The ART of Implementing an Antiretroviral Stewardship Program
By addressing ART-related medication errors and increasing linkage to care, antiretroviral stewardship programs can improve management of inpatients with HIV.
Antiretroviral stewardship is an emerging field that aims to optimize the use of antiretrovirals in patients with HIV. With the introduction of modern combination antiretroviral therapies (ART), people living with HIV (PLWH) are more likely to be hospitalized for non–AIDS-defining illnesses than ever before.1 While in the hospital, however, patients are at risk for drug-related errors with ART. Retrospective studies evaluating medication errors in this population report rates of at least 1 error in 12% to 86% of admissions.2,3 The most commonly reported errors are incomplete regimens, inappropriate dosing for altered renal function, missed opportunistic infection (OI) prophylaxis, and drug-drug interactions. These errors put patients at risk for drug toxicity as well as viral resistance. In an effort to reduce medication errors, institutions have incorporated antiretroviral stewardship into antimicrobial stewardship (ASPs) programs.
Various antiretroviral stewardship strategies have been described in the literature.4 The most frequently described is a targeted prospective audit and feedback on antiretrovirals that assesses completeness of regimens, appropriate renal dosing, avoidance of drug-drug interactions, and appropriate use of OI prophylaxis. This intervention has generally been completed by pharmacists trained in infectious diseases and physicians at different frequencies: daily, twice weekly, or weekly. Studies consistently demonstrate a reduction in the rates of medications errors when ART is regularly reviewed.4 Other strategies include standardization of ART formularies and computerized provider order entry, targeted education on ART, restriction of ART to infectious disease (ID) providers, and direct linkage to care through ID consultation.
IMPLEMENTATION
Determining the best way to implement an inpatient antiretroviral stewardship program (ARVSP) depends on a number of factors, including institutional resources and priorities. Most published articles on the subject describe similar steps to developing and executing these interventions.
1 IDENTIFY OPPORTUNITIES FOR IMPROVEMENT
Before instituting an ARVSP, evaluate ART prescribing practices at your institution to determine where interventions are needed. Given the shifting landscape of antiretrovirals from complex regimens to complete single-tablet treatment and long-acting injectable options, the rate and type of medication errors may differ compared with what has previously been reported. In addition, the tracing from admission to discharge of processes like medication reconciliation that are commonly associated with ART-related errors may help identify those that must be addressed.
Formulary management. Evaluate the ART and OI prophylaxis formulary to identify the agents that are in stock. The formulary should align with current guideline-recommended ART regimens as well as local prescribing patterns. If the hospital is associated with ambulatory HIV clinics, ask whether a list can be generated to show the most common ARTs prescribed for patients over the past 12 months. If not all ART are on formulary, outline a process for the safe administration of home medications or procurement of nonformulary ART.
Medication reconciliation. This is another important component of ARVSP because many PLWH have been on multiple ART regimens over the years. It also applies to prescriptions for OI prophylaxis. If a reconciliation is not correctly performed at both admission and discharge, significant errors can occur, like the initiation of incomplete regimens or previous regimens.
Electronic medical record (EMR) review. Reviewing ART orders in the EMR may reveal simple adjustments that can decrease errors. For instance, if an ART is a once-daily medication that should be taken with food, the default frequency could be “daily with breakfast.”
2 ENGAGE THE STAKEHOLDERS
Next, it is important to determine who should be involved in implementing the ARVSP. These individuals can provide valuable input and feedback on how to address those areas requiring improvement identified in the baseline assessment. ASP teams are generally the groups that lead ARVSP interventions as part of their normal activities; however, they may not verify all ART orders or perform medication reconciliation. Other groups to include in planning stages are the pharmacy department, ID specialists and health care providers responsible for medication reconciliation, like nurses, and the information technology (IT) staff. IT expertise is critical to identifying PLWH. To identify patients for review, some institutions may use a list based on the codes in the International Classification of Diseases, Tenth Edition (ICD-10), whereas, others may have a report of orders for ART agents, and still others may employ a combination of the two performed with the resources available. These may be changes to the ART formulary, a medication reconciliation process, or medication orders based on the needs assessment outlined above. In addition, determine what education is needed and how ART will be reviewed.
Educational materials. Health care providers who do not regularly care for PLWH are often not up to date or comfortable with ART agents. Everyone involved in safely reinitiating ART in the inpatient setting—physicians, advanced practice providers (APPs), pharmacists, and/or nurses—should be educated on ART via in-services and the linking of information in CPOEs. In addition, handouts/pocket guides can be created that include common drug-drug interactions, dosing recommendations for patients with renal and/or hepatic dysfunction, and enteral administration instructions for patients who cannot take oral medications. Toronto General Hospital’s Immunodefic iency Clinic, for example, has developed a resource for healthcare providers that includes a thorough review of oral ART options with instructions for crushing and splitting tablets.5
ARVSP in practice. ARVSP activities often mirror those of a typical ASP. A prospective audit with feedback of ARTs and OI prophylaxis can be conducted at regular intervals (daily, twice weekly, weekly, etc) and/or ART initiation can be restricted to ID/HIV specialized health care providers like pharmacists, physicians, and APPs. In addition, the ARVSP team can partner with the ID consult team to improve linkage to care6 through mandatory consultation for inpatients with HIV or the recommendations made through prospective audit with feedback.
4 POST-IMPLEMENTATION REVIEW
Limited data exist on the long-term impact of ARVSP practices. Post-implementation review is needed to evaluate the efficacy of the changes made and to identify additional areas of improvement. As the landscape of ART prescribing practices changes, current ARVSP practices may need to be optimized to adapt to once-daily combination regimens and long-acting injectables.
CONCLUSION
Antiretroviral stewardship is an emerging tool for improving patient outcomes and reducing medication errors in PLWH, but it is not a one-size-fits-all approach. Before introducing new practices, it is essential to identify institution-specific areas of improvement and engage all team members. ARVSP can take many forms, and those forms will likely change as more streamlined prescribing practices emerge. Pairing new ARVSP initiatives with regular post-implementation review will identify needs and illuminate possibilities in this ever-changing field.
References
1. Davy-Mendez T, Napravnik S, Hogan BC, et al. Hospitalization rates and causes among persons with HIV in the United States and Canada, 2005-2015. J Infect Dis. 2021;223(12):2113-2123. doi:10.1093/infdis/jiaa661
2. Yehia BR, Mehta JM, Ciuffetelli D, et al. Antiretroviral medication errors remain high but are quickly corrected among hospitalized HIV-infected adults. Clin Infect Dis. 2012;55(4):593-599. doi:10.1093/cid/cis491
3. Li EH, Foisy MM. Antiretroviral and medication errors in hospitalized HIV-positive patients. Ann Pharmacother. 2014;48(8):998-1010. doi:10.1177/1060028014534195
4. 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;70(11):2241-2246. doi:10.1093/cid/ciz792
5. Tseng A, Foisy M, Hughes C. Oral antiretroviral/HCV DAA administration: information on crushing and liquid drug formulations. Northern Alberta Program, Toronto General Hospital. October 2022. Accessed February 27, 2023. https://www.hivclinic.ca/main/drugs_extra_files/Crushing%20and%20Liquid%20ARV%20Formulations.pdf
6. Roshdy D, McCarter M, Meredith J, et al. Implementation of a comprehensive intervention focused on hospitalized patients with HIV by an existing stewardship program: successes and lessons learned. Ther Adv Infect Dis. 2021;8:20499361211010590. doi:10.1177/20499361211010590
