HIV Pharmacy Services across SWAGNET

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HIV Pharmacy Services across SWAGNET

• Carole Wells
• Principal Pharmacist
• HIV Services Team Leader
• St Georges

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Summary

• Who provides the services?
• What services are provided?
• When are services provided?
• How do you access the services?
• Future service developments

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Who provides the service?

• Mayday Dan Godfrey 10 sessions (3)
• Kingston Sharon Byrne 3 sessions (2)
• St Helier Donna Johnson 2 sessions (2)
• Roehampton Carole Wells 2 sessions(1)

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Who provides the service at St Georges?

• Pharmacists
• Donna Johnson 8 sessions (3)
• Sharon Byrne 7 sessions (3)
• Carole Wells 7 sessions (1)
• C Grade vacant 10 sessions

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Who provides the service at St Georges?

• Senior Technicians
• Sarla Maisuria Adult
• Tracey Perkins Paeds.
• Assistant
• Garth Fairclough

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Pharmacy staff roles

• Assistant - ordering, pre-packing, dispensing,
  topping up stocks
• Technician - dispensing, technical check, basic
  counselling, dispensary management
• Pharmacist - adherence support, information
  advice, input to protocols, trials, training,
  formulary input, financial reporting,
  prescription screening

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What services are provided?

• Supply of medication (Dispensing)
• Adherence Support
• Information and advice

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Supply of Medication

• Purchasing / contracting
• e.g. Combivir 270 v 400 / month
• Ordering
• Pre-packing / over labelling
• Topping up stocks
• Dispensing
• e.g. 15,000 Combivir / month
• 3,500 tenofovir / month

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Adherence Support - Rationale

• lt95 adherence - poor outcomes (Paterson et
  al,2000)
• 100 adherence - better outcomes (Fischl et al,
  2000, Mannheimer et al, 2002)
• 10 improvement - 21 ? disease progression
  (Bansberg et al, 2001)
• maintaining undetectable VL - ? hospital costs
  (Stansell et al, 2000)

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Promoting Good Adherence

• BHIVA / MSSVD guidelines on the provision of
  adherence support to individuals receiving
  antiretroviral therapy (2002 - draft)
• 20 evidence based recommendations for provision
  of adherence support
• St Georges Queen Marys Model to support HIV
  Medication Adherence (April 2001)

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Suggested Pharmacist Appointments Schedule

• 6,14 week follow up
• Ongoing /maintenance every 6months
• Changing ART

• Newly diagnosed / transfer of care
• Considering / about to start
• Starting ART
• 2 week post-start follow up

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Considering ART Discussion

• Expectations / patients priorities
• Understanding of disease
• VL
• CD4
• need for ART
• adherence
• resistance

• Lifestyle assessment
• routines
• work
• home circumstances
• storage facilities
• health medication history
• diet restrictions
• recreational drugs

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Considering ART Discussion

• Offer placebo trial
• Discuss possible side effects - general
• Possible food restrictions
• Offer literature
• ARV drugs
• other aspects of HIV
• group specific

• Reinforce need for good adherence
• Demonstrate
• medications
• adherence devices

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Starting ART Discussion

• Review / confirm understanding of the above
• Provide specific instructions for regimen
  selected confirm understanding
• Reinforce importance of adherence
• Provide adherence devices if required

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Pharmacist Adherence follow up - 2, 6, 10, 14
weeks 6monthly

• Full assessment of adherence
• other issues
• consider TDM if appropriate

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Changing ART Discussion

• Full assessment of adherence -if ART has failed
• Repeat lifestyle assessment
• As per Starting ART protocol

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Prioritising Patients for Pharmacist Support

• Likely to start ART in the next few weeks
• Patients who are starting ART
• Changing ART due to failure or toxicity
• Suspected / known adherence problems
• Self referrals

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Reasons for Pharmacist Referral
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Adherence Support Clinics at St Georges
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Adherence Support Clinics
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How do you access the services?

• Booked appointments - in advance
• through reception
• via computer
• Walk in - availability depends on patient numbers

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In the Future

• Consolidate adherence support
• Develop routine multidisciplinary assessment of
  adherence
• Evaluation of Pharmacy Services
• Specialist Pharmacist on call?
• Implementation of pharmacists as supplementary
  prescribers?

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Conclusion

• Aim to provide a service that makes use of
  medication
• safe
• effective
• cost-effective
• enables patients to be
• informed
• able
• committed to treatment