Drug burden index in people living with HIV over 50 years of age in a real clinical practice cohort.

OBJECTIVES: To determine DBI and its relationship with polypharmacy and pharmacotherapeutic complexity (PC) in a cohort of PLWH over 50 years of age at follow-up of pharmacotherapy in a tertiary hospital. METHODS: Observational and retrospective study that included PLWH in active antiretroviral treatment over 50 years of age who have been followed up in outpatient pharmacy services. Pharmacotherapeutic complexity was estimated through Medication Regimen Complexity Index (MRCI). Collected variables included comorbidities, current prescriptions and its classification according to anticholinergic and sedative activity and associated risk of falls. RESULTS: Studied population included 251 patients (85.7% men; median age: 58 years, interquartile range: 54-61). There was a high prevalence of high DBI scores (49.2%). High DBI was significantly correlated with a high PC, polypharmacy, psychiatric comorbidity and substances abuse (p<0.05). Among sedative drugs, the most prescribed were anxiolytic drugs (N05B) (n=85), antidepressant drugs (N06A) (n=41) and antiepileptic drugs (N03A) (n=29). For anticholinergic drugs, alpha-adrenergic antagonist drugs (G04C) were the most prescribed (n=18). Most frequent drugs associated with risk of falls were anxiolytics (N05B) (n=85), angiotensin-converting enzyme inhibitors (C09A) (n=61) and antidepressants (N06A) (n=41). CONCLUSION: The DBI score in older PLWH is high and it is related to PC, polypharmacy, mental diseases and substance abuse as is the prevalence of fall-related drugs. Control of these parameters as well as the reduction of the sedative and anticholinergic load should be included in the lines of work in the pharmaceutical care of people living with HIV+.

[Translated article] 2022 update of the indicators for quality of care and pharmaceutical care for people living with human immunodeficiency virus.

OBJECTIVE: To update and define indicators for improving the quality of care and Pharmaceutical Care for people living with HIV infection in Spain. METHOD: The present project, which updates the previous version of the 2013 document, was developed in four work phases carried out between January and June 2022. In phase 1, the organization phase, a working group was created, made up of seven hospital pharmacy specialists with extensive experience in pharmaceutical care and from different SFHs in Spain. In addition, another 34 specialists participated in the evaluation of the indicators through two rounds of online evaluation to generate consensus. For phase 2, initially, a review of the identified reference literature was carried out with the aim of establishing a basis from which to define a proposal for quality criteria and indicators. Then, a preliminary proposal of criteria was made and revisions were established for their adjustment in several telematic work meetings. In phase 3, consensus was established based on the Delphi-Rand/UCLA consensus methodology. In addition, all the indicators classified as appropriate and necessary were grouped according to two levels of monitoring recommendation, so as to guide the hospital pharmacy services in the priority of their measurement: key and advanced. Finally, in phase 4, the final project document was prepared, along with the corresponding descriptive sheets for each indicator in order to facilitate the measurement and evaluation of the indicators by the hospital pharmacy services. RESULTS: Following the consensus methodology used, a list of items made up of 79 appropriate and necessary indicators was drawn up to establish a follow-up and monitoring of the quality and activity of Pharmaceutical Care for people living with HIV. Of these, 60 were established as key and 19 advanced. CONCLUSIONS: The indicators defined and updated, since the previous version of 2013, are intended to be a tool for professionals to guide decision-making and facilitate the measurement and assessment of the most relevant aspects of the quality and pharmaceutical care of people living with HIV.

2022 update of the indicators for quality of care and pharmaceutical care for people living with human immunodeficiency virus. / Actualización 2022 de los indicadores para la calidad asistencial y la atención farmacéutica a las personas que viven con el virus de la inmunodeficiencia humana.

OBJECTIVE: To update and define indicators for improving the quality of care and pharmaceutical care for people living with HIV infection in Spain. METHOD: The present project, which updates the previous version of the 2013 document, was developed in four work phases carried out between January and June 2022. In phase 1, the organization phase, a working group was created, made up of seven hospital pharmacy specialists with extensive experience in pharmaceutical care and from different SFHs in Spain. In addition, another 34 specialists participated in the evaluation of the indicators through two rounds of online evaluation to generate consensus. For phase 2, initially, a review of the identified reference literature was carried out with the aim of establishing a basis from which to define a proposal for quality criteria and indicators. Then, a preliminary proposal of criteria was made and revisions were established for their adjustment in several telematic work meetings. In phase 3, consensus was established based on the Delphi-Rand/UCLA consensus methodology. In addition, all the indicators classified as appropriate and necessary were grouped according to two levels of monitoring recommendation, so as to guide the hospital pharmacy services in the priority of their measurement: key and advanced. Finally, in phase 4, the final project document was prepared, along with the corresponding descriptive sheets for each indicator in order to facilitate the measurement and evaluation of the indicators by the hospital pharmacy services. RESULTS: Following the consensus methodology used, a list of items made up of 79 appropriate and necessary indicators was drawn up to establish a follow-up and monitoring of the quality and activity of pharmaceutical care for people living with HIV. Of these, 60 were established as key and 19 advanced. CONCLUSIONS: The indicators defined and updated, since the previous version of 2013, are intended to be a tool for professionals to guide decision-making and facilitate the measurement and assessment of the most relevant aspects of the quality and pharmaceutical care of people living with HIV.

