pharmte guidebook final

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Table of Contents

Section 1: About this Guide ..........................................................................................................................5Introduction........................................................................................................................................................6Acknowledgements............................................................................................................................................7Why train Pharmacists? ..................................................................................................................................... 8

Section 2: Recommendations for Multi-Level Program Development ...........................................9AETC Training Levels .................................................................................................................................... 10Developing Level 1 Trainings........................................................................................................................11Developing Level 2 Trainings........................................................................................................................12Developing Level 3 Trainings........................................................................................................................13

HIV Clinical/Hospital-based Preceptorships .........................................................................................13HIV Community Pharmacy-based Preceptorships ................................................................................ 16Adapting Existing Preceptorships............................................................................................................. 19Frequently Asked Questions about Level 3 Preceptorships .................................................................21

Developing Level 4 Trainings........................................................................................................................23

Section 3: Helpful Training Materials.....................................................................................................24Pharmacists Caf.............................................................................................................................................25Needs Assessment Surveys and Program Agendas ....................................................................................26

Section 4: Marketing Strategies ................................................................................................................27Overview ...........................................................................................................................................................28How to Identify Pharmacies ..........................................................................................................................28How to Reach Pharmacists ............................................................................................................................28

Section 5: Continuing Pharmacy Education .........................................................................................30Definition of Continuing Pharmacy Education ..........................................................................................31Continuing Education for Pharmacists ........................................................................................................31Providing Continuing Pharmacy Education ................................................................................................ 31

Conclusion ......................................................................................................................................................32

References .......................................................................................................................................................32


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Table of Contents continued

Abbreviations..................................................................................................................................................33

List of Helpful Resources ...........................................................................................................................34

Appendixes......................................................................................................................................................35

A. Drug Interactions WorkshopB. HIV Pharmacology WorkshopC. Summary List of Common Training Topics for PharmacistsD. Sample Needs Assessment SurveyE. Program Agenda: HIV Clinical Pharmacy PracticumF. Program Agenda: HIV Pharmacy Practicum in the

Community Pharmacy SettingG. Program Agenda: Family-Centered HIV Pharmacy Practicum

H.

Program Agenda: HIV Update for PharmacistsI.

Quick Tips on How to Reach Community PharmacistsJ. State Pharmacy AssociationsK. Accredited Pharmacy Schools

Developing Regional Approaches to Training Community Pharmacists, 2008 Page 4


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Introduction

The AIDS Education and Training Centers (AETC) Meeting the Resource Needs of Community

PharmacistsWorkgroup is pleased to share with the AETC network a resource entitled DevelopingRegional Approaches to Training Community Pharmacists An AETC Program Coordinators Guide.Based onexcerpts of a training guide produced in 2002 by the San Francisco AETC, a Local Performance Site(LPS) of the Pacific AETC, this tool is a collection of HIV pharmacy training recommendations andeducational resources.

Recommendations presented in this Guideby the workgroup members represent their collectiveexperiences to date with targeted clinical and community-based pharmacists for multi-level HIVprogramming. The target audience for the Guideincludes AETC program coordinators and othersinvolved in developing AETC pharmacy training programs such as HIV-specialty pharmacists andmedical directors. The goals of this Guideare to:

1) Outline successful strategies and alternate methods of developing AETC pharmacy programs.2) Describe marketing tips for training programs.3) Offer helpful training tips and resources on the development of pharmacy-specific training

programs.

Membership of the Meeting the Resource Needs of Community PharmacistsWorkgroup iscomprised of AETC pharmacy faculty and program coordinators from diverse settings across theUnited States who have delivered targeted HIV trainings for pharmacists for a decade. Byillustrating proven strategies that have been used for producing effective HIV pharmacist trainingprograms in this Guide, workgroup members hope to encourage all regional AETCs to examine theircurrent methods for delivering pharmacy trainings and utilize this Guideto enhance their currentpharmacy training efforts.



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Acknowledgements

This Guidewas developed by members of the Meeting the Resource Needs of CommunityPharmacists Workgroup.

Authors:

Kirsten Balano, PharmD; Pacific AETC

Whitney Buckley, PharmD; Mountain Plains AETC

Jean Lee, PharmD; BCPS; Midwest ATEC (MATEC)

Supriya Modey, MPH, MBBS; AETC National Resource Center

David Rosen, MSW, LCSW, C-ASWCM; New York/New Jersey AETC (Workgroup Leader)

Suellyn Sorensen, PharmD, BCPS; Midwest ATEC (MATEC)

Other collaborating members:

Edward Dillon, R.Ph.; National Community Pharmacists Association (Workgroup Leader)

Cristina Gruta, PharmD; National HIV/AIDS Clinicians' Consultation Center Blake Max, PharmD; Midwest ATEC (MATEC)

Andrea Norberg, MS, RN; AETC National Resource Center

Trushar Sheth, R.Ph., CCP; Giannottos Pharmacy

Guide book Reviewers:

Cristina Gruta, PharmD; National HIV/AIDS Clinicians' Consultation Center

Andrea Norberg, MS, RN; AETC National Resource Center

Jamie Steiger, MPH; AETC National Resource Center

Workgroup Coordinators:

Supriya Modey, MPH, MBBS; AETC National Resource Center (Managing Editor)

Monique Valentine, MSPH ; AETC National Resource Center

Graphic Designer:

Karen A. Forgash, BA ; AETC National Resource Center



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Why Train Pharmacists?

