How common is HIV where you live? How often do you see patients who have HIV in your practice? Which patients are at higher risk of having HIV? What is your role in caring for patients who have HIV?

How is HIV transmitted from person to person? What on-the-job activities do you participate in that are associated with the risk of HIV transmission? What misconceptions have you heard about how HIV is transmitted?

Elliot is a new patient in the pharmacy today. He is a 35-year-old male with no known chronic medical conditions. His social history is significant for occasional alcohol consumption. He denies smoking or illicit drug use. He reports having unprotected sex with multiple male partners over the last six months.

What behaviors, if any, increase his risk for transmitting or acquiring HIV?

Who should be routinely screened for HIV? How often is it recommended to test for HIV? What is your involvement with HIV testing? What do the different HIV tests look for? How soon can HIV be detected after an exposure?

Let's go back to the case regarding the patient named Elliot. Remember he is a 35-year-old male, has no known chronic medical conditions. His social history is significant for occasional alcohol consumption. He denies smoking or illicit drug use. He reports having unprotected sex with multiple male partners over the last six months. He has no complaints today and denies any recent illnesses.

Should Elliot be offered HIV testing today? If so, which test(s) should be used?

In a healthcare setting, persons being tested for HIV should be notified orally or in writing that the test is planned and that he or she can decline the test. Informed consent (getting permission from the patient) is required prior to testing someone for HIV in a nonhealthcare setting (community-based organization, outreach setting, mobile vans, etc.). In any setting, as part of the discussion about HIV testing, the person to be tested must be told that their name, the fact that they have been tested, and their test results will remain confidential, to the extent required by the law. However, patients should be told that their information will be reported to the county department of health if they have a positive HIV test. Patients should be told about the availability and location of sites at which anonymous testing is performed. Each county health department maintains a list of sites where anonymous testing is performed.

After test results are received, all reasonable efforts must be made to inform the person of their test results. The information given to the patient will depend on the results of the HIV test.

Information to provide (within two weeks of results) when a test is positive:

Information to provide (within two weeks of results) when a test is negative:

Since patients don't get diagnosed with HIV or sexually transmitted infections (STIs) in the pharmacy setting, pharmacies are not required to report these patients to the local department of health. However, prescribers who diagnose and/or treat patients with STIs (including HIV/AIDS) and laboratories that conduct these tests are required to report. Pharmacy staff have a responsibility to keep information about a patient's condition confidential.

The use of voluntary, confidential partner services helps patients with HIV notify those people around them who are at risk of exposure to HIV. Those notified may then choose whether or not to be tested for HIV. Notified individuals are not told who reported their name. Nor is information reported back to the original patient with HIV. Contact your local health department for additional information on this program in your area.

How can the transmission of HIV be prevented? What infection control procedures are used in your facility to help protect against bloodborne pathogens, such as HIV? What are universal precautions?

Let's go back to Elliot, the new patient at the pharmacy today. He reports having unprotected sex with multiple male partners over the last six months.

What information about safer sex practices should Elliot receive?

Nonoxynol-9, a commonly used spermicidal agent, does NOT protect against HIV virus or other STIs. In fact, nonoxynol-9 can increase the risk of HIV transmission [20].

What is pre-exposure prophylaxis? How often do you interact with patients who are receiving pre-exposure prophylaxis? Which patients should receive pre-exposure prophylaxis? What regimens are used for pre-exposure prophylaxis?

Some states allow pharmacists to provide PrEP through a protocol or collaborative practice agreement. If your pharmacy is involved in furnishing PrEP to patients, work together as a team to help streamline this process. For example, pharmacy technicians can help support pharmacists by developing a system for efficient documentation, billing, patient follow-up, etc.. If your pharmacy isn't able to provide PrEP to patients without a prescription from a prescriber, pharmacy teams can still play an active role in screening and referring patients who are likely to benefit.

Let's go back to Elliot. He is a 35-year-old male patient who has no known chronic medical conditions. His social history is significant for occasional alcohol consumption. He denies smoking or illicit drug use. He reports having unprotected sex with multiple male partners over the last six months.

Is PrEP appropriate for Elliot? If so, what regimen would you expect to be started? What test(s) should be done prior to starting PrEP?

What is postexposure prophylaxis? When is postexposure prophylaxis used? How long should patients take postexposure prophylaxis? What regimens have you seen used for postexposure prophylaxis?

Be aware that for now, there are not enough data to recommend tenofovir alafenamide-containing products for PEP.

What are the different stages of HIV? How does HIV progress to AIDS? How is AIDS diagnosed and what are some examples of opportunistic infections?

CDC considers the following illnesses to be AIDS-defining conditions [45]:

How is HIV managed? What are the goals of therapy? What does a typical HIV medication regimen look like?

The classes of FDA-approved antiretrovirals include [53]:

In addition, two drugs (ritonavir and cobicistat) are used as pharmacokinetic enhancers, or more commonly referred to as "boosters," to help improve the effects of protease inhibitors and the INSTI elvitegravir [53].

Examples of nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs) include:

NRTIs

NNRTIs

*Also available in one or more combination products. See list below.

Examples of PIs include:

*Also available in one or more combination products. See list below.

^αFormulated in combination with cobicistat or ritonavir to boost concentration of the PI.

†Although ritonavir is a PI, it's generally used as a booster in HIV treatment regimens.

Examples of INSTIs include:

*Also available in one or more combination products. See list below.

^ꞵIndicated for PrEP only.

At the time of publication, the other available classes of antiretrovirals include:

Examples of combination products used in the treatment of HIV include:

*Unlike all of the other products on this list which are oral medications, this is an IM injection.

Let's go back to Elliot who is a 35-year-old male patient at risk for HIV due to having unprotected sex with multiple male partners over the last six months.

An HIV point-of-care test was performed and was reactive for HIV. Elliott was referred to a provider who ordered an HIV confirmatory test which was positive. Therefore, he was not offered PrEP. He is agreeable to starting ART. He is HLA-B*5701 positive and he does not have hepatitis B infection. Which regimen(s) would you expect to see prescribed for his initial therapy?

In general, INSTI-based regimens are preferred because they are highly effective, well tolerated, and have fewer drug interactions compared to PI-based regimens. However, patients with a history of having received the cabotegravir long-acting injectable for PrEP will require INSTI genotypic resistance testing before initiating INSTI therapy. This is because drug levels of long-acting cabotegravir may be present in some individuals for up to four years, and this persistent suboptimal drug exposure may select for INSTI-resistant virus [53].

There are some HIV medication-specific drug-drug interaction resources that you may find useful [41,57,58]:

In Florida, physicians and midwives who care for pregnant patients are required to provide HIV testing (and other STI testing) to the patient and counsel the patient on the availability of treatment if they test positive. The provider must tell the patient that they will be tested and of their right to refuse. If the patient objects, a reasonable attempt must be made to obtain a written statement of objection, signed by the patient, and placed in the medical record.

Pay extra attention to HIV meds during medication reconciliation. Up to 86% of hospitalized patients with HIV experience at least one medication error. These errors most commonly involve antiretroviral regimens, dosing, scheduling, and drug-drug or drug-food interactions [65].

Use the toolbox, Medication Adherence Strategies (link provided in the Additional Resources section) to help patients stick to their regimen.

How do you ensure confidentiality for patients with HIV/AIDS in the pharmacy? Do you have room to improve? Are other pharmacy technicians and pharmacists in your practice setting making good decisions to ensure confidentiality for patients?

The Golden Rule approach is an excellent model to use in caring for patients with HIV. The Golden Rule is, "Do unto others as you would have them do unto you."