Study on the approach to HIV: health management and the healthcare process in Spain.

INTRODUCTION: HIV continues to represent a problem of great relevance for public health in Spain. This study aims to carry out an analysis that will provide in-depth knowledge of the resources, clinical care, and management during the diagnosis, follow-up, and treatment phases of HIV infection in Spain. METHODS: In the first phase, a multidisciplinary Scientific Committee designed an information collection tool in the form of a survey. In the second phase, carried out in the autonomous communities of Andalusia, Catalonia, and La Rioja, a multidisciplinary group of 42 experts, representatives of the public administration, clinical profiles, and representatives of NGOs in the field of HIV answered the survey. RESULTS: The assessment of HIV resources is generally positive. As regards diagnosis, the experts considered that there was good coordination between Primary and Hospital care. Regarding treatment, the evaluations reflected good opinions on therapeutic conciliation and adherence, with a negative opinion in the evaluation of drug interactions with antiretroviral treatment. Regarding follow-up, the perception expressed was disparate concerning the coordination between Hospital and Primary Care as well as the adaptation of care to chronicity, aging, fragility, mental health, and oncological processes. CONCLUSION: There are certain processes that can be improved in the management of HIV infection in people with HIV in Spain, including protocols for follow-up and coordination between primary and hospital care in the treatment and follow-up of the disease.

Simplification and Multidimensional Adaptation of the Stratification Tool for Pharmaceutical Care in People Living With HIV.

BACKGROUND: People living with human immunodeficiency virus (HIV) require specific pharmaceutical care (PC). Although the 2017 Capacity-Motivation-Opportunity (CMO) PC model allows a multidisciplinary approach that focuses on patient needs, it is too complex and presents room for improvement. OBJECTIVE: The aim of this study is to simplify and adapt the previous 2017 PC tool through a multidimensional approach to improve HIV patient care, to prove the validity of the model in real-life patients. METHODS: The new PC tool was generated by keeping some of the variables of the 2017 document and conducting a literature search. Content validity was determined by a 2-round Delphi methodology with an expert panel of 42 pharmacists. Consensus for the first and second rounds was defined as ≥70% agreement. The tool generated was validated in 407 real-life patients. RESULTS: Thirty-seven experts completed the first round of the Delphi survey and 36 the second. No consensus was reached for 3 variables, any of the frequency options and 4 interventions, while the experts agreed not to include 1 intervention in round 1. Consensus to include them was found for all but 1 variable and 1 intervention in round 2. The final tool obtained to select and stratify HIV-positive patients was composed of 9 dimensions divided into 17 variables. The new tool was validated with real-life patients and 3 priority levels were defined. CONCLUSIONS AND RELEVANCE: We created a new pyramid of score thresholds to classify patients into priority levels. The new tool simplifies the 2017 model and improves its utility to help HIV-positive patients, owing to its multidimensional approach.

Influence of polypharmacy in the simultaneous presence of high pharmacotherapeutic complexity, drug interactions and non-adherence to medication in patients with HIV infection. Project 3-HIT.

INTRODUCTION: The high pharmacotherapeutic complexity, drug interactions and lack of adherence to concomitant medication are circumstances with negative consequences in the clinical evolution of patients with HIV infection. The 3-HIT phenomenon refers to the simultaneous occurrence of these situations. The objective of the study is to determine the prevalence of the phenomenon 3-HIT in the polymedicated HIV population as well as to determine factors related to its occurrence. METHODS: Observational, retrospective and single-center study that included all elderly patients on active antiretroviral treatment in pharmacotherapeutic follow-up between January and March 2020. A logistic regression model was carried out to evaluate the factors associated with the occurrence of the 3-HIT concept with the variables significantly associated with this phenomenon and those considered clinically relevant. RESULTS: 428 patients were included, registering a prevalence of polypharmacy in 25.9% of the study sample. The 3-HIT phenomenon was detected in 6.3% of the patients. For each concomitant drug prescribed the risk of developing the phenomenon 3-HIT increases 1.5 times. CONCLUSION: Prevalence of the phenomenon 3-HIT is high in HIV patients with polymedication. A change in the pharmaceutical care model to a multidimensional setting is essential, together with pharmacotherapeutic optimization strategies to improve patient health outcomes.