The role of a pharmacist in HIV care has evolved over the years. Today, pharmacists are an integralpart of the HIV care team and fill an important niche in areas of HIV management such as patienteducation and identification and prevention of medication errors.

Pharmacists and HIV Patients: Optimizing HIV Therapy

Pharmacists play a crucial role in educating patients about HIV medications. The introduction ofhighly active antiretroviral therapy (HAART) in 1990s has added complexity to HIV treatment suchas adverse effects and drug-drug interactions (Hardy, 2005). Also, the introduction of newantiretroviral (ARV) drugs in the last few years brought new set of potential pharmacologicproblems. It is important for pharmacists to educate patients about possible drug interactions andalleviate any fears or misconceptions that patients might have about side effects or drug interactions.Unresolved patient concerns could lead to poor adherence, which may increase the risk of ARVdrug resistance, a serious global treatment problem. Pharmacists should help patients understand

HIV therapy goals and help design interventions to enhance adherence, especially for those patientson long term treatment who may experience pill fatigue. Ongoing communication with patientsalso helps foster a trusting relationship between the patient and the pharmacist.

Preventing Medication Errors

Pharmacists also play an important role in the identification and prevention of medication errors.These errors could be caused by prescriber, patients, or the pharmacy itself. Due to the complexnature of HIV and its co-morbidities, patients are often prescribed medications for otheropportunistic infections, which may cause drug-drug or food-drug interactions with HIVmedications. Pharmacists should communicate with the prescriber to clarify any medication or

dosing changes, or any unclear prescriptions (e.g., similar sounding medications or abbreviations) tohelp reduce prescription errors. Pharmacists can also help patients prevent medication errors byasking them to repeat dosing instructions. They can help patients get organized with pillboxes,timers, and alarms.

With HIV management evolving at a rapid pace, successful training will keep HIV-specialtypharmacists well informed about the latest advancements in HIV care, which in turn will help themexcel in their vital role as part of the HIV care team.



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Overview

Each year, regional AETCs and their Local Performance Sites (LPS) conduct various trainingprograms. AETC Training Levels provide a framework for these training programs. This sectionincludes an overview of these guiding levels and describes how to implement AETC pharmacy-specific training programs for training levels 1-4 in particular. Program coordinators may adapt theinformation shared in this section based upon their regional or local needs.

AETC Training Levels

There are five basic AETC training levels that range from didactic presentations to clinicalconsultations and programmatic technical assistance. Table 1 provides Pacific AETCs briefdescription of the five levels of training.

Table 1: AETC Training Levels

AETC Training Level Description

Participants are often passive learners, with programs varying in length

from brief lectures to conferences.

Format used:

Level 1:

Didactic Presentation

Panel discussions

Self-instructionalmaterials

Journal clubs

Teleconferences

Didactic presentations

Participants may engage in interactive and skills-building activitiescharacterized by active trainee participation.

Level 2:Skills BuildingWorkshops

Format used:

Case discussions

Role play

Simulated patients

Train the trainer (TOT)

Other skill building activitiesParticipants may engage in training that includes activities where the traineeis actively involved with clinical care experiences involving patients.

Level 3:Clinical Training

Format used:

Preceptorships Mini-residencies

Observation of clinical care ateither AETC training site or thetrainees worksite

Participants may engage in training that includes patient-specificclinical consultation provided to health care professionals.

Level 4:Clinical Consultation

Format used: Clinical

consultation

Case-based discussions

Level 5:Technical Assistance Technical assistance offered by the Local Performance Site (LPS).

For more specific examples and resources under these training levels, please visit AETC NRCwebsite: www.aidsetc.org



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Developing Level 1 Pharmacy Trainings

Level 1 trainings are primarily lecture-style trainings where most learners are introduced to theAETC and begin their learning relationship. Successfully engaging participants at this level oftraining is likely to start a relationship where participants will want to return for more training andengage in more active learning opportunities. These can be stand alone events (i.e., dinner/lunchtime lectures) or part of a full-day/multi-day program.

