Med errors may occur in over 80% of hospitalized patients living with HIV.
Work with your infectious disease colleagues to create an antiretroviral stewardship program...and consider these strategies to ensure safe transitions of care.
Admission. Use an EHR-generated list to identify patients with HIV...those with positive tests or taking antiretrovirals. Talk to patients to determine their regimen and assess adherence.
Try to ensure the complete HIV regimen is restarted within 24 hours of admission. Don’t start a partial regimen...this may lead to resistance.
And follow your non-formulary and home med policies when needed.
Switch non-formulary HIV combo meds to individual components if needed. And for patients on tenofovir, feel comfortable using either tenofovir DISOPROXIL fumarate or tenofovir ALAFENAMIDE.
During hospitalization. Follow the patient’s home med schedule as closely as possible...especially with timing around meals.
For example, darunavir, atazanavir, and rilpivirine should be given WITH food...and efavirenz withOUT food.
And schedule cobicistat or ritonavir to be given at the same time as other HIV meds...since they boost antiretroviral levels.
Also keep in mind, many HIV meds come in liquid form or can be crushed for administration via feeding tubes if needed. But follow your hazardous meds policy when handling abacavir, nevirapine, and zidovudine.
Check for possible CYP450 interactions...such as with azole antifungals, anticoagulants, or anticonvulsants.
And watch for interactions with acid suppressants, calcium, iron, magnesium, or zinc...these can decrease the absorption of some antiretrovirals.
Monitor for changes in renal function and adjust doses as needed. But be aware, guidance may vary. For example, manufacturer recs suggest adjusting lamivudine for CrCl below 50 mL/min...other data suggest below 30 mL/min.
Discharge. Ensure patients are discharged on the correct HIV regimen...especially if your hospital has automatic interchanges.
For any patients starting antiretrovirals for the first time, check that they can afford their new regimen.
- Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. Department of Health and Human Services. February 27, 2024. https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-arv/guidelines-adult-adolescent-arv.pdf (Accessed February 27, 2024).
- Koren DE, Scarsi KK, Farmer EK, et al. A Call to Action: The Role of Antiretroviral Stewardship in Inpatient Practice, a Joint Policy Paper of the Infectious Diseases Society of America, HIV Medicine Association, and American Academy of HIV Medicine. Clin Infect Dis. 2020 May 23;70(11):2241-2246.
- Durham SH, Badowski ME, Liedtke MD, et al. Acute Care Management of the HIV-Infected Patient: A Report from the HIV Practice and Research Network of the American College of Clinical Pharmacy. Pharmacotherapy. 2017 May;37(5):611-629.
- Brizzi MB, Burgos RM, Chiampas TD, et al. Impact of Pharmacist-Driven Antiretroviral Stewardship and Transitions of Care Interventions on Persons With Human Immunodeficiency Virus. Open Forum Infect Dis. 2020 Aug 24;7(8):ofaa073.