Prevalence of compliance with PIMDINAC criteria among elderly people living with HIV and in non-infected outpatients with other chronic diseases.

BACKGROUND: There is a high prevalence of multimorbidity and polypharmacy among older people, especially in people living with HIV (PLWH) with an increased life expectancy due to effective antiretroviral therapy (ART). Consequently, there is a higher risk of potentially inappropriate medications (PIM), potential drug-drug interactions (DI), and problems of non-adherence to treatment (NAC) in older PLWH. PIMDINAC criteria (potentially inappropriate medications (PIM), drug-drug interactions (DI), and non-adherence to treatment (NAC)) purport to jointly analyse these problems. The purpose of the study was to compare the prevalence of PIMDINAC criteria among elderly PLWH and non-infected patients with chronic diseases, and to determine whether HIV infection constitutes a predictor of the presence of PIMDINAC criteria, totally or partially. METHODS: A cross sectional study was conducted between February and June 2020. HIV positive patients aged ≥65 years were compared with a group of patients with chronic conditions attending the outpatient hospital pharmacy service. RESULTS: The study involved 140 patients: 47 HIV positive and 93 HIV negative, and mean age was 69 versus 73 years, respectively (p=0.062). The prevalence of total PIMDINAC criteria was similar between the groups (12.5 vs 10.8%, p=0.505). In relation to inappropriate medication, no differences were observed between groups (48.9 vs 55.9%, p=0434). Drug-drug interactions were higher in patients with chronic conditions (52.7 vs 25.5%, p=0.002) compared with non-adherence, which was higher in people with HIV (22.6 vs 65.6%, p<0.001). No differences in polypharmacy (≥6 and 11 drugs) rates were observed. CONCLUSIONS: PIMDINAC criteria were highly prevalent in older PLWH, similar to non-infected patients. HIV infection in older people was associated with a lower risk of drug-drug interactions. However, non-adherence was a risk factor compared with age matched controls. Deprescribing strategies, including a capability-motivation-opportunity pharmaceutical care model based intervention should be implemented in clinical routines.

Prevalence of PIMDINAC criteria and associated factors in elderly HIV patients.

INTRODUCTION: Aging of people living with HIV could be related to potentially inappropiate medication prescriptions, drugs interactions and lack of drugs adherence. PIMDINAC criteria seek to jointly analyze these problems. The objective of this study is to determine the prevalence of PIMDINAC criteria in an elderly HIV population. METHODS: Observational, cross-sectional, multicenter study that included patients older than 65 years in pharmacotherapeutic follow-up between February-April 2020. The main endpoint was the percentage of PIMDINAC criteria identified in the study population. RESULTS: Forty-seven patientes were included, identifying total PIMDINAC in 12.5%. Non-adherence to concomitant treatment was detected in 65.6% of patients, potentially inappropiate medication in 48.9% and drugs interactions in 25.2%. The number of concomitant drugs and polypharmacy were associated with a higher appearance of PIMDINAC criteria. CONCLUSION: The prevalence of PIMDINAC criteria in elderly HIV patients is high.

Prevalence of polypharmacy and associated factors among patients living with HIV infection in Spain: The POINT study.

PURPOSE: Survival in people living with HIV (PLWH) has increased and thus people are aging with HIV, increasing the frequency of multimorbidity and polypharmacy. This cross-sectional study was conducted to evaluate the prevalence of polypharmacy among PLWH who were on antiretroviral treatment and were followed in an outpatient setting by the pharmacy department of several hospitals across Spain. In addition, we aimed to evaluate factors associated with polypharmacy and treatment complexity among this population. MATERIAL AND METHODS: We recorded information on demographic data, data on disease control including viral load and CD4 count at the time of inclusion, comorbidities, pharmacologic treatment and drugs interactions. Polypharmacy was defined as the use of 6 or more different drugs, including antiretroviral medication; major polypharmacy was defined as the use of ≥11 different drugs. RESULTS: Overall, 1225 PLWH were eligible in the study. The median (IQR) age was 49 (40-54). Comorbidities were present in 819 (67%) PLWH and 571 (47%) had two or more comorbidities. Overall, 397 (32.4%, 95% CI 29.8-34.9) PLWH met the criteria for polypharmacy, and 67 (5.5%, 95% CI, 4.2-6.7) had major polypharmacy. Several factors were associated with polypharmacy such as type of antiretroviral treatment, presence of potential interactions, the use of several types of medications and the number of comorbidities. Treatment complexity was also a factor strongly associated with polypharmacy; for each point increase in the medication regimen complexity index (MRCI), the likelihood of polypharmacy increased 2.3-fold. CONCLUSIONS: Polypharmacy is frequent among PLWH in Spain and contributes to a relevant extent to treatment complexity.

