The Patient-Centered HIV Care Model (PCHCM) integrates the services of community-based HIV specialized pharmacists and HIV medical providers to deliver patient-centered care for people with HIV. PCHCM expands upon the medication therapy management model1 by including information sharing between partnered pharmacy and clinic teams; collaborative medication-related action planning between pharmacists, medical providers, and patients; and quarterly follow-up pharmacy visits. Patients participating in the intervention had improved retention in care and viral suppression rates.
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Despite the known benefits of viral suppression, not all people with HIV are virally suppressed. A lack of coordinated HIV care may contribute to poor retention in care and lower likelihood of reaching viral suppression. Even when people with HIV receive care from multiple health care providers, they often receive all their medications from one pharmacy, making the pharmacist a key point of contact. Given the complexities in selecting appropriate regimens and ongoing monitoring necessary to identify drug resistance, adverse events, drug interactions, contraindicated therapy, and poor adherence, providers should work collaboratively with pharmacists in a multidisciplinary team to support patients’ complex needs, including their needs related to medication adherence.
Pharmacists are trained to help patients manage and adhere to complex medication regimens and can assist healthcare providers with selection or modification of appropriate antiretroviral therapy regimens. Community pharmacists with HIV specialty training also have in-depth knowledge of interactions between antiretroviral therapy and medications used to treat comorbid conditions, medication adverse events that can affect adherence to and effectiveness of treatment, and patient education and adherence counseling.
Medication therapy management1 is a distinct service or group of services provided by health care providers, including pharmacists, to ensure the best outcomes for patients.
Medication therapy management consists of five key components:
- Medication therapy review
- Personal medication record
- Medication-related action plan
- Intervention and/or referral
- Documentation and follow-up
The medication therapy review is a process of assessing medication regimens for indication, effectiveness, safety, and adherence. It may also include review of response to therapy and appropriateness of each medication. The review could be comprehensive where all of a patient’s medications and health conditions are reviewed by the pharmacist, or it can be targeted toward specific medications or medical conditions.
The personal medication record is a comprehensive record of each patient’s current medications, compiled by the pharmacist for use by the patient. A medication-related action plan is a list of actions for the patient to use in tracking progress for self-management. Intervention and/or referral occurs when the pharmacist provides consultative services and intervenes to address medication-related problems. Referral to a healthcare provider may occur when the patients’ needs extend beyond the pharmacists’ expertise or scope. The final steps in the medication therapy management model include documentation of services provided and scheduling of a follow-up visit, as needed.
The PCHCM structure expanded upon the existing medication therapy management model to be inclusive of clinical medical providers. The key differences between PCHCM and medication therapy management are:
- Information sharing between pharmacy and clinic teams
- Collaborative medication-related action planning between pharmacists, medical providers, and patients
- Quarterly follow-up pharmacy visits
In order for the pharmacists to conduct broader and more precise medication therapy management, nursing staff provided the pharmacists with patients’ medical history. This information included current and previous medical conditions, HIV viral load and CD4 test results, other laboratory test results, current and discontinued medications, drug allergies, immunizations, and social history.
To assess treatment response and identify potential medication-related adverse events, pharmacists also:
- Proactively monitored prescription refills—consistent with the HIV-specialized pharmacy program of the participating pharmacy—to ensure continuous adherence to treatment
- Provided individualized adherence support
- Monitored medical history, including clinical and laboratory test results
When issues were identified during the medication therapy management sessions or review of patients’ medical and prescription refill histories, the pharmacists worked directly with their partnered clinic to make recommendations and discuss potential action plans and intervention strategies. Pharmacists, patients, and medical providers worked together to implement the action plans, and progress was reviewed at subsequent visits.
The original evaluation study was conducted in 10 sites each composed of a medical clinic and one or two community-based retail pharmacies. Seven of the 10 sites received RWHAP funding. Retention in care, viral suppression, and sustained viral suppression were compared pre- and post-intervention for 765 participants between August 2014 and September 2016. All three outcomes significantly improved for participating patients.
|Evaluation data||Medical record data, including lab test results|
Retention in care: at least one medical visit with a physician, nurse practitioner, or physician assistant, in each 6-month period of the 12-month measurement period with a minimum of 60 days between medical visits.