Since differences between Level 1 trainings offered to community pharmacists and other healthcareproviders (i.e., physicians, physician assistants (PA) and nurses) are few, AETCs/LPSs can use thetraining skills and tools they have for other healthcare providers and market them for communitypharmacists. Common Level 1 training topics for community pharmacists are listed below.

Common Level 1 Training Topics include:

New Antiretroviral Medication Updates

Managing Adverse Reactions to HIV Medications

Pharmacokinetics/Pharmacogenomics and Therapeutic Drug Monitoring

Medication Errors in HIV

Medicare Part D and Access to HIV Medications

Some helpful tips for developing pharmacy-specific Level 1 trainings are as follows:

Invite community pharmacists to programs currently being offered to other professionaldisciplines. Having the whole healthcare team sit side-by-side can create an interestinglearning environment.

Connect with local professional pharmacist organizations (e.g., state and/or local pharmacyassociation) that often offer continuing education (CE) opportunities on HIV-specific topics.Solicit important training topics from their representatives.

Consider offering pharmacist-specific CE credits administered by the Accreditation Council forPharmacy Education (ACPE). Refer to Sections 4 and 5 for more information on marketingstrategies and continuing pharmacy education (CPE).

Advertise future training opportunities, particularly those that offer skills-building and more in-

depth HIV content, i.e., attend higher level AETC trainings.

Use evaluation forms to rate the training event and solicit future training topics.



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Level 2 trainings are interactive learning opportunities such as case discussions and other skillsbuilding activities. These are often novel training modalities for community pharmacists, who moreoften have access to lecture-style learning. Given the complexities and rapidly evolving information

in HIV care and treatment, Level 2 trainings provide the opportunity for participants to learn howto research and utilize information to care for their patients.Level 2 trainings can be stand-alone trainings, or part of larger programs. Community pharmacistscan be invited to Level 2 training opportunities with other disciplines and this can allow problem-solving opportunities among the healthcare team. NOTE:In developing cases for communitypharmacists, keep in mind that often they do not have access to laboratory information (i.e., CD4cell counts, viral load, and genotype). Common Level 2 training topics for community pharmacistsare listed below

Common Level 2 Training Topics include:

Use of New Antiretroviral Medications

Adherence Counseling

Identifying and Managing Drug-Drug Interactions

Managing HIV Adverse Drug Reactions

Providing Culturally Competent HIV Care

Role of the Community Pharmacist in the HIV Care Team

HIV 101: When to Start Antiretroviral Therapy and What to Start With

As mentioned earlier, participants are more actively involved in Level 2 trainings. Interactive, case-based workshops are ideal for Level 2 trainings. Two examples are below:

Drug Interactions Workshop: In this workshop, participants are broken into small groups andprovided with case scenarios that review antiretroviral drug interactions. Participants are encouragedto discuss the case with their group members, identify various drug interactions, and develop apharmaceutical care plan. See Appendix A for more information about this workshop and relatedcase scenarios.

HIV Pharmacology Workshop: This workshop encourages participants to work in teams toidentify the appropriate category for the different antiretroviral medicines (both generic and brandnames). See Appendix B for HIV Pharmacology Workshop exercises.



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Developing Level 3 Pharmacy Training

Level 3 training programs consist of clinical training which requires a certain amount ofobservational patient-pharmacist contact hours, or preceptorships. There are several methods fordesigning pharmacy-specific Level 3 preceptorships that will be described step-by-step in thissection. They are as follows:

HIV Clinical/Hospital-based Preceptorships

HIV Community Pharmacy-based Preceptorships

Adapting Existing Preceptorships/Mini-Residencies

HIV Clinic/Hospital-based Preceptorships

Most Level 3 pharmacy trainings are clinic/hospital-based preceptorships. Members of the Meetingthe Resource Needs of Community Pharmacists Workgroup have recommended the following stepsto develop a training program in a HIV clinic or hospital (also shown in Figure 1):

1. Identify a clinic/hospital-based preceptorship site:

a)

The clinic/hospital should be a facility that treats a significant number of HIV-infectedpatients and is staffed by a physician (MD), nurse practitioner (NP), or physician assistant(PA) who is considered to be an expert in HIV care.

b)The clinic/hospital should be a facility that employs a HIV-specialty pharmacist to assistwith the medical co-management of HIV-infected patients. This pharmacist may be directstaff of the clinic/hospital or an intern through a pharmacy residency program.