Drug-drug interactions between treatment specific pharmacotherapy and concomitant medication in patients with COVID-19 in the first wave in Spain.

Primary aim was to assess prevalence and severity of potential and real drug-drug interactions (DDIs) among therapies for COVID-19 and concomitant medications in hospitalized patients with confirmed SARS-CoV-2 infection. The secondary aim was to analyze factors associated with rDDIs. An observational single center cohort study conducted at a tertiary hospital in Spain from March 1st to April 30th. rDDIs refer to interaction with concomitant drugs prescribed during hospital stay whereas potential DDIs (pDDIs) refer to those with domiciliary medication. DDIs checked with The University of Liverpool resource. Concomitant medications were categorized according to the Anatomical Therapeutic Chemical classification system. Binomial logistic regression was carried out to identify factors associated with rDDIs. A total of 174 patients were analyzed. DDIs were detected in 152 patients (87.4%) with a total of 417 rDDIs between COVID19-related drugs and involved hospital concomitant medication (60 different drugs) while pDDIs were detected in 105 patients (72.9%) with a total of 553 pDDIs. From all 417 rDDIs, 43.2% (n = 180) were associated with lopinavir/ritonavir and 52.9% (n = 221) with hydroxychloroquine, both of them the most prescribed (106 and 165 patients, respectively). The main mechanism of interaction observed was QTc prolongation. Clinically relevant rDDIs were identified among 81.1% (n = 338) ('potential interactions') and 14.6% (n = 61) (contraindicated) of the patients. Charlson index (OR 1.34, 95% IC 1.02-1.76) and number of drugs prescribed during admission (OR 1.42, 95% IC 1.12-1.81) were independently associated with rDDIs. Prevalence of patients with real and pDDIs was high, especially those clinically relevant. Both comorbidities and polypharmacy were found as risk factors independently associated with DDIs development.

Prevalence of PIMDINAC criteria and associated factors in elderly HIV patients. / Prevalencia y factores asociados con la presencia de criterios PIMDINAC en pacientes VIH de edad avanzada.

INTRODUCTION: Aging of people living with HIV could be related to potentially inappropriate medication prescriptions, drugs interactions and lack of drugs adherence. PIMDINAC criteria seek to jointly analyze these problems. The objective of this study is to determine the prevalence of PIMDINAC criteria in an elderly HIV population. METHODS: Observational, cross-sectional, multicenter study that included patients older than 65 years in pharmacotherapeutic follow-up between February-April 2020. The main endpoint was the percentage of PIMDINAC criteria identified in the study population. RESULTS: Forty-seven patientes were included, identifying total PIMDINAC in 12.5%. Non-adherence to concomitant treatment was detected in 65.6% of patients, potentially inappropriate medication in 48.9% and drugs interactions in 25.2%. The number of concomitant drugs and polypharmacy were associated with a higher appearance of PIMDINAC criteria. CONCLUSION: The prevalence of PIMDINAC criteria in elderly HIV patients is high.

Prevalence of polypharmacy and associated factors among patients living with HIV infection in Spain: The POINT study.

PURPOSE: Survival in people living with HIV (PLWH) has increased and thus people are aging with HIV, increasing the frequency of multimorbidity and polypharmacy. This cross-sectional study was conducted to evaluate the prevalence of polypharmacy among PLWH who were on antiretroviral treatment and were followed in an outpatient setting by the pharmacy department of several hospitals across Spain. In addition, we aimed to evaluate factors associated with polypharmacy and treatment complexity among this population. MATERIAL AND METHODS: We recorded information on demographic data, data on disease control including viral load and CD4 count at the time of inclusion, comorbidities, pharmacologic treatment and drugs interactions. Polypharmacy was defined as the use of 6 or more different drugs, including antiretroviral medication; major polypharmacy was defined as the use of ≥11 different drugs. RESULTS: Overall, 1225 PLWH were eligible in the study. The median (IQR) age was 49 (40-54). Comorbidities were present in 819 (67%) PLWH and 571 (47%) had two or more comorbidities. Overall, 397 (32.4%, 95% CI 29.8-34.9) PLWH met the criteria for polypharmacy, and 67 (5.5%, 95% CI, 4.2-6.7) had major polypharmacy. Several factors were associated with polypharmacy such as type of antiretroviral treatment, presence of potential interactions, the use of several types of medications and the number of comorbidities. Treatment complexity was also a factor strongly associated with polypharmacy; for each point increase in the medication regimen complexity index (MRCI), the likelihood of polypharmacy increased 2.3-fold. CONCLUSIONS: Polypharmacy is frequent among PLWH in Spain and contributes to a relevant extent to treatment complexity.

