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NASTAD ADAP Conference, July 15, 2009 Ronald H. Goldschmidt, MD Cristina Gruta, Pharm D

Resources for ADAP Programs AIDS Education and Training Centers (AETCs) National HIV Telephone Consultation Service (Warmline) Clinical Pharmacist Roles in ADAP Programs. NASTAD ADAP Conference, July 15, 2009 Ronald H. Goldschmidt, MD Cristina Gruta, Pharm D San Francisco General Hospital

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NASTAD ADAP Conference, July 15, 2009 Ronald H. Goldschmidt, MD Cristina Gruta, Pharm D

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  1. Resources for ADAP ProgramsAIDS Education and Training Centers (AETCs) National HIV Telephone Consultation Service (Warmline) Clinical Pharmacist Roles in ADAP Programs NASTAD ADAP Conference, July 15, 2009 Ronald H. Goldschmidt, MD Cristina Gruta, Pharm D San Francisco General Hospital University of California San Francisco

  2. 11 Regional AETCs130 Local Perfomance Siteswww.aidsetc.org

  3. Target Populations Physicians Advanced practice nurses Nurses Physician assistants Pharmacists Oral health professionals Other healthcare professionals, including medical case managers Ryan White Program-funded providers serving hard-to-reach and underserved populations

  4. Trainings Didactic Presentations Interactive Skills Building Intensive Hands-On Clinical Training with Patients Patient Specific Clinical Consultations Technical Assistance and Capacity Building

  5. Profession of AETC Training Attendees July 1, 2006 - June 30, 2007 19,597 training events 46,896 hours of training 126,528 healthcare providers trained (73,157 trainees) 44% minority 66% minority-serving *Includes nurses, nurse practitioners, and advanced practice nurses Source: HRSA/HAB, 2008

  6. Most Frequent Topics Discussed Antiretroviral Therapy Diagnostic Tests & Disease Progression Adherence Clinical Manifestations of HIV Co-Morbidities Substance Use Opportunistic Infections Drug-Drug Interaction Adverse Drug Reactions Prevention Racial/Ethnic Minorities Risk Assessment Women with HIV Basic Science/ Epidemiology/Global

  7. National Centers National Resource Center National Evaluation Center National Minority AETC National HIV Telephone Consultation Center

  8. National Resource Center Training Materials Curricula Charts and Tables Online Training Pocket Guides Self-Study Materials Slide Sets Training Materials Web Links

  9. Slide sets Adolescents African Americans Antiretroviral Therapy Case Finding Corrections Cultural Competence Drug Interactions Epidemiology General Testing HIV Testing Hepatitis Co-infection Latinos (U.S.) Managing Side Effects Mental Illness & Health Food Safety & Nutrition Older Adults Opportunistic Infections Oral Health Palliative Care Pediatrics Post-exposure Prophylaxis Preventing Mother-to-Child Transmission Prevention with Positives Primary Care Resistance Testing Sexually Transmitted Infections Starting Treatment Substance Use/Abuse

  10. Clinical Manual for Management of the HIV-Infected Adult, 7/10/07 Each chapter can be accessed on line Testing and Assessment Health Maintenance and Disease Prevention Antiretroviral Therapy Complications of Antiretroviral Therapy Complaint-Specific Workups Disease-Specific Treatment Pain and Palliative Care Neuropsychiatric Disorders Populations Resources for Clinicians and Patients

  11. National HIV/AIDS Clinicians’ Consultation CenterUCSF – San Francisco General Hospital Warmline(800) 933 - 3413 National HIV Telephone Consultation Service Consultation on all aspects of HIV testing and clinical care PEPline(888) 448 - 4911 National Clinicians’ Post-Exposure Prophylaxis Hotline Recommendations on managing occupational exposures to HIV and hepatitis B & C Perinatal HIV Hotline(888) 448 - 8765 National Perinatal HIV Consultation & Referral Service Advice on testing and care of HIV-infected pregnant women and their infants Referral to HIV specialists and regional resources HRSA AIDS ETC Program & Community Based Programs, HIV/AIDS Bureau & Centers for Disease Control and Prevention (CDC) www.ucsf.edu/hivcntr

  12. Physicians Internal Medicine Infectious Diseases Family Medicine Ob-Gyn Clinical Pharmacists ------------------------------------------------ Expert consultation, free of charge National Clinicians’ Consultation Center (NCCC)Warmline, PEPline and Perinatal Hotline

  13. NCCC Call Volume Since 1992

  14. Total Consultations Provided by the NCCC 2008 Warmline - 1992 41,833 calls to date PEPline - 1997 78,831 calls to date Perinatal Hotline - 2004 1,573 calls to date 122,287 calls to date Currently: 13,178 calls/yr (1,178 calls/month) Warmline 321 PEPline 747 Perinatal Hotline 31

  15. Facility of Warmline Callers2008

  16. Profession of Warmline Callers2008

  17. HIV+ Patient Load of Warmline Callers2008

  18. Warmline Call Topics2008

  19. WarmlineNon-Occupational Exposures Call Topics2008

  20. PEPline Callers2008

  21. PEPline Call Type2008

  22. Most common HIV Testing Qs Indeterminate tests Interpretation of Western Blot Rapid test v. Standard tests False positives and negatives Confirmatory testing After Rapid or Standard test Concurrent illnesses/problems – effects on tests Pregnancy, IDU, acute illness, autoimmune disease State laws Post-exposure (after occupational / non-occupational exposures) Confidentiality issues Consent