2. Choose a HIV-specialty pharmacist from the clinic/hospital to serve as the primarypharmacy preceptor:Request a meeting with the clinic/hospitals HIV-specialty pharmacist to discuss their interest inworking with your AETC/LPS in building a new HIV clinic/hospital pharmacy preceptorship

at their site. During the meeting, several key issues will need to be addressed, including:a) Purpose of the program and key participant learning objectivesb) Operational issues such as:

participant attendance, training structure (half-day, full-day, multi-day, etc.),

HIPAA concerns, financial compensation for faculty and/or site , required paperwork for ACPE-accreditation, AETC and any clinic/hospital internal

policies regarding external learners on the premises, and delineation of responsibilities and required staff time commitment

3. Get medical administration buy-in: meet with the Clinic/Hospitals Medical DirectorIf buy-in occurs by the HIV-specialty pharmacist, request a second meeting to be scheduled by theHIV-specialty pharmacist with the clinic/hospitals Medical Director to discuss the above points.Address any issues the Medical Director may have.

4. Draft the program detailsThe process for program development begins if buy-in occurs by the Medical Director. Thisprocess may involve the following steps:



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a) Identify a regional ACPE provider. Discuss costs and processes for accrediting the Level3 preceptorship.

b) Set the program agenda, ensuring that the minimum required patient observational contactis included.

NOTE: Be sure to involve an HIV-specialty pharmacist in determining program details.

NOTE:The patient observation component should focus on the role of the HIV-specialtypharmacist in the co-management of patients with the clinician in terms of regimen choices,drug interactions, adherence counseling and side effects management. Other trainingcomponents (i.e., inclusion of case review, didactic lectures on ARVs, HIV 101, etc.) shouldevolve from your discussions with the HIV-specialty pharmacist and the Medical Director.

c) Develop an agreementwith the clinic/hospital detailing: 1) curriculum payment, 2)management of participant enrollment, 3) policies and HIPAA requirements, and 4) rolesand responsibilities.

NOTE:Payment methods may vary across AETCs. Also, in some regions, once there is a

consensus between the AETC/LPS and the clinic/hospital, a memorandum of agreement issigned.

d) Provide faculty with the learning objectivesand request a draft PowerPoint slidepresentation for the didactic component. The AETC/LPS program coordinator shouldreview the slides, which will then be reviewed by the ACPE accreditation team.

e) Develop an evaluation toolthat includes a set of pre/post test questions and answer key.f) Prepare handout materialsincluding the program agenda, slide sets and any other relevant

materials.g) Pilot testyour training by selecting a known HIV pharmacist as your test subject. Request

any feedback he/she may have.h)Implement the suggested changes and select a second pharmacist who is notan HIV

expert to attend a second pilot training. Be sure to request feedback from the secondpharmacist.i)

Submit the curriculum for ACPE accreditationonce the necessary changes have beenmade.

j)

Design marketing materials for the preceptorship (see Section 4 on Marketing Strategiesfor marketing tips).



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Figure 1: Summary of Developing HIV Clinic/Hospital-Based Preceptorships

Step 1:Identify a clinic or a hospital

Characteristics of the clinic/hospital: Treats a number of HIV-infected patients

Employs a HIV-specialty pharmacist

Step 2:Choose a HIV-specialty pharmacist from the clinic/hospital to serve as the primary preceptor

Discussion Points: Purpose of the program and learning objectives Operational issues

Step 3:Meet with the Clinic/Hospitals Medical Administration

Discussion Points: Purpose of the Program Other operational issues

Step 4:Draft program details

This process may involve the following steps: Identify a regional ACPE provider

Set the program agenda

Develop an agreement with the clinic/hospital regarding operational issues Provide the faculty with learning objectives

Develop an evaluation tool

Prepare handout materials

Pilot test your training

Submit the curriculum for ACPE accreditation

Market the training program

Common training topics for clinical/hospital-based preceptorships include:

HIV Pharmacotherapy Update and Drug Interactions

Co-Management Approach to HIV Care

HIV Medical Update



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HIV Community Pharmacy-based Preceptorships

There are several similarities, as well as differences, when developing pharmacy-focused trainingprograms based in a community practice (or retail) pharmacy setting versus one in a clinic/hospital-based setting. To help develop community pharmacy-based training preceptorships, Workgroupmembers recommended the following steps (also summarized in Figure 2):

1. Identify a community pharmacy preceptorship sitewith the following characteristics:a) Significant number of ARVs provided to HIV-infected patientsb) Staff dedicated to client well-beingc) Staff willing to communicate regularly with medical providersd) Staff committed to addressing adherence issues with clients within the community settinge) Separate consultation room is available to engage patients in adherence discussions

2. Meet with the Pharmacy store ownerRequest a meeting with the Pharmacy owner and/or the primary staff pharmacist to discuss their

interest in developing a new HIV pharmacy preceptorship at their community site. During themeeting, several key issues will need to be discussed, including:a) Programs purposeand key participant learning objectivesb) Operational issuessuch as:

participant attendance,

training structure (half-day, full-day, multi-day, etc.),

sites policies and HIPAA concerns (i.e., community pharmacy internal policies regarding

external learners on the premises),

financial compensation for faculty and/or site , and

paperwork for ACPE-accreditationc) Staff time commitment, including faculty who will receive the training

d)

Program roles and responsibilitiesfor AETC program coordinator and pharmacy faculty.e) Patient flow on the training date. The community pharmacy will have to ensure enough

HIV-infected patients visit the store on the training date for refills and adherence counselingto provide the learner with the minimum required patient observation contact hours.