Prevalence of polypharmacy and pharmacotherapy complexity in elderly people living with HIV in Spain. POINT study.

OBJECTIVE: To determine the prevalence of polypharmacy in persons living with  HIV of at least 65 years of age receiving antiretroviral treatment. A  characterization of antiretroviral treatment, as well as a determination of the  prevalence of comorbidities; of the most common types of concomitant medication; of adherence rates; of the pharmacotherapeutic  complexity; and of drug-drug interactions were also among the goals of the  study. METHOD: This was a multi-center, cross-sectional observational study that  included persons living with HIV aged 65 years or more who were on active  antiretroviral treatment. Demographic, clinical (viral load, CD4 count and  comorbidities) and pharmacotherapeutic (type of antiretroviral treatment: single tablet regimen, polypharmacy [six active ingredients or more] and major  polypharmacy [11 active ingredients or more] variables were considered).  Adherence to antiretroviral treatment was measured by dispensation records and the Simplified Medication Adherence Questionnaire, while adherence to  concomitant medication was measured using dispensation records and the  Morisky-Green questionnaire. The Medication Regimen Complexity Index was  calculated. Drug-drug interactions were analyzed using the Liverpool and  Lexicomp databases. RESULTS: Seventy-four patients (86.5% male) were included, with a median age  of 69 years (66.7-72.0). The sexual route was the most common route of  transmission of the disease (67.6%). The virus was undetectable in 89.2% of  patients; the CD4 count was over 200/mL in 94.6% of the sample. The median  number of comorbidities was 3.5 (2.0-5.0), 52.7% of them being cardiovascular; 50.0% related to the central nervous system; 17.6% hepatic; and 8.1%  consisting in chronic pulmonary disease. A total of 81.1% of patients received  triple therapy and 48.6% single tablet regimen. The median number of  concomitant drugs administered was 5.0 (2.0-7.0), polypharmacy was observed  in 71.6% of cases and major polypharmacy in 25.7%. Antihypertensive and  cardiovascular drugs were prescribed to 56.8% of patients, lipid-lowering drugs  to 50.0%, antiulcer agents to 33.8% and psychoactive drugs to 32.4%.  According to dispensation records, adherence to antiretroviral treatment was  85.1% and to concomitant medication 62.8%. The median Medication Regimen Complexity Index for the whole treatment was 13.0 (8.0-17.6). Potential drug- drug interactions were observed in 55.4% of patients and contraindicated interactions in 12.2%. CONCLUSIONS: Elderly persons living with HIV exhibit a high prevalence of  polypharmacy, pharmacotherapeutic complexity, poor adherence and drug-drug  interactions. For that reason, pharmacotherapeutic optimization must be a  priority in these patients.

