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A career as a specialist HIV pharmacist

Haley Hill was previously staff editor at Hospital Pharmacist

Blood tests

As a specialty, HIV therapy is relatively young. It has only been in the past 15 years or so that medical consultants have been trained to specialise in HIV and, in some small HIV units, pharmacists still work across more than one specialty. Because the treatment is entirely drug-based, input from pharmacists is respected as an invaluable contribution to the management of HIV therapy.

Counselling

Drug therapy for patients with HIV is generally a life-long commitment. Appropriate counselling is fundamental to ensure compliance and ultimately the best patient outcome. Heather Leake Date, principal pharmacist for HIV and sexual health at Brighton and Sussex University Hospitals NHS Trust, said: “HIV therapy requires a high level of adherence to work effectively. An adherence rate of approximately 95 per cent is required for effective treatment.” She said that it is also important to assess the patients’ health beliefs and ascertain any barriers to treatment that there may be: “You have to have some understanding of health psychology to counsel HIV patients and you have to use different approaches in supporting patients with their treatment and dosing.

Interactions

Elizabeth Davies, lead directorate pharmacist for HIV and genito-urinary medicine at Chelsea and Westminister Hospital, London, said that there are many significant interactions between anti-HIV drugs and other drug therapies that the patient may be taking: “Such interactions are well documented and the dose adjustments can be complicated,” she said. Ms Davies gave the example of rifampicin interacting with antiretrovirals. “There are many HIV patients who have co-existing tuberculosis, therefore rifampicin is commonly prescribed with antiretrovirals.” She said that the summary of product characteristics for most antiretrovirals contains a statement regarding the interaction with rifampicin and lists recommended dosage adjustments. Ms Leake Date gave an example of a patient taking antiretrovirals and using a fluticasone inhaler who developed Cushing’s syndrome as a result. “Patients do not always perceive inhaled preparations as being a drug, and this is where counselling and patient education comes in,” she explained. Ms Leake Date also highlighted the importance of educating the patient on the possible interactions between HIV therapy and recreational drugs and herbal supplements.

Ms Davies said that recommended dosing adjustments are based on pharmacokinetic studies rather than therapeutic drug monitoring (TDM), “although TDM does also have a place in the monitoring of HIV therapy,” she said. Ms Leake Date thinks that TDM is likely to play an important part in HIV treatment in the future, particularly in protease inhibitor therapy. “Protease inhibitors are substrates for cytochrome P450 and P-glycoprotein, which results in a potential for marked inter-patient variability of drug levels,” she explained. “Non-nucleoside reverse transcriptase inhibitors are also metabolised by cytochrome P450 and can be monitored by TDM, but with nucleoside reverse transcriptase inhibitors it is the intracellular levels that are important, so this is more tricky to monitor,” she said. At present, TDM is only being performed on a small scale, but it is likely that it will start to be used more widely: “This is an area in which the pharmacist may take on an extended role in the future,” she said.

Managing therapy

Ms Davies explained that managing patients’ therapy is an important aspect of an HIV pharmacist’s role. “The patients will be taking these drugs for life. It is important that therapy is managed seamlessly so it does not interfere with their work and other aspects of their life,” she said.

At Chelsea and Westminster Hospital, an e-mail clinic “Option E” has been set up. Ms Davies explained that the patients come to the clinic out-of-hours, for example in the evening, and have their blood sample taken by a nurse. The blood results are reviewed and interpreted and then e-mailed to the patient. Having completed a supplementary prescribing course, Ms Davies has been able to write the prescription. The drugs are dispensed and delivered to the patient’s address. “This is a relatively new service and, currently there are around 75 patients registered with the Option E clinic,” she said.

Ms Leake Date said that at her hospital there is a team approach to the management of patient therapy. She explained that the multidisciplinary team have weekly meetings. “If the viral load is detectable (ie, >50 copies/ml), the patient case is presented to the team and discussed,” she said. “There may be several explanations for a detectable viral load, for example recently initiated therapy that has not had a chance to work.” She explained that the possible causes are discussed within the team and a decision for the future management of therapy is made. “A pharmacist’s input is fundamental in these meetings,” she said.

New drugs

“Anti-HIV drug development is a fast-moving area, with the US Food and Drug Administration often fast-tracking drugs for approval,” explained Ms Davies. This means new anti-HIV drugs are often available for use before they have been granted a UK product licence. Ms Davies said that, in her role, she is involved in managing the entry of such drugs. “This involves assessing eligibility criteria and liaising with pharmaceutical companies,” she said. She explained that she contributes to drug guidelines within her trust and is involved with the London HIV New Drugs Group. The group reviews the evidence for new drugs, looks at the clinical- and cost-effectiveness of the drugs and ultimately approves them (or not) for use.

Clinical trials

“Because of the rapid development of new drugs, clinical trials are another aspect to my role as lead HIV pharmacist,” Ms Davies said. “Currently we are conducting approximately 45 HIV clinical trials.” HIV pharmacists will inevitably have some involvement in clinical trials and need to be familiar with European Union directives and good clinical practice international standards for conducting such trials, she explained.

Funding

Ms Davies explained that because anti-HIV drugs are expensive and therapy is life-long, the drug budget she manages forms a significant proportion of the trust’s overall drug budget. “I have to liaise with the finance managers, the London HIV Consortium, consultant medical staff and the pharmaceutical industry on funding issues,” she said.

In London, the commissioning of HIV therapy has been recently centralised via the London HIV Consortium. “This allows patients to receive the same [approved] therapy from whichever hospital they attend,” she said. She pointed out that this central commissioning is only for treatment centres in London and hence there may still be variations in accessibility to therapies across the rest of the UK.

Summary

HIV as a specialty is a fast-moving area, with new drugs being released regularly, making it exciting and challenging. However, despite the increasing number of new cases every year, HIV is still a relatively small specialty, with few positions for pharmacists across the UK compared with other areas of clinical pharmacy. “This could potentially limit career progression for pharmacists wishing to remain working in HIV. However, because the role is so diverse, the skills you learn as an HIV pharmacist are transferable to other clinical specialties and operational positions within pharmacy,” Ms Davies explained.

Citation: Tomorrow's Pharmacist URI: 10004444

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