key: cord-0956833-d82gfl3m
authors: Sorbera, Maria; Fischetti, Briann; Khaimova, Rebecca; Niewinski, Mateusz; Wen, Kelly
title: Evaluation of virologic suppression rates during the COVID‐19 pandemic with outpatient interdisciplinary HIV care
date: 2021-03-16
journal: J Am Coll Clin Pharm
DOI: 10.1002/jac5.1422
sha: bcd21c6e8d3eecdba57a9f33a4e58ae5c6e04a62
doc_id: 956833
cord_uid: d82gfl3m

INTRODUCTION: The Coronavirus Disease 2019 (COVID‐19) pandemic has presented social distancing challenges leading healthcare systems to adapt and utilize telemedicine platforms more than ever before. Reducing patient exposure to COVID‐19 became a primary concern, especially for populations at an increased risk for severe illness, such as human immunodeficiency virus (HIV) positive patients. OBJECTIVES: The primary objective of this study was to measure the impact of pharmacy services including telehealth through the percentage of virologically suppressed patients (HIV ribonucleic acid [RNA] < 200 copies/mL) during the pre‐COVID and post‐COVID time periods. Secondary objectives included the percentage of patients with undetectable viral loads (HIV RNA < 20 copies/mL), percentage of patients with cluster of differentiation 4 (CD4) cell counts greater than 200 cells/mm(3), and changes in CD4 cell counts and percentages pre‐COVID and post‐COVID. METHODS: This was a retrospective chart review at a single center HIV primary care clinic in Brooklyn, NY evaluating electronic medical records (EMRs) of 211 HIV‐positive patients. Pre‐COVID was defined as 1 year prior to March 13, 2020, and post‐COVID was defined as March 13 to July 20, 2020. RESULTS: Viral load suppression rates for pre and post‐COVID were 88.6% and 85.3%, respectively (P = .28). Undetectable viral load rates for pre and post‐COVID were approximately 81.5% and 74.4% (P = .096). Mean CD4 cell counts and percentages were 617 cells/mm(3) and 29% for pre‐COVID, and 460 cells/mm(3) and 22% for post‐COVID. CD4 cell counts greater than 200 cells/mm(3) pre‐COVID and post‐COVID was 92.6% and 78.3%, respectively (P = .001). CONCLUSION: Utilization of pharmacy services including telehealth, may allow clinical pharmacists to collaboratively provide remote services without jeopardizing patient outcomes. Larger studies are needed to confirm these findings, and display the long‐term impact and satisfaction of these services.

On March 13, 2020, the United States declared the Coronavirus Disease 2019 (COVID-19) a national emergency. Since November 2020, COVID-19 has been confirmed in over 102 million cases worldwide, 1 with 25 million confirmed cases in the US. 2 A respiratory infection that can be spread from person to person, COVID-19 may present with a range of mild to severe symptoms including fever, cough and shortness of breath. Individuals at a heightened risk are believed to be older adults and those with preexisting underlying comorbidities such as cardiovascular disease, diabetes, and respiratory illnesses. 3 The Centers for Disease Control identified people living with Human Immunodeficiency Virus (PLWH) as a population that may be at an increased risk for severe illness from COVID-19 compared with those of the general population. 4, 5 Data regarding the actual disease risk among PLWH is lacking. D'Souza et al distributed a telephone survey to asses symptom and testing prevalence to 3411 patients, of whom 61% were human immunodeficiency virus (HIV)-positive. Symptoms were similar among HIV-positive and negative patients; however, a higher percentage of PLWH tested positive for COVID. 6 These data differs from other reports displaying PLWH have similar positivity rates. 7 PLWH are a unique population with uncertain and conflicting data regarding their risks for COVID-19 making it critical for healthcare professionals to truly understand how the HIV epidemic and COVID-19 pandemic comingle and affect one another.

