Emerging models are focusing on HIV, viral hepatitis and STI care in community pharmacy settings.
From long-acting injectable HIV therapies to hepatitis C testing, new models of care are creating opportunities for pharmacists to expand their impact. Few understand that shift better than the Burnet Institute’s Kate Mackie, an infectious diseases clinical pharmacist with more than 20 years’ experience across HIV, viral hepatitis and sexual health.
Ahead of her PSA26 Masterclass, co-delivered with Monash University infectious diseases Professor Joseph Doyle and Associate Professor Amanda Wade, Ms Mackie shares some of the trends shaping the future of care and what pharmacists need to know to stay ahead.
From daily tablets to long-acting injectables
One of the most significant recent developments in HIV care is the arrival of long-acting injectable therapy. Cabotegravir plus rilpivirine (Cabenuva), listed on the Pharmaceutical Benefits Scheme (PBS) for people living with HIV who are already virologically suppressed, replaces a daily oral tablet with two intramuscular injections every 8 weeks.
Community pharmacists are already beginning to administer it, Ms Mackie said.
‘With a fingerprick of blood, you get a result back with a really highly accurate test that says whether a person has ever been exposed to hepatitis C.’
Kate Mackie
‘A number of pharmacies around Melbourne [for example] have started offering it, and they’re usually pharmacies that are located pretty close to a clinic that has a lot of patients living with HIV, so they can offer that service pretty easily, and set up a system to enable it,’ she said.
‘It’s a step further than administering a vaccine, but it’s certainly something pharmacists [can] deliver.’
However, rilpivirine (Cabenuva) is not suitable for every patient living with HIV. ‘They can’t have failed similar treatments in the past or have resistance to any of the two components in the treatment, so it’s certainly not suitable across the board at all,’ Ms Mackie said.
Adherence to the dosing schedule is also non-negotiable. ‘We have to make sure the patient is able to attend every 8 weeks,’ she said. ‘If the patient travels a lot, or it’s not going to fit into their routine, then it’s not something that will be suitable. While there is 7 days of leeway on either side of the target injection date, it’s important to have those injections on time.’
Efficacy relative to oral therapy is another consideration. ‘In terms of its efficacy at keeping someone virally suppressed, it’s quite close to the orals,’ Ms Mackie said.
‘Even if you have perfect adherence, occasionally patients will fail – so if the viral load starts climbing back up, then they might get some resistance to those agents, and then it might affect what oral agents they can take.’
While it’s ‘not suitable for everyone’, it’s helpful to have options that can be better tailored to individual patients.
‘They’re obviously part of the decision about whether [Cabenuva] is going to be suitable for them or not – but it’s something else on the menu,’ she added.
Updates in preventative care
Beyond treatment, the prevention space is another area of growing pharmacy opportunity within infectious disease care.
‘In terms of pharmacy offerings, we’ve got PrEP [Pre-Exposure Prophylaxis] and Doxy-PEP [Doxycycline Post-Exposure Prophylaxis], and there’s probably moves in the future to have pharmacists prescribing this, because they are protocolised, and there are guidelines you can follow for the delivery of safe care as a prevention strategy,’ Ms Makie said.
Long-acting injectable PrEP offers an alternative to daily oral tablets, delivering sustained HIV prevention via periodic injections rather than a pill regimen. Cabotegravir is administered every 2 months after two initial monthly starter doses, but it’s not yet listed on the PBS for prevention in Australia.
‘Only a limited number of patients with contraindications to oral PrEP were able to enter a compassionate supply program in Australia,’ she said.
Point-of-care testing in pharmacy
Hepatitis C testing offers another frontier for pharmacy involvement. Through the Burnet Institute’s EXPAND-C Project, Ms Mackie is leading work that will see pharmacists offer hepatitis C point-of-care testing via a Therapeutic Goods Administration-approved device, harm reduction information and treatment referral options.
‘With a fingerprick of blood, you get a result back with a really highly accurate test that says whether a person has ever been exposed to hepatitis C,’ she said.
In practice, the result appears within approximately 1 minute. ‘By the time you sit down with the patient to explain it – and add the fingerprick blood sample to the reagent followed by the clarifying solution – the result appears pretty much straight away.’
Unlike the take-home HIV and STI tests pharmacies currently stock, this test is only TGA-approved for use by healthcare workers.
‘It’s pretty easy to use. The pharmacist can then help connect the patient to further care if the test is positive,’ Ms Mackie said.
While stigma can affect diagnosis and care, international data shows pharmacist involvement can significantly increase treatment uptake.
‘In Scotland they’ve got some really good pharmacy models, and [one] paper showed that people were twice as likely to commence and complete hepatitis treatment when they had pharmacy-based care compared to usual clinical care,’ she said.
Learn more about the future of HIV, viral hepatitis and STI care at PSA26. Register now to attend.
