Call to Action: Antiretroviral Stewardship in the Inpatient Setting Would Cut Down on Resistance

Antimicrobial stewardship is a popular buzzword in the field of infectious disease, but another that’s garnering attention is antiretroviral stewardship.

Amid growing reports of viral resistance in patients living with HIV, the Infectious Diseases Society of America (IDSA), HIV Medicine Association, and American Academy of HIV Medicine have issued a joint policy paper regarding the role of antiretroviral stewardship in inpatient practice. The call to action was published in Clinical Infectious Diseases.

Thanks to modern antiretroviral (ARV) therapy, people living with HIV are living longer, more fulfilled lives. But, at the same time, increased longevity means a higher rate of comorbidities, which can require inpatient care.

“Vigilant pharmacologic management of ARVs in the inpatient setting has now evolved to include not only evidence-based selection of appropriate ARVs, but also management of concurrent infectious and noninfectious complications and comorbidities, which require careful selection of concomitant drug therapy,” the authors write.

People living with HIV who are admitted to the hospital are at significant risk of medication errors, which can occur up to 86% of the time, according to some studies cited by the authors. Most commonly, these errors are drug omissions in a patient’s ARV regimen, incorrect dosing/scheduling of ARVs, and drug interactions.

These errors can lead to resistance, among other things. Because of this risk, the authors are proposing an addition to the definition of “antimicrobial stewardship” created by the Society for Healthcare Epidemiology of America, IDSA, and the Pediatric Infectious Diseases Society.

The addition addresses “antiretroviral stewardship,” defined as “coordinated interventions designed to improve continuity of care for patients receiving ARVs through the utilization of evidence-based ARV practices including medication reconciliation, dosing, mitigation of drug interactions, and prevention of viral resistance.”

ARV stewardship is attainable through the creation of antiretroviral stewardship programs (ARVSPs), the authors write.

“ARVSPs should seek to provide comprehensive and cost-effective care for the purpose of achieving outcomes that improve the quality of life of any person receiving ARVs,” the call to action reads. “An ARVSP should provide guidance and/or a forum for collaboration between pharmacists, physicians, and other health care professionals to optimize drug therapy outcomes with a focus on ARV management.”

Critical components of an ARV stewardship program include tracking and reporting use of ARVs, completing prompt and accurate medication reconciliation, assisting primary care services with transitions of care, assessing engagement in care, linkage to care between inpatient and outpatient disease-state management, and educating health care providers and learners.

IDSA, HIV Medicine Association, and American Academy of HIV Medicine go on to lay out specific strategies for implementing ARV stewardship programs, categorized into 3 parts: 1) checklists to ensure safe prescribing practices; 2) computerized provider order entry sets; and 3) prospective review strategies by physician-pharmacist collaborations for anticipated needs of people living with HIV during hospitalization.

“Expanded stewardship programs that include an emphasis on ARVs can prevent virologic failure, viral resistance, deleterious drug interactions, and adverse drug events,” the authors conclude. “Similar to the implementation of [antimicrobial stewardship programs], ARVSPs will require advocacy, assessment of best practices, and a multidisciplinary, institutional-based approach to achieve improvements in patient care.”