A syndemic occurs when two or more epidemics interact synergistically to produce an increased burden of disease. 8 The coexistence of the global COVID-19 pandemic and HIV/acquired immunodeficiency syndrome (AIDS) epidemic mutually enhance vulnerability which can significantly affect the overall health of a population. 4 Of those infected with HIV in the United States, nearly half are 50 years of age or older. 4, 9 Although older patients living with HIV have the potential threat of negative outcomes due to COVID-19, it is believed younger HIV-positive individuals are also at risk following the recent data displaying the vulnerability of populations aged 18-49 years. 4 In addition, immunocompromised HIV-positive individuals with lower CD4 cell counts, unsuppressed HIV RNA viral loads, and/or the presence of other comorbidities may be at an even greater risk of infection and complications. Aside from health complications, PLWH can also be confronted with further challenges including mental health, substance abuse, and societal stigmas creating a complex syndemic when occurring simultaneously with COVID-19. 10 In order to ensure optimal health outcomes and maintain viral load suppression rates during this global pandemic in PLWH, it is critical to prevent lapses in care, and ensure adherence to antiretroviral therapy (ART). Viral load suppression is both an individual and public health concern as patients on ART with undetectable viral loads preserve their health and significantly reduce the risk of transmitting the virus along with other opportunistic infections.

Amidst the pandemic, telehealth provided a platform for patients to navigate the health system and access routine care while reducing their exposure. 11 to establish care with an infectious disease physician and are seen by an interdisciplinary team including a clinical pharmacist. Patients who may prefer one-on-one visits are able to be seen by one of the physician assistants or nurse practitioners. As of January 2020, approximately 45% of patients were seen in the interdisciplinary model and 55% in the one-on-one format. Interdisciplinary clinic occurs Monday to Friday with pharmacotherapy clinic having three sessions per week.

During interdisciplinary clinic, medical residents see the patients first.

Once the residents have completed their visit, the infectious disease physician, clinical pharmacist (including pharmacy residents), and students then round into each clinic room. The medical resident presents the patient to the team, and from there the team discusses and agrees on a treatment plan. The clinical pharmacist in the room focuses on medication reconciliation, patient assessment, clinically significant drug-drug interactions, and chronic disease state management, in addition to e-prescribing medications to the patient's pharmacy. Commonly, patients with uncontrolled chronic disease states seen in interdisciplinary clinic are referred to pharmacotherapy clinic for further management.

After COVID-19 was declared a national emergency, the PATH Center transitioned to mainly virtual visits with the goal to ensure continuity and optional care while preventing lapses in medication adherence, specifically with ART. As an interdisciplinary clinic, clinical pharmacists play a critical role in patient care through collaborative drug therapy management. Pharmacotherapy visits and medication management was completely transitioned to telemedicine for the first time. This study describes the steps taken by the clinical pharmacists at the PATH Center during the COVID-19 pandemic in a joint effort with physicians, nurses, and case workers to manage patients remotely, and evaluates the impact on patient outcomes. 

There was a total of 211 patients with medication refill requests sent to the clinical pharmacists with the majority of patients being Black or African American (76.77%) having a mean age of 53 years and identifying as male (57%). All patients included did have prescription coverage with the majority being federally insured through Medicaid.

Overall, patients were being managed on an Integrase inhibitor (INSTI)-based antiretroviral regimen (81.9%) with 45.2% on bictegravir, 18.6% on dolutegravir, and 18.1% on elvitegravir, respectively. Additional baseline characteristics can be found in Table 1 . In addition, the lack of data regarding chronic disease states management other than HIV was identified as a limitation. This is mainly due to the clinic requiring patients to present for laboratory work only when medically necessary in an attempt to limit patient exposure. It This study provided evidence that pharmacy services including telehealth may be an option to collaboratively manage PLWH in order to maintain virologic suppression rates when in-person visits are not feasible or safe. It is believed that the refill authorizations performed by the clinical pharmacists, which included adherence assessments, prevented gaps in medication use and likely contributed to the nonstatistical difference in viral loads pre-COVID and post-COVID.

Beyond the pandemic, remote services can be an alternative for stable HIV-positive patients as a supplement to in-person visits. Access to resources will need to be addressed to ensure all patients eligible for virtual visits have the opportunity.

Utilization of pharmacy services including telehealth may allow clinical pharmacists to collaboratively provide remote services without jeopardizing patient outcomes. The results from this study display the potential interdisciplinary role clinical pharmacists have in maintaining viral load suppression rates in PLWH through virtual services. Larger, future studies are needed to confirm these findings, and display the long-term impact and satisfaction of these services.

The authors declare no conflicts of interest.

https://orcid.org/0000-0003-3394-7033

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Evaluation of virologic suppression rates during the COVID-19 pandemic with outpatient interdisciplinary HIV care