Taking antiretroviral therapy exactly as prescribed is not only essential for lowering the amount of HIV in an infected individual, but also critical for reducing the risk of transmission.

With more than 25 antiretroviral drugs in 6 drug classes available, it may take some time for patients to find the treatment that is right for them. Once they do, the next step is to stay adherent to the selected therapy, which is a key area where pharmacists can help.

Some of the ways pharmacists can aid patients with HIV is through refill reminders, pillboxes, or delivery of medications to patients’ homes or workplaces.

Despite their best efforts, however, some patients may still struggle with adherence.

Aaron Rigali, PharmD, director of Empath Health Pharmacy based in Florida, recently launched an HIV specialty program that caters to the needs of this patient population.
He spoke with Pharmacy Times about the following 4 barriers to HIV medication adherence that he frequently sees:

1. Cost and insurance

In Dr. Rigali’s experience, the average insurance plan allows for a 3- to 5-day early fill, which does not provide much of a buffer in case an issue arises.

“These medications are very expensive, and when there is an insurance issue…it is nearly impossible to resolve before the patient is out of medication, and very few can afford a $50 tablet,” Dr. Rigali said.

Some common insurance issues are co-pays of $100 or more, prior authorization requests, high deductible plans, and gaps in coverage.

Prior authorization requests may take a week or more to resolve, and some high deductible plans are $1500 for the first fill, Dr. Rigali maintained.

The gaps in coverage, meanwhile, may stem from the loss of a job, a change in plans on the partner’s end, or challenges with enrolling in Medicaid plans.
Even a small co-pay may result in HIV medication nonadherence, he added.

“I can’t imagine a scenario where $2.65 collected by a [pharmacy benefit manager] on a $2000 medication is worth the risk, however small, of affecting or delaying the pickup of HIV medications when the cost of nonadherence can be great,” Dr. Rigali said.

2. Privacy

It is not uncommon that a patient wants to keep his or her HIV status a secret, which may cause some problems with adherence and access to their medications.

Some patients want to avoid large retail chain pharmacies where they may run into someone they know. Others do not want to use a mail-order pharmacy that delivers their HIV medications to their house.

While some patients may be forced into narrow networks or mail-order pharmacies, Dr. Rigali expressed a wish that patients could choose the environment that works best for them.

3. Changing assistance programs

Assistance programs or changes in health insurance plans can also cause confusion for patients.

Dr. Rigali gave the example of the Florida AIDS Drug Assistance Program, which is now transitioning patients into Affordable Care Act plans.

“In general, these plans provide adequate medication coverage after a deductible is met, but often leave the patients with ongoing expenses for other medical services, especially laboratory fees,” he said.

4. Complicated medication regimens

Guidelines for some patients with HIV may require them to take 2 nucleoside/nucleotide reverse transcriptase inhibitors in combination with integrase strand inhibitors, non-nucleoside reverse transcriptase inhibitors, or protease inhibitors with a pharmacokinetic booster.

Not surprisingly, this can cause confusion for the average patient. The names of drugs may be foreign to patients, and they may have a hard time keeping track of what to take at what time.
However, Dr. Rigali said, “this is less and less of a problem as more drugs have come to market, including single pill/day combination tablets.”

Nevertheless, 2 things are still needed: commitment from the patient and a strong relationship with a pharmacy “willing to do the work to focus on adherence,” Dr. Rigali maintained.