3. Develop program detailsIf buy-in occurs by the pharmacy store owner/pharmacist, begin the process fordevelopment of the program, similar to what is described under the HIV Clinic/Hospital-basedPreceptorshipsection. The Workgroup members suggest the following steps:

HELPFUL TIP: To ensure adequate patient flow in the store on the training date,pharmacies could offer the following incentives:Pay patients to come in at set intervalsOffer patients store coupons or vouchers if they came in during the training date and

time for their refills

a) Identify a regional ACPE provider. Discuss costs and processes for accrediting theLevel 3 preceptorship.



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b) Set the program agenda, ensuring that the minimum required hours of patientobservational contact is included.

NOTE:Patient observation component should focus on the role of the communitypharmacist in the co-management of patients with the HIV medical provider. Other

training components (i.e., inclusion of case review, didactic lectures on avoiding drugerrors, improving communication between community pharmacist and HIV medicalprovider, etc.) should evolve from your discussions with the pharmacist/store owner.

NOTE:Be sure to involve Pharmacy owner/primary staff pharmacist in determiningprogram details.

c) Develop an agreementwith the community pharmacy site detailing: 1) trainingpayment, 2) management of participant enrollment, 3) sites policies and HIPAAconcerns, and 4) roles and responsibilities.

NOTE: Payment methods may vary across AETCs. Also, in some regions, oncethere is a consensus between the AETC/LPS and community pharmacy store, a

memorandum of agreement is signed.d) Engage the AETC HIV-specialty pharmacist in discussionswith current

community pharmacy issues to develop the preceptorship collaboratively.

NOTE: It is advisable to pay the AETC faculty and the community owner separatelyfor curriculum development.

e) Provide the curriculum writer(s) with the learning objectivesand draft aPowerPoint presentation for the didactic component. The regional AETC or LPSprogram coordinator should review the slides, which will then be reviewed by theACPE accreditation team.

f) Develop an evaluation toolwhich includes a set of pre/post test questions and

answer key.g) Prepare handout materialsconsisting of the agenda, slide sets and any other

relevant materials.h) Assess the community pharmacist faculty candidatesability to represent the

AETCs as the main community pharmacy trainer. This assessment should becompleted by the AETC HIV-specialty pharmacist.

i) Pilot test your training. Use the AETC HIV-specialty pharmacist as your testsubject and solicit any feedback he/she may have.

h) Implement the suggested changes and select a community pharmacist (either fromthe same store or from a busy HIV-specialty pharmacy) to attend the second pilottraining. Request feedback from the community pharmacist.

i)

Submit the curriculum for ACPE accreditationonce the necessary changes havebeen made.j)

Design marketing materials for the preceptorship (see Section 4 on MarketingStrategies for marketing tips).



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Figure 2: Summary of Developing HIV Community Pharmacy-Based Preceptorships

Step 1:Identify a community pharmacy preceptorship site

Characteristics of the preceptorship site: Provides significant number of ARV medications

Holds a strong reputation for its services

Has a separate consultation room for patients

Step 2:Meet with the pharmacy store owner

Discussion Points:

Purpose of the program

Operational issues

Staff time commitment and responsibilities

Patient flow on the training date

Step 3:If the pharmacy store owner agrees, draft the program details

This process may involve the following steps:

Identify a regional ACPE provider

Set the program agenda

Come to an agreement with the clinic/hospital regarding operational issues

Provide the faculty with learning objectives

Develop an evaluation tool Prepare handout materials Pilot test your training

Submit the curriculum for ACPE accreditation

Market the training program

Common training topics for Community Pharmacy-based preceptorships include:

Addressing HIV Drug Errors in the Retail Pharmacy Setting

Interactions between Common OTC Products and HIV Medications

Putting Theory into Practice: Medication Counseling with HIV Patients



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Adapting Existing Preceptorships/Mini-Residency

Although it is ideal to have preceptorship events in the clinic/hospital or in a well-knowncommunity pharmacy store, Workgroup members realize that often AETCs/LPSs do not have aHIV-specialty pharmacist in their clinic/hospital or a local community pharmacy capable ofconducting pharmacy trainings. In such cases, consider adapting existing medical or nursingpreceptorships for community pharmacists. Possible scenarios for adapting preceptorships can befound below.

