By Annette M. Boyle

Nasia Safdar, MD, PhD

MADISON, WI—Antiretroviral medications have transformed HIV from a death sentence into a chronic disease, but the drugs’ effectiveness depends on rigorous adherence to sometimes-complex regimens.

For veterans with HIV, adherence is often made difficult by the policies and procedures of the mail-order pharmacy system that they must use to obtain their medications. Nearly half of veterans with HIV in a recent study in Research in Social and Administrative Pharmacy reported that they ran out of medications because of issues with the VA’s mail order pharmacy system.1

Veterans who receive care through the VA must use the Consolidated Mail-Order Pharmacy (CMOP) system to obtain all medications for chronic conditions. In general, the veterans in this study reported high satisfaction with the mail-order pharmacy overall and in terms of its accuracy and their ability to use it when traveling. They had significant issues with medication coverage, however.

“What sets HIV patients apart from other mail-order users is their dependence on near-perfect adherence for sustained HIV suppression and survival and the virus’s long incubation period,” which often means patients take antiretrovirals for years or decades, the authors wrote.

The sequential, mixed-methods study of 57 veterans with HIV receiving care at a VA infectious disease clinic found that several factors associated with the mail-order pharmacy make “near-perfect adherence” particularly challenging for HIV patients.

Timing emerged as the major issue. In some locations, the mail-order “pharmacy defaults to a 90-day supply of a medication with exceptions for high-cost and high-risk medications. The antiretroviral medications fall into the high cost category,” co-author Andrew Wilcox, PharmD, chief of pharmacy at the William S. Middleton Memorial Veterans Hospital in Madison explained to U.S. Medicine. As a result, veterans with HIV can only receive 30 days of antiretrovirals at a time.

That creates a host of problems for these vulnerable patients, who frequently have a number of comorbidities, such as diabetes and hypertension, in addition to HIV. The majority of the veterans in the study had four or more conditions and required multiple medications. Most of their medications had 90-day refill cycles. The difference in timing for refills, combined with a lack of synchronization for those on the 90-day schedule, contributed to confusion, late refills and missed doses.

As one veteran noted in an interview, “I get confused as which one I—because I have like so many meds. … And then, you know, like a follow-up if that’s necessary. And then I get confused; did I order this one or not?”

Another told the researchers, “I knew I could tell myself if I’ve got to reorder because I only have so many left. Well, then I forgot. And two or three days later, I reorder it. By then I have skipped like every other day to make sure that I would have enough.”

Long Lead Times

To receive their HIV medications on time, veterans reported needing to place their refill orders at least 10 days in advance. Additional lead time was required, if the standard six refills had been completed, as all antiretroviral prescription renewals must be submitted to the Infectious Disease Clinic, even for patients who have no changes in their medications. That review process can add a week or more to the refill time.

In several interviews, veterans recounted waiting 10 days for medications and then calling to check on the status, only to be told that the pharmacy had no record that they had called in a refill. In other instances, the order had been misplaced or took three weeks to arrive.

According to the study, these issues contributed to 47% of the patients in the study reporting running out of HIV medications. Of those, 31% said they sometimes ran out, while 12% said they usually ran out and 2% said they almost always ran out of medication before their refills arrived.

One veteran said he had “to head to the ER … three times already” to receive medication to bridge until his refills arrived.

Being able to receive a few days’ doses from the local hospital was one of several ways veterans said the VA worked with them to fill in gaps in medication coverage. “The interviews suggested the VA was very responsive in ensuring patients received the medications when informed of such situations. Veterans reported a number of work-arounds in place to ensure quick delivery, such as overnight shipping and providing emergency supply,” said study co-author Nasia Safdar, MD, PhD, associate chief of staff for research and staff physician in infectious diseases at the Middleton VAMC.

The researchers recommended several ways to reduce the risk of missed doses and the burden associated with refills for antiretrovirals for veterans who have HIV. They noted that many veterans expressed a desire to receive their antiretroviral medications on the same 90-day cycle as their medications for other chronic conditions. Previous studies support the patients’ view, finding that providing multiple month-refills improves adherence, the authors said.

The researchers also saw a role for pharmacists in helping patients streamline and synchronize their medication schedules. In addition, they recommended a system-initiated automated ordering process that could relieve patients of the need to remember to place refill orders.

The researchers found that pharmacists could serve as a valuable resource for patients, many of whom found the information sheets provided with their medications difficult to understand and lacking in crucial information. Pharmacists could also help patients with drug-drug interactions and side effects, which at least one patient reported addressing by unilaterally deciding to cut his dosage in half, rather than consulting with either his physician or a pharmacist.

“With the increasing complexity of drug therapy, pharmacists are uniquely positioned to provide patient-centered medication management services as part of interdisciplinary teams,” said Safdar. “In veterans living with HIV/AIDS, clinical pharmacists can monitor medication regimens for effectiveness and adherence, as well as manage adverse effects. Pharmacist can also tailor and simplify medication education for ease of understanding and comprehensively review patient medication regimens.”

  1. Desai KR, Chewning B, Wilcox A, Safdar N. Mail-order pharmacy experience of Veterans living with AIDS/HIV. Res Social Adm Pharm. 2017 Feb 24. pii: S1551-7411(17)30098-0. doi: 10.1016/j.sapharm.2017.02.005. [Epub ahead of print]