Pharmacists taking a lead in AIDS and HIV prevention
and treatment
Further to the joint declaration of the World Health
Organization and the International Pharmaceutical Federation that was
signed at the Vancouver Congress in 1997, a session was held in Singapore
on September 3 on the role of the pharmacist in AIDS prevention and treatment.
Opening the session, Marthe Everard, of the WHO’s
department of essential drugs and medicines policy, Geneva, Switzerland,
said that world-wide 15,000 people were infected with HIV every day. Of
these, 95 per cent were in developing countries and 47 per cent were women.
She explained that the United Nations had developed a strategy on access
to HIV-related drugs which had been adopted by nine UN agencies. It was
a four-part strategy intended to guide and co-ordinate activities in relation
to access to drugs for AIDS treatment. The parts were ensuring
- rational selection and use of HIV drugs
- affordable pricing
- sustainable financing
- health systems were reliable
Rational selection was necessary because in different
parts of the world different opportunistic infections were prevalent and
this could make planning difficult. The affordability of HIV drugs also
varied from country to country along with wholesale prices of the drugs.
But differential pricing, where different prices were charged in different
countries, could go some way towards making drugs more affordable. Reliable
health systems were required because of the need for essential activities
like voluntary testing and counselling, and providing psychosocial support
and palliative care.
Ms Everard concluded by saying that it was WHO’s
goal to have five million people on antiretroviral therapy by 2006, and
she challenged FIP to come up with ways of involving pharmacists in that
project.
Marthe Everard: challenging FIP to get pharmacists involved
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Michael Madalon: compliance management strategies
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Compliance
How pharmacists could play a part in monitoring
drug compliance in HIV disease was outlined by Michael Madalon, senior
clinical pharmacist at the University of Wisconsin Hospital and Clinics,
United States.
He explained that drug compliance in HIV patients
really needed to be optimal in order to suppress detectable virus and
reduce progression of the disease. Presently there were few drug regimens
that were “forgiving”; all were complex and had associated toxicities.
Compliance was generally suspected to be insufficient and might be the
“weak link” in complex antiretroviral therapy.
Mr Madalon described some compliance management
strategies that pharmacists could become involved in. The first was self-reporting
by the patient. This was inexpensive and subjective but was often over-estimated,
perhaps because of poor recall.
A second strategy was to look at insurance claims.
However, Mr Madalon said that these records were not generally available
to practitioners. They were more useful for looking at long-term compliance
records and offered information without intruding into patients’ lives.
Strategy three was directly observed therapy. This
had been shown to be a powerful strategy, especially if the patient was
new to treatment. It was more suitable for certain patient sites, for
example, prisons and care centres, and would require modification for
use in the community.
Fourthly, said Mr Madalon, electronic devices could
be used. These were excellent tools for recording dosing patterns, but
they were expensive and bulky.
Mr Madalon’s fifth strategy was therapeutic drug
monitoring. This was a useful tool for adjusting dosage regimens, assessing
drug interactions and managing toxicity because it gave a glimpse of what
was going on at blood level.
Finally, there were laboratory markers, such as
CD4 counts, although these were better suited as predictors of outcomes,
he said.
So, what was the role of the pharmacist as a member
of a compliance support team? First, pharmacists would have to know their
patients. They would need to be available, be good listeners, be non-judgemental,
knowledgeable, motivated, sensitive and trustworthy. They should discuss
tools for improving compliance with patients and act as a monitor for
drug interactions. They should telephone patients a few days after they
start a new regimen to see if there are problems, and should then telephone
every 30 days, Mr Madalon suggested. They could even offer some form of
directly observed therapy, if that was felt to be necessary.
An AIDS prevention strategy in Thailand
The final speaker, Professor Porntip Chuamanochan,
of the faculty of pharmacy at the University of Chiang Mai, Thailand,
described the role of the pharmacist in HIV prevention in her country.
She explained that when an increasing number of HIV-positive cases were
being discovered in Northern Thailand in the early 1990s, pharmacists
and drug store personnel took action. They participated in conferences
and workshops and prepared themselves for giving advice on HIV prevention
to their clients.
This HIV/AIDS prevention and care programme led
to an awareness among the public that pharmacists and drug store personnel
could provide qualified services. Professor Chuamanochan believed that
this would lead to the recognition of the pharmacy as a “community health
station”.
Pharmacists played a role in HIV prevention in the
community, too. Since the disease was seen to be spreading rapidly among
adolescents and women, a group of pharmacists and sociologists set up
a scheme targeted at young male and female migratory factory workers.
Professor Chuamanochan said that “peer education”, in the form of group
discussion and problem-solving activities about gender roles, social norms
and their impact on communities, had been found to be the most effective
means of HIV and AIDS prevention education. This peer education also showed
an increase in communication between boys and girls on their knowledge,
beliefs and experiences related to HIV risk and prevention.
Peer education had since been implemented in 12
factories in the Chiang Mai area. Professor Chuamanochan said that the
factory owners involved were able to foresee that it could strengthen
the well-being of their employees and would be cost-effective.
A particular success was that factory workers extended
the information received from peer education activities to their families
and friends in their home villages.
Professor Chuamanochan concluded by saying that
her experience had shown that active adolescent groups, housewife groups
and Buddhist monks had potential for organising effective HIV/AIDS prevention
education for their peers. Pharmacists, sociologists and village leaders
needed to work together to provide appropriate information for these groups
to help them communicate with their peer groups effectively. The information
would then be disseminated throughout the community.
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