Scenario 1: For AETCs/LPSs without a HIV-specialty pharmacist working inan HIV clinic or hospital setting in their geographic region

In this situation, consider these options:1.Collaborate with another AETC/LPSwhere such a pharmacist position exists. Request a

collaborative partnership so community pharmacists can be referred to this site for training,following the steps outlined in the HIV Clinic/Hospital-based Preceptorships section.

2.Connect with an HIV clinic that has existing medical/ nursing preceptorships. Askrepresentatives at the site(s) if they are open to having community pharmacists attend an adaptedversion of the medical/nursing program.

Upon agreement:a)

Contact the regional AETCs primary clinical pharmacy faculty and request a meeting withthe medical preceptorship sites faculty to:

1) Review and adapt the medical program to meet the identified needs of communitypharmacists, as viewed by the medical and pharmacy faculty.2) Determine training logistics, including ACPE accreditation requirements.3) Determine faculty composition. Two options are: a) only medical and nursing staffwill conduct the trainings (exclude pharmacist co-faculty) or b) an external pharmacy

faculty will be allowed to come on-site to co-teach the program with the medical staff.

b) Pilot test the training program, following the steps outlined in the HIV Clinic/Hospital-basedPreceptorshipssection.



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Scenario 2: For AETCs/LPS lacking a suitable community pharmacy in theirgeographic region

In this situation, consider these options:1. Contact another AETC/LPSwith a community pharmacy in place. Request a collaborative

partnership, enabling community pharmacists to be trained at another AETC/LPS site. Followthe steps outlined in the HIV Community Pharmacy-based Preceptorshipssection.

NOTE:Make sure the chosen community pharmacy has the following characteristics:a) provides a significant number ARV medications to HIV-infected patientsb)is well known for its services, which includes:

staffs dedication to client well-being,

willingness to communicate regularly with medical providers and

commitment to addressing adherence issues with clients within the community settingc) has a separate consultation room to engage patients in adherence discussions

2. Connect with a community pharmacy from another region, which has at least one of theabove criteria in place, to discuss the possibility of setting up a capacity-building technicalassistance (TA) scenario. In this scenario, the AETC/LPS will help the community pharmacy toestablish itself as their HIV training partner.

Upon agreement:a)Contact the regional AETCs primary clinical pharmacy faculty and request a meeting with the

community pharmacy to:1) Review the pharmacys current capacity to deliver expert HIV2) Determine if the pharmacy has the capacity to become a suitable HIV training site with

AETC/LPS support3) Determine pharmacy sites training needs if technical assistance is warranted

4) Develop and implement a TA workplan focused on a community pharmacypreceptorship program that has been adapted to the sites new capacities

b)Pilot test the preceptorship as outlined in HIV Community Pharmacy-based Preceptorshipssection.



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Frequently Asked Questions about Level 3 Preceptorships

1. What should I do if the sites pharmacy does not have a separateconsultation room?

If the sites pharmacy does not have aseparate consultation room, perhaps the training can be held

at your AETC/LPS, at a nearby HIV clinic, or an HIV/AIDS community-based organization(CBO). Your AETC/LPS might be able to facilitate any required negotiations to enable thecollaborative partnership to occur. Transportation of pharmacy customers to the training site wouldneed to be addressed, as well as the comfort level of the sites identified pharmacist faculty indelivering private adherence counseling sessions to patients.

2. What are my options if there are no HIV-specialty pharmacists in myclinic/hospital?

Ideally, the best option is to have a HIV-specialty pharmacist at the clinic/hospital training site.However, for some AETCs/LPSs, this may not be possible. In such cases, collaborate with anotherAETC/LPS where such a pharmacist position exists. Another option is to connect with an HIV

clinic that has existing medical/ nursing preceptorships that can be adapted for communitypharmacists. Please refer to theAdapting Existing Preceptorshipssection for more detailed information.

3.

I need a cross program consultation. Who can I contact in the AETCnetwork?

The following AETC pharmacists can be contacted for cross program consultation:

Name AETC/LPS Contact Information

Orrick, Joanne Florida/Caribbean AETC [email protected]

Thompson, Michael Florida/Caribbean AETC [email protected]

Lee, Jean Midwest ATEC [email protected], Blake Midwest ATEC [email protected]

Miller ,Christopher NY/NJ AETC [email protected]

Faragon, John NY/NJ AETC [email protected]

DiCenzo, Robert NY/NJ AETC [email protected]

Cantenzaro, Linda NY/NJ AETC [email protected]

Humberto, Jiminez NY/NJ AETC [email protected]

Kanmaz, Jiminez NY/NJ AETC [email protected]

Conry, John NY/NJ AETC [email protected]

Rosen, David NY/NJ AETC [email protected], Roopali NY/NJ AETC (718) 488-1004

Ballard, Craig Pacific AETC [email protected]

Balano, Kirsten Pacific AETC [email protected]

Bradford, Colwell Pacific AETC [email protected]



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4. Can a preceptorship be adapted to address the unique issues involved in thepharmaceutical management of HIV-positive pregnant women and children?