Objetivo: Determinar la prevalencia de polifarmacia en personas que viven con  VIH de al menos 65 años en tratamiento antirretroviral. Describir el tratamiento  antirretroviral, determinar la prevalencia de comorbilidades, el tipo de  medicación concomitante más frecuente, la adherencia, la complejidad farmacoterapéutica y las interacciones.Método: Estudio observacional, transversal y multicéntrico en el que se incluyeron a personas que viven con VIH de al menos 65 años con  tratamiento antirretroviral activo. Se recogieron variables demográficas, clínicas (carga viral, linfocitos CD4 y comorbilidades) y farmacoterapéuticas (tipo  de tratamiento antirretroviral, regímenes con single- tablet-regimen, polifarmacia ­seis principios activos incluyendo tratamiento  antirretroviral­, polifarmacia mayor ­11 principios activos incluyendo  tratamiento antirretroviral­). Se midió la adherencia al tratamiento  antirretroviral con los registros de dispensación y con el Simplified Medication  Adherence Questionnaire, y la adherencia al tratamiento concomitante mediante  los registros de dispensación y el cuestionario Morisky-Green. Se calculó el  índice de complejidad farmacoterapéutica a través del Medication Regimen  Complexity Index. Se revisaron las interacciones con la base de datos de  Liverpool y Lexicomp. Resultados: Se incluyeron 74 pacientes (86,5% hombres) con una mediana de  edad de 69 (66,7-72,0) años. La vía sexual fue la forma más frecuente de  adquisición (67,6%). Presentaron indetectabilidad del virus el 89,2% de los  pacientes y con una cifra de linfocitos CD4 de más de 200/ml el 94,6%. La  mediana de comorbilidades fue de 3,5 (2,0-5,0): cardiovascular 52,7%, sistema  nervioso central 50,0%, hepática 17,6% y enfermedad pulmonar crónica 8,1%.  Recibieron triple terapia el 81,1% y single-tablet-regimen el 48,6%. La mediana  de fármacos concomitantes fue 5,0 (2,0-7,0), polifarmacia 71,6% y polifarmacia mayor 25,7%. Medicamentos antihipertensivos y del sistema cardiovascular  fueron prescritos en un 56,8% de los pacientes, hipolipemiantes 50,0%,  antiulcerosos 33,8% y psicofármacos 32,4%. La adherencia según registros de  dispensación del tratamiento antirretroviral fue del 85,1% y de la medicación  concomitante del 62,8%. La mediana del Medication Regimen Complexity Index  del tratamiento completo fue 13,0 (8,0-17,6). Tenían al menos una interacción potencial el 55,4% y al menos una contraindicada el 12,2% de los pacientes.Conclusiones: Las personas mayores que viven con VIH tienen una alta  prevalencia de polifarmacia, complejidad farmacoterapéutica, baja adherencia al  tratamiento e interacciones, por lo que la optimización farmacoterapéutica debe  ser una prioridad en este tipo de pacientes.

Consensus document on enhancing medication adherence in patients with the human immunodeficiency virus receiving antiretroviral therapy.

Adherence to treatment in patients living with HIV remains the focus of attention of health professionals and researchers. However, patient profiles and the  available therapeutic arsenal have changed greatly over the last decade.  Inadequate adherence not only to antiretroviral therapy but also to other  prescribed drugs remains the main cause of therapeutic failure. There are  several factors associated with poor adherence and others that facilitate it,  hence the importance of identifying, managing and correcting situations that  may hinder adherence. Likewise, adherence should be periodically reassessed  during the follow-up of ART and other prescribed drugs. It has so far proved  impossible to find a single method capable of providing a reliable measurement  of adherence. That is why it is necessary to use a combination of multiple easy- to-implement methods. Additionally, a good relationship with the patient  facilitates the conveyance of adequate information on adherence. It is currently  considered that interventions to improve adherence should be multidisciplinary,  individualized and adjusted to the new patterns of infection transmission, and  that controlling adherence to other drugs prescribed to patients with HIV should  be part of such interventions. This document provides an update on the  recommendations published in 2008 based on a review of the scientific  literature. The main goal is to help healthcare professionals dedicated to the  clinical and therapeutic management of HIV patients (doctors, pharmacists,  nurses, psychologists and social workers) improve adherence of such patients to  all the drugs prescribed to them as treatment for their HIV infection.

La adherencia al tratamiento en el paciente con infección por el virus de la  inmunodeficiencia humana sigue siendo foco de atención de profesionales sanitarios e investigadores. Sin embargo, el perfil del paciente y el  arsenal terapéutico disponible han cambiado enormemente en la última década.  La adherencia inadecuada, no solo al tratamiento antirretroviral sino también a otros fármacos prescritos, sigue siendo la principal causa de fracaso  terapéutico. Existen diversos factores asociados a la mala adherencia y otros  que facilitan la misma, de ahí la importancia de identificar y manejar las  situaciones que puedan dificultar la adherencia e intentar corregirlas. Asimismo, se debe reevaluar periódicamente la adherencia durante el  seguimiento del tratamiento antirretroviral y del resto de los fármacos  prescritos. En la actualidad no existe un método único para medir la adherencia  de forma fiable. Por ello se hace necesario utilizar varios métodos combinados de fácil realización. Adicionalmente, una buena relación entre el  personal sanitario y los pacientes facilita la obtención de una adecuada  información sobre la adherencia. Las intervenciones para mejorar la adherencia  deben ser multidisciplinares, individualizadas y ajustadas a los nuevos patrones  de transmisión de la infección, y es fundamental incluir el control de la adherencia a otros fármacos prescritos al paciente con el virus de la  inmunodeficiencia humana. El presente documento actualiza las  recomendaciones publicadas en 2008 tras una revisión de la literatura científica,  lo que ha permitido emitir unas recomendaciones consensuadas para la mejora  de la adherencia al tratamiento. El objetivo principal es ayudar a todos los  profesionales sanitarios dedicados al control clínico y terapéutico de los  pacientes con el virus de la inmunodeficiencia humana (médicos, farmacéuticos,  enfermeras, psicólogos y trabajadores sociales) a mejorar la adherencia a toda  la farmacoterapia que tengan prescrita.

