David Koren, PharmD, on Implementing Antiretroviral Treatment Stewardship Programs

A significant risk exists for medication-related errors during hospitalization and at transitions of care among patients with HIV who are receiving antiretrovirals. 

To reduce this risk and promote patient safety, the Infectious Diseases Society of America (IDSA), HIV Medicine Association (HIVMA), and American Academy of HIV Medicine (AAHIVM) have released a joint policy paper¹ that raises awareness about the implementation of antiretroviral stewardship programs (ARVSPs) in hospital settings.

We asked David Koren, PharmD, a clinical pharmacist specialist in infectious diseases/HIV at Temple University Hospital and coauthor of the policy paper, about how to successfully implement ARVSPs.

INFECTIOUS DISEASES CONSULTANT: What prompted the IDSA, HIVMA, and AAHIVM to release this joint policy paper?

David Koren: Published antiretroviral-related error rates in the inpatient setting are high, and stewardship can be thought of, in the broadest sense, as actions to benefit patient safety. This was an opportunity to bring a known problem to light, appropriately name it, and highlight possible solutions to address it.

ID CON: The antiretroviral stewardship programs you raise awareness about are modeled after antimicrobial stewardship programs. In what ways are the programs similar/different? 

DK: Antimicrobial stewardship and antiretroviral stewardship are both broad terms that include individualized approaches to benefit patient safety. Although components of both programs may be similar—which may include, but are not limited to, chart reviews—published error rates demonstrate that antiretrovirals may not be incorporated into existing efforts. These errors demonstrate the need for directed, targeted interventions based on local institutional needs. As a unique aspect of ARVSPs, transitions of care—both on admission and discharge—are heavily emphasized, as these medications are generally delivered as continuation from outpatient therapy.  

ID CON: The paper highlights 3 main categories of ARVSP approaches. Are there any advantages or drawbacks one approach has over another? And what should a clinician consider when deciding which approach to implement?

DK: The 3 main categories of published ARVSP approaches—clinical checklists, chart review, and interventions directed by computerized provider order entry (CPOE)—have all been successful in their own institutions, but if a clinician is deciding to implement such a program, he or she should first do a self-assessment that includes the following questions: “Do we see a large population of patients living with HIV or who use antiretrovirals for another indication?” “Are local experts—whether infectious disease or otherwise—routinely present for questions?” “What are the local medication accession policies, such as when a patient presents reporting a home medication that the institution does not carry?” These questions may help clinicians decide what is individually appropriate and feasible.

ID CON: What are a few of the main points a clinician must keep in mind to ensure that the implementation of an ARVSP is successful?

DK: To ensure success of any program, a local champion should oversee efforts as well as perform regular outcome assessments to ensure effectiveness. One important point discerned from the review of literature was that successes of published approaches were bolstered by general awareness and education among providers that such resources/interventions exist.

ID CON: What are the barriers to ARVSP implementation some clinicians might face, and how can they be overcome?

DK: Time and resources. ARVSPs may take several forms—such as a separate program or incorporated into existing stewardship efforts—based on local needs, and a clinician must decide which approach is right for his or her institution. Additionally, antiretroviral-specific champions or experts may not readily be available in all locations and at all needed times; the article mentions possible interprofessional (physician/pharmacist) or interdisciplinary partnerships that may form an array of support.

Reference:

1. 1. 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 [published online September 6, 2019]. Clin Infect Dis. doi:10.1093/cid/ciz792.