Program Coordinators can design a "Family-Centered" HIV preceptorship for pharmacists who areinvolved in the on-going management of pregnant women, infants, children and adolescents eitherin community practice or clinical care settings. The focus of the preceptorship should be on the roleof the pharmacist within an HIV family-centered care team and it should be situated in a pediatricHIV clinic where pregnant women and children are routinely being co-managed by a medicalprovider and an HIV-specialty pharmacist. To help develop a Family-Centered HIV preceptorshipprogram, follow the steps outlined in HIV Clinic/Hospital-based Preceptorships. Please refer toAppendix G for a sample Family-Centered HIV preceptorship program agenda.



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Level 4 training programs consist of group case discussions. Real cases, without personal identifiers,are presented by the training participants to the faculty. Discussion follows the presentation. Thefollowing is a suggested step-by-step method for designing a pharmacist-specific Level 4 trainingexperience that meets the requirements of the AETC program:

1)Contact various HIV clinicsand request the names of two or three pharmacies that theirpatients commonly go to.

2)Contact each pharmacy and invite their staff for a case discussionprogram. To generateinterest, be sure to mention that the program is free and that expert HIV faculty will be availableto their staff. If possible, consider providing dinner and ACPE credits.

NOTE: Initially, the AETC may need to provide the cases for discussion, to give examples ofhow to use case-based discussion for education.

3)Schedule regular case discussions(i.e., every 2-3 months) with the pharmacy and identify akey pharmacist in the store.

4)Contact the key pharmacist1-2 weeks prior to your next casediscussion to remind them toidentify cases for discussion. As the relationship develops, you could invite the HIV clinic(s)providers to attend. This will help foster relationships between clinic and pharmacy.

NOTE:Trainers are encouraged to bring articles and/or guidelines that support the casediscussion topics.

Common Level 4 Case Discussion topics include: HIV regimen changes

Avoiding drug errors

Adherence counseling issues

Over-the-counter (OTC) product interactions with ARVs

How to handle physician communication problems

Please refer to Appendix C for a summary of common topics for all levels of pharmacytrainings.



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Pharmacists Caf

When pharmacists gather for trainings, it is often helpful to begin with an ice breaker for the trainingparticipants. One example of an icebreaker is the Pharmacists Caf, which is an open discussionforum to share ideas on issues that matter most to the pharmacists. This format is based on trainingtechniques from a group calledThe World Caf. This group has a website that describes theresearch and process principles regarding the use of conversations and questions and to utilize thecollective intelligence of a group to create shared purpose. This methodology is most effective forgetting participants talking and sharing prior to a Level 2 skills-building training.

For more informatin on The World Caf, visit:www.theworldcafe.com

Format for Pharmacists CafTools for how to use this technique can be found on the website above. Below is an example of thistechnique.

Room Set Up and Preparation:

Learners should be grouped at round tables or other seating structure conducive for conversations.Index cards and pens/pencils should be available to the learners. Poster paper will also be used tosummarize themes from the exercise.

The AETC facilitator or faculty should set the tone to be conversational, like those that happen incoffee houses or around the water coolers at work. Here are the steps that follow:

1) Each group should identify a Table Host

2) The Table Host will pose a question and take note of key points shared by the participants

Possible questions are:

How are pharmacists most helpful to people infected with HIV?

How are pharmacists helpful to the primary care team that cares for people living with HIV(i.e., physicians, nurses, case managers, etc.)?

What opportunities are there for pharmacists to be recognized as valued members of everyHIV-infected patients care team?

How can we continue these conversations?

3) Other group members should join the conversation and each member should be heard from.

Note: As mentioned above, offer all members some index cards on which they can take notes.

4) After 10 minutes, Table Host will remain and others will travel to another table.



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5) Table Host will welcome new guests, summarize ideas from the first group and pose the nextquestion.

6) New members will share their ideas, which will be recorded by the Table Host.

7) Table Host will share the notes with the larger group.

Once the larger group has reconvened, the AETC facilitator or faculty will use the poster paper tosummarize comments from the Table Hosts. These posters can be saved during the course of thetraining. Learners should be encouraged to add any additional comments, themes or drawings to theposters during breaks.

Needs Assessment Surveys

Workgroup members have been developing pharmacy training programs for several years. Theseexperienced trainers recommend beginning your program planning with a needs assessment survey

to learn the needs of your audience. As a result, this Workgroup also started by creating a needsassessment survey specifically to determine the educational needsof community pharmacists (please seeAppendix D). Users are encouraged to adapt the sample needs assessment survey.

