequelae of untreated STIs.