Effect on the adherence to concomitant medications after initiation of treatment with direct-acting antiviral agents against hepatitis C virus.

INTRODUCTION: Many patients with hepatitis C virus (HCV) have associated comorbidities that require complex treatments. We sought to determine the impact of treatment with direct-acting antiviral agents (DAAs) for HCV on adherence to prescribed concomitant medications for associated comorbidities and to identify predictors of non-adherence to comedications. PATIENTS AND METHODS: HCV-infected patients treated with DAAs in a Spanish hospital between January 2015 and December 2016 and followed-up by the pharmacy unit were included in the study. Adherence to concomitant comedication prescribed before and during HCV therapy with DAAs was compared to adherence during the same number of weeks before DAA initiation. Demographic, clinical and pharmacotherapy variables were analyzed to determine factors associated with non-adherence. A multivariate regression model was created for prediction of non-adherence to concomitant medication. RESULTS: Data from 214 patients using prescribed concomitant therapies were analyzed. Significant reduction on adherence to comedications was observed after initiation of DAA treatment compared with a similar period before therapy initiation (29.9% vs. 36.9%, p=0.032). The univariate analysis showed that polypharmacy and presence of vascular disease were associated negatively with adherence to concomitant medications (87.8%, p=0.006 and 84.7%, p<0.001, respectively). Multivariate analysis indicated that HIV/HBV coinfection was associated with adherence (OR 0.19; 95% CI 0.09-0.39), while polypharmacy was a predictor for non-adherence (OR 4.54; 95% CI 1.48-13.92). DISCUSSION: Adherence to concomitant medications decreases in HCV-infected patients when DAA therapy is initiated. Polypharmacy is a predictor for non-adherence, while HIV/HBV coinfection reduce non-adherence rates. Polymedicated patients on DAAs might benefit from close follow-up and educational programmes to improve their adherence.

The challenge of aging and pharmacoterapeutic complexity in the HIV + patient.

OBJECTIVE: To describe the current knowledge and management of aging and  pharmacotherapeutic complexity in HIV + patients. METHOD: A review of literature was carried out, including articles, originals or  reviews, published in English or Spanish, from 2007 to 2017, which analysed the aging and pharmacotherapeutic complexity in HIV + patients. The terms  «Polypharmacy¼/¼Polypharmacy¼, «Aging¼/¼Aging¼, «Frailty¼/¼Fragility¼,  «Pharmacotherapeutic Complexity¼/¼Medication Regimen Complexity¼ and  «HIV¼/"HIV¼ were combined. The review was carried out independently by two  authors. The degree of agreement, according to the Kappa index, was analysed. Results: A total of 208 references were analysed, including, finally, only 68. An  aging of the population and an increase in associated comorbidities have been  identified, especially over 50 years-old. Immunological changes similar to those  that are generated in a non-infected elderly population have been described.  These conditions influencing the prescription of antiretroviral treatment,  according to studies identified. In parallel, polypharmacy is increasingly present,  being defined exclusively by the concomitant use of five drugs.  Pharmacotherapeutic complexity, through the Medication Regimen Complexity  Index, has begun to analyse and relate to health outcomes. There has been a  need to know and apply concepts already known in non-HIV-aged population,  such as de-prescription, potentially inappropriate medication, cholinergic risk, although few results are available. CONCLUSIONS: There is a growing interest to know about the relationship between HIV and aging. Pharmacotherapeutic complexity is  beginning to be used as a pharmacotherapeutic follow-up criterion due to its influence on health outcomes. It is necessary to manage and incorporate new  concepts that help pharmacotherapeutic optimization in this population.