Program Agendas

A program agenda provides a snapshot of the training event and serves as a marketing point,drawing participants to the event. Responses received from the needs assessment surveys shape thedevelopment of a program agenda. To maximize participant attendance, program agendas shouldinclude preferred topics and a convenient time, as indicated by the survey respondents. Workgroup

members have shared some of their successful training program agendas (see Appendixes E-H).Users are encouraged to adapt and customize the sample program agendas to regional planning andtraining efforts.

List of agendas in Appendix E-H:a)

One-day program:1) Clinical Pharmacy Practicum

Target Audience: clinical pharmacists2) HIV Pharmacy Practicum in the Community Setting

Target Audience: registered community pharmacists3) Family-Centered HIV Pharmacy Practicum

Target Audience: community pharmacistsb) One and one-half day program:

1) HIV Update for PharmacistsTarget Audience: community and clinical pharmacists



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Overview

There are two important factors that contribute to effective outreach and promotion of pharmacisttraining programs on HIV:

1. Availability of low-cost continuing pharmaceutical education (CPE) credits for the trainingprogram (See the next section on Continuing Education Creditfor detailed information onoffering CPE credits).

2. Involvement of key stakeholders such as individual pharmacists, community pharmacies,local/state pharmacy associations and consumer groups, when appropriate.

Listed below are tips for outreach, marketing and promotion of pharmacist training activities onHIV. These marketing tips have also been outlined in Appendix I.

How to Identify Pharmacies:

Contact the State Board of Pharmacy or State Pharmacy Association (Appendix J lists the StatePharmacy Associations) for a list of community pharmacies and their address.

There may be a cost associated with obtaining a list of community pharmacies; however, thismay be a worthwhile investment to market the pharmacy programs.

Perform Internet searches (e.g., based on geographical data and zip codes).

Ask Medicaid, wholesalers or pharmaceutical representatives where patients fill prescriptions.

The phone book or the internet may be utilized to identify pharmacy wholesalers orpharmaceutical representatives.

How to identify specific pharmacies dispensing antiretrovirals:

Obtain a list from the AIDS Drug Assistance Program (ADAP).

ADAP also provides data on the number of prescriptions filled by specific pharmacies.

Contact Ryan White funded medical practices.

A list of funded programs is available at:http://hab.hrsa.gov/programs/granteecontacts.htm

How to Reach Pharmacists:

Contact the American Association of Colleges of Pharmacy (AACP) to reach both facultyand pharmacy students. Student organizations may be helpful to identify graduatingstudents. For the list of accredited schools of pharmacy, refer to Appendix K.

Contact local, state, and /or national pharmacy associations.

Target pharmacists in the local area; contact the states professional pharmacy association toobtain a roster of local chapter affiliates and contacts. These groups may be willing toinclude the promotional materials with their newsletters and/or promote the HIV training.



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Contact the State Board of Pharmacy for a list of pharmacists and their contact information.Requesting a list of practitioners in specific training areas may require more effort.

Drawback to using this mailing list: It may include every registered pharmacist in thestate and may not segregate community pharmacists from hospital-basedpharmacists.

Target pharmacists participating in regional trainings /conferences.

Visit the American Society of Health-System Pharmacists web site for links toASHP stateaffiliate chapters, pharmacy associations and organizations, pharmacy schools,

nontraditional pharmacy programs, pharmacy residency sites, pharmacy technician trainingprograms and other health-related sites:http://www.ashp.org/Import/ABOUTUS/WhoWeAre/StateAffiliates/Resources/Other

ASHPResources.aspx



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Definition of Continuing Pharmacy Education

Accreditation Council for Pharmacy Educations (ACPE) newly revised definition effective August1, 2007:Continuing education for the profession of pharmacy is a structured educational activity designed or intended to supportthe continuing development of pharmacists and/or pharmacy technicians to maintain and enhance their competence.Continuing pharmacy education (CPE) should promote problem-solving and critical thinking and be applicable to thepractice of pharmacy.

Continuing Education for Pharmacists

Pharmacists should develop and maintain proficiency in five core areas:

Delivering patient-centered care,

Working as part of interdisciplinary teams,

Practicing evidence-based medicine,

Focusing on quality improvement, and

Using information technologyACPE-accredited providers have to assure that continuing education activities comply with thedefinition and that activity content is applicable to the practice of pharmacy.

To maintain pharmacy licensure, all state boards of pharmacy require pharmacists to participate inaccredited or approved continuing education activities. Additionally, an increasing number of stateboards of pharmacy require pharmacy technicians to participate in continuing education activities inorder to re-register or reapply for their licensure.

ACPE-approved continuing pharmacy education