Viral suppression: an HIV viral load of < 200 HIV RNA copies/mL at the last test in the 12- month measurement period.Sustained viral suppression: HIV viral loads < 200 HIV RNA copies/mL at the last two test results in the 12-month measurement period.
Retention in care:
Sustained viral suppression:
Sources: (1) Byrd KK, Hou JG, Bush T, et al. Adherence and viral suppression among participants of the Patient-centered Human Immunodeficiency Virus (HIV) Care Model Project: A collaboration between community-based pharmacists and HIV clinical providers. Clin Infect Dis. 2020;70(5):789-797. doi:10.1093/cid/ciz276; (2) Byrd KK, Hardnett F, Clay PG, et al. Retention in HIV care among participants in the Patient-Centered HIV Care Model: A collaboration between community-based pharmacists and primary medical providers. AIDS Patient Care STDS. 2019;33(2):58-66. doi: 10.1089/apc.2018.0216
Integration of clinic and pharmacy services. Sites had to revise clinic and pharmacy procedures to accommodate the implementation of the intervention and to ensure collaboration between community-based HIV specialized pharmacists and medical clinics. Sites integrated services from community-based HIV specialized pharmacists with medical clinic providers to deliver patient-centered care for people with HIV, in addition to refilling prescriptions. In addition to medical care providers, there were, on average two community-based HIV specialized pharmacists and three pharmacy technicians at each site.
HIV training for pharmacists. All pharmacists and pharmacy technicians received training on HIV treatment and prevention, stigma, and cultural responsiveness. The HIV treatment and prevention training was developed by Walgreens, the National Alliance of HIV Education and Workforce Development, and the American Academy of HIV Medicine. The HIV treatment training included antiretroviral pharmacology, identification and management of drug resistance, medication contraindications, drug interactions, and adverse effects. The HIV stigma and cultural competency trainings were developed by Walgreens and accredited for continuing education by the Accreditation Council for Pharmacy Education.
In 2016, the evaluation team examined the cost and cost-effectiveness of PCHCM2 with a subset of the sites and found that overall and at each site, the intervention was cost saving as the program cost was lower than the lifetime HIV treatment cost averted. The annual clinic cost was $74,043 and the annual pharmacy cost was $152,698 for a combined overall intervention cost of $226,741. The overall average cost per patient was $813, which includes the average clinic cost of $265 and average pharmacy cost of $547.
Byrd KK, Hou JG, Bush T, et al. Adherence and viral suppression among participants of the Patient-centered Human Immunodeficiency Virus (HIV) Care Model Project: A collaboration between community-based pharmacists and HIV clinical providers. Clin Infect Dis. 2020;70(5):789-797. doi:10.1093/cid/ciz276
Byrd KK, Hardnett F, Clay PG, et al. Retention in HIV care among participants in the Patient-Centered HIV Care Model: A collaboration between community-based pharmacists and primary medical providers. AIDS Patient Care STDS. 2019;33(2):58-66. doi: 10.1089/apc.2018.0216
Byrd KK, Hardnett F, Hou JG, et al. Improvements in retention in care and HIV viral suppression among persons with HIV and comorbid mental health conditions: Patient-Centered HIV Care Model. AIDS Behav. 2020;24(12):3522-3532. doi:10.1007/s10461-020-02913-2
Shrestha RK, Schommer JC, Taitel MS, et al. Costs and cost-effectiveness of the Patient-Centered HIV Care Model: A collaboration between community-based pharmacists and primary medical providers. J Acquir Immune Defic Syndr. 2020;85(3):e48-e54. doi:10.1097/QAI.0000000000002458
- American Pharmacists Association; National Association of Chain Drug Stores Foundation. Medication therapy management in pharmacy practice: core elements of an MTM service model (version 2.0). J Am Pharm Assoc (2003). 2008 May–Jun;48(3):341–53. doi: 10.1331/JAPhA.2008.08514. PMID: 18595820.
- Shrestha RK, Schommer JC, Taitel MS, et al. Costs and cost-effectiveness of the Patient-Centered HIV Care Model: A collaboration between community-based pharmacists and primary medical providers. J Acquir Immune Defic Syndr. 2020;85(3):e48-e54. doi:10.1097/QAI.0000000000002458