HIV Treatment Optimization

Tampa—Medicaid is the largest payer of HIV care in the United States, covering about 4 in 10 patients with HIV. According to estimates, Medicaid spends $5.3 billion on HIV prevention and treatment, with prescription drugs as the largest expense. With the expansion of Medicaid, individuals with HIV have more access to screening and treatment, more access to preventive care, and are better managed in terms of treatment adherence. During a session at the AMCP meeting, HIV treatment, coverage, and guidelines were discussed.

Lori Hensic, PharmD, health sciences assistant clinical professor, University of California, San Diego, opened the session by examining the impact the Patient Protection and Affordable Care Act and Medicaid expansion will have on HIV treatment. Benefits of coverage expansion include access to screening and treatment, access to preventive care, and closer management of treatment adherence. However, funding for safety net programs could potentially decrease or be completely eliminated. There is also an absence of information given to patients regarding benefits, drug formularies, and providers. In terms of managed care, there may be coverage problems with access to providers, antiretroviral (ARV) therapy, transitions of care, and cost-containment.

William Valenti, MD, clinical associate professor of medicine, University of Rochester School of Medicine in Dentistry, Rochester, New York, continued the discussion by examining quality improvement in HIV treatment. According to Dr. Valenti, the National HIV/AIDS Strategy (NHAS) is a comprehensive plan developed to address the HIV epidemic in the United States. The NHAS has 3 main objectives: (1) decrease the rate of new HIV infections; (2) decrease the number of HIV-related health inequalities; and (3) increase access to care and enhance health outcomes (See Table below).

Federal guidelines recommend that all patients with HIV receive ARV therapy, and screening for HIV is recommended for all individuals aged 15 to 65 years. A 2013 study from the Centers for Disease Control and Prevention found that of the 82% of patients diagnosed with HIV, 66% were receiving care. Of the 66% receiving care, 37% retained care, 33% patients were prescribed ARV therapy, and 25% experienced viral suppression.

To increase the number of HIV patients that experience viral suppression, federal resources must be leveraged, according to Dr. Valenti. He noted that in order to improve HIV patient care, a platform must be created and utilized for supervising federally funded HIV programs that assist in the prevention and treatment of HIV patients.

Dr. Valenti said that future steps would include standardizing care across private, public, and government programs; monitoring the implementation of standardization; streamlining all complied data; and incorporating reporting systems into electronic medical records.

There are 4 major complexities with HIV care, according to Dr. Hensic: (1) comorbidities; (2) drug interactions; (3) nonadherence; and (4) side effects. Of the patients with HIV, 25% are coinfected with hepatitis C virus and 10% with hepatitis B virus.

There are multiple opportunistic infections, such as mucocutaneous candidiasis and toxoplasmosis, which are more likely to effect HIV patients. There is also a high potential of drug–drug interactions in non-nucleoside reverse transcriptase inhibitors and protease inhibitors and a medium potential in C-C chemokine receptor type 5.

Dr. Valenti offered strategies for healthcare providers to improve coverage for HIV patients:

·      Abide by HIV treatment guidelines

·      Employ feasible cost-sharing

·      Enact effective pharmacy practices

·      Add Ryan White providers into networks

·      Allow HIV providers to be primary care providers

·      Put HIV quality measures into place

Dr. Valenti said these strategies can enhance the overall outcome for patients and improve the use of funds to optimize HIV treatment and care.