Having worked with PLWH since 1982 to present, in many healthcare settings (academic clinics, private practice, and community health center/FQHC in urban areas), I can share with you that punitive healthcare policies rarely result in the kind of outcome that you are seeking with your patients. One of the most important principles that I have learned is that removing or minimizing barriers to seeking and maintaining healthcare is as, if not more, important than the provision of healthcare itself.
First and foremost, establish a phlebotomy service in your clinic or have your clinic staff (MAs, LVNs, RNs, MDs) draw, process and send out the blood tests. Ask yourself how you would comply with multiple-stop healthcare. Your patients are often just as busy as you are and have less resources/support to deal with their lives demands.
There is much more potential downside to electively stopping a PLWH's ART regimen than simply continuing it especially with our modern second generation integrase inhibitor-based single-tablet regimens (Dovato, Biktarvy, Triumeq) and the one boosted protease inhibitor regimen (Symtuza). The potential harm from the patient trying to "stretch out" their medications and underdose their ARVs with resulting viremia and and viral resistance as well as potential for HIV transmission to others are strongly in favor of continuing prescriptions.
Prescriber knowledge of and adherence to the DHHS and IAS-USA ART Guidelines for first-line and switch therapy recommendations is important to maximize the efficacy and safety of ART. In other words, boosted integrase inhibitor regimens (Genvoya, Stribild) are no longer recommended due to higher GI intolerance, higher viral failure and viral resistance at the time of failure and many drug-drug interactions due to the cobicistat.
DHHS guidelines recommends that once a PLWH on ART has has stably suppressed HIV (VL<50 copies/mL for ~ 2 years), Viral load can be checked every 6 to 12 months and CD4+ T cell counts once-yearly as well. If there are other medical concerns, and there often is with our PLWH aging with HIV, more frequent lab tests and visits may be necessary.
I have found that meeting PLWH where they are, i.e., connecting with them via telemedicine and virtual clinic visits and placing lab orders at laboratories with extended or weekend hours for the infrequently needed tests goes a long way in ensuring adherence to ARVs.
Best of luck with your advocacy to convince your clinic administrators to take action to improve and not impede your patients healthcare.
David Hardy, MD
Los Angeles, California
AAHIVM and HIVMA member
W. David Hardy
Los Angeles CA
Sent: 03-29-2021 10:52
From: Sean Leonard
Subject: Patient compliance?
Being a newbie in the HIV treatment around my wanted to ask the community a question regarding treatment compliance.
I have a number of patients for which I provide primary care, and hopefully in the near future I will be responsible for their HIV treatment as well. However, these patients are not fully compliant with treatment program for their HIV medications.
They will often miss appointments, or not get the blood work done. Our facility does not provide phlebotomy services on site and as a consequence, patients need to go to a local lab for blood testing.
It has been the practice of our facility to deny them refills of there ART therapy through our Ryan White program until they can comply with adding blood work done or having at least a telemedicine appointment with the provider.
While I understand the ramifications of not routinely checking blood work including renal function, liver function, routine annual TB testing, viral load and CD4 count.
I was recently reprimanded for providing a refill of the patient's Genvoya. This patient has been routinely undetectable, with stable-ish CD4 count. He reports 100% compliance with ART therapy, however has been noncompliant with quarterly office visits and lab draws (may be having 2 appointments and to lab draws annually). I provided the patient a refill of his medication that would carry him through until his next appointment with our office HIV specialist. The alternative would have been that he had a lapse in treatment for 1-1/2 months.
In a previous forum post, someone replied they worked in a similar setting, and they will provide an initial medication refill (thread was removed, I forgot the actual durations) something like 30 days, then 14 days, then 7 days. I found this intriguing, and something I will likely implement.
I was wondering if anybody had any other solutions/ways of promoting compliance. And what you have done a similar situation. Personally, in most areas of medicine, I typically err on the side of providing treatment for the patient.
I have also been working towards advocating that our clinic provide phlebotomy services for the patients in-house. (As a former med tech, ER tech and paramedic, I have offered to provide phlebotomy training for our staff, but the powers-that-be have not moved forward with this recommendation).