  23. Special characteristics of NCCC consultations? Clinical faculty blend of… Expert knowledge Primary care foundation Multidisciplinary approach Non-judgmental approach to consultation Readily available

  24. National HIV/AIDS Clinicians’ Consultation CenterWarmline, PEPline, Perinatal HotlineUCSF – San Francisco General Hospital State HIV Testing Laws Compendium www.ucsf.edu/hivcntr Descriptions of each state’s HIV testing laws Definitions of commonly used terms Links to helpful resources Health Resources and Services Administration (HRSA) AIDS Education and Training Centers and Centers for Disease Control and Prevention (CDC)

  25. State HIV Testing Laws Compendium - Topicswww.ucsf.edu/hivcntr Requirements and restrictions on testing Anonymous or confidential testing Consent requirements Written, verbal, none Opt-in, opt-out Counseling requirements Pre-test, post-test; mandatory vs. recommended; etc. Special situations (pregnancy, criminal justice system) Disclosure Reporting requirements, including name-based reporting

  26. Cristina Gruta, PharmD cgruta@nccc.ucsf.edu HIV Pharmacist Specialist, NCCC Asst Clin Professor (WOS), UCSF School of Pharmacy Pharmacist Support of ADAP

  27. San Francisco Area AETC Model AETC Pharmacist Trainings

  28. Why train pharmacists? Integral part of HIV healthcare team whether in ambulatory, inpatient, or community practice setting Pharmacists as both patient educators and clinicians fills good niche for HIV medication management Adverse effect management Drug-drug interactions Adherence counseling

  29. Pharmacist HIV Trainings:SFAETC Model Since 1999, SFAETC has been conducting HIV trainings directed to community pharmacists Trainings borne out of partnership with California ADAP Statewide needs assessment done to determine HIV training needs of pharmacists staffing stores with low-, moderate-, and high-volume HIV customers http://www.aidsetc.org/pdf/workgroups/pharmTE-Guidebook_FINAL.pdf

  30. Pharmacist HIV Trainings:SFAETC Model Needs assessment established core competencies for pharmacist trainings Make pharmacist trainees more aware of HIV resources Review issues around HIV client confidentiality and cultural competency Provide updates on the latest advances in HIV care Heighten awareness surrounding intricacies of HIV-specific adherence counseling Heighten awareness of integrating pharmacy services to system of care and local HIV community

  31. Pharmacist HIV Trainings:SFAETC Model Designed a one-day training, “The Community Pharmacist: A Key Member of the HIV Care Team” Formats were didactic presentations and case-based workshops Workshop topics: Drug-drug interactions Adherence support HIV resistance testing interpretation Adverse effect management

  32. Pharmacist HIV Trainings:SFAETC Model First course in May 2000 ~ 12 courses >600 pharmacists trained More recent iteration of course has focused on medication errors Beyond the one day training format Group consultation led by SFAETC PharmD at community pharmacies “HIV 101” trainings by SFAETC PharmD at low-volume pharmacies

  33. Pharmacist HIV Trainings:Beyond the SFAETC Model http://www.aidsetc.org/pdf/workgroups/pharmTE-Guidebook_FINAL.pdf

  34. DISCLAIMER! The following slides were NOT reviewed by California SOA/ADAP Pharmacy Consultation Support for California ADAP

  35. CA SOA-PAETC Partnership Medical-Pharmacy Consultation support for CA SOA since 1999 PAETC consultation team consists of two MDs, one PharmD, and one RN all expert in HIV Provides medical and pharmacy-related perspective/advice to various SOA sections ADAP EIP/TMP CBC CSP Also provides direct global cross-sectional support, e.g. QM, clinic chart reviews

  36. Pharmacist Consultation Support for California ADAP Specific projects ADAP Medical Advisory Committee (MAC)-- provide technical assistance to ADAP officials about MAC clinical discussions Develop process for systematic review of agents for ADAP formulary consideration Cost-containment consultations-- give input on potential clinical impact of potential cost containment steps

  37. Pharmacist Consultation Support for California ADAP Specific projects, cont’d T-20 access program (2003-2005) Screened all ADAP clients for T-20 eligibility Approval criteria dependent on CD4+ count and resistance profile of virus If CD4+ 50-200, need to have 2 other active agents If CD4+ 50, can have </=1 active agent Time-intensive clinical screening of pt’s HIV treatment history including resistance test interptretation >300 clients screened

  38. Pharmacist Consultation Support for California ADAP Ongoing projects Provide clinical support/tools in developing/implementing ART prescribing criteria Clinical opinions on pipeline ART agents and expected time of FDA-approval Periodic formulary review

  39. Pharmacist Consultation Support for California ADAP Ongoing projects Clinical inquiries regarding appropriate ART use Review and provide clinical input regarding prior authorization criteria (e.g. maraviroc PA and tropism assay requirement) Provide clinical information regarding off-label use

  40. Future Directions ADAP needs clinical “eyes” to ensure programs are on target HIV pharmacists involvement in formulary discussions on national level HIV expertise to inform formulary decisions and ADAP questions Pharmacotherapy of hepatitis co-infection and primary care conditions Quality management projects Optimizing of ADAP prescribing with goal of decreasing duplications, omissions, errors, etc. Caring for HIV in primary care settings Educational support for new or experienced primary providers HIV trainings booklets of drugs/ interactions, etc. HIV expert consultation perhaps key to care for HIV pts in primary care setting

  41. rgoldschmidt@nccc.ucsf.edu cgruta@nccc.ucsf.edu

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