Objetivo: Describir el conocimiento actual y el manejo del envejecimiento y la  complejidad farmacoterapéutica en pacientes VIH ≥ .Método: Se realizó una revisión bibliográfica, incluyéndose artículos, originales o revisiones, publicados en lengua inglesa o española, desde 2007 al 2017, que analizaron el envejecimiento y la complejidad farmacoterapéutica  en pacientes VIH ≥ . Se combinaron los términos:  "Polypharmacy"/"Polifarmacia", "Aging"/"Envejecimiento", "Frailty"/"Fragilidad",  "Complejidad Farmacoterapéutica"/"Medication Regimen Complexity" y  "HIV"/"VIH". La revisión se realizó de forma independiente por dos autores. Se  analizó el grado de concordancia según el índice Kappa.Resultados: Se analizaron 208 referencias bibliográficas, incluyéndose finalmente 68. Se ha identificado un envejecimiento de la  población y un incremento de las comorbilidades asociadas, especialmente a  partir de los 50 años. Se han descrito cambios inmunológicos similares a los que  se generan en la población anciana no infectada. Esto condiciona, según estudios identificados, la prescripción del tratamiento antirretroviral. Paralelamente, el concepto de polifarmacia está cada vez más  presente, definiéndose exclusivamente por el uso concomitante de cinco  fármacos. La complejidad farmacoterapéutica, a través del Medication Regimen Complexity Index, se ha empezado a analizar y a relacionar con  resultados en salud. Se ha evidenciado una necesidad de profundizar y aplicar conceptos ya conocidos en la población no VIH envejecida, como  desprescripción, medicación potencialmente inapropiada, riesgo colinérgico, etc., aunque existen pocos resultados disponibles.Conclusiones: Existe un interés creciente en profundizar en la relación VIH y  envejecimiento. La complejidad farmacoterapéutica está empezando a utilizarse  como criterio de seguimiento farmacoterapéutico por su influencia en los  resultados en salud. Es necesario manejar e incorporar nuevos conceptos que  ayuden a la optimización farmacoterapéutica en esta población.

Effect of a Structured Pharmaceutical Care Intervention Versus Usual Care on Cardiovascular Risk in HIV Patients on Antiretroviral Therapy: INFAMERICA Study.

BACKGROUND: HIV+ patients have increased their life expectancy with a parallel increase in age-associated comorbidities. OBJECTIVE: To determine the effectiveness of an intensive pharmaceutical care follow-up program in comparison to a traditional model among HIV-infected patients with moderate/high cardiovascular risk. METHOD: This was a multicenter, prospective, randomized study of a structured health intervention conducted between January-2014 and June-2015 with 12 months of follow-up at outpatient pharmacy services. The selected patients were randomized to a control group (usual care) or intervention group (intensive pharmaceutical care). The interventional program included follow-up of all medication taken by the patient to detect and work toward the achievement of pharmacotherapeutic objectives related to cardiovascular risk and making recommendations for improving diet, exercising, and smoking cessation. Individual motivational interview and periodic contact by text messages about health promotion were used. The primary end point was the percentage of patients who had reduced the cardiovascular risk index, according to the Framingham-score. RESULTS: A total of 53 patients were included. As regards the main variable, 20.7% of patients reduced their Framingham-score from high/very high to moderate/low cardiovascular risk versus 12.5% in the control group ( P=0.016). In the intervention group, the number of patients with controlled blood pressure increased by 32.1% ( P=0.012); 37.9% of patients overall stopped smoking ( P=0.001), and concomitant medication adherence increased by 39.4% at the 48-week follow-up ( P=0.002). Conclusion and Relevance: Tailored pharmaceutical care based on risk stratification, motivational interviewing, and new technologies might lead to improved health outcomes in HIV+ patients at greater cardiovascular risk.

Identification of the Medication Regimen Complexity Index as an Associated Factor of Nonadherence to Antiretroviral Treatment in HIV Positive Patients.

BACKGROUND: Multiple studies have identified a relationship between the complexity of a medication regimen and non-adherence. However, most studies in people who live with HIV (PLWH) have focused on antiretroviral use and have failed to consider the impact of other medications. OBJECTIVE: The aim of our study is to identify the Medication Regimen Complexity Index (MRCI) as an associated factor for nonadherence to antiretroviral treatment (ART). The secondary aim is to analyze the relationship between clinical and pharmacotherapeutical variables and adherence to antiretroviral treatment and to generate an adherence model. METHODS: A transversal, observational study. Patients included were PLWH over 18 years of age on active antiretroviral therapy. Patients who participated in clinical trials or who did not meet the inclusion criteria were excluded. We had studied HIV transmission mode, viral load, treatment status, number of comorbidities and complexity index as factors associated with adherence to ART. RESULTS: We included 619 patients in the study. Number of comorbidities ( p = 0.021; OR = 1.038-1.570); viral load ( p = 0.023; OR = 1.108-4.505) and MRCI ( p < 0.001; OR = 1.138-1.262) (ART and concomitant treatment) were the independent associated factors to ART nonadherence. The value of the Hosmer and Lemeshow test confirmed the validity of this model (P = 0.333). CONCLUSION: A higher MRCI was associated with non-adherence. Therefore, the regimen complexity calculation may be appropriate in daily practice for identifying patients at a higher risk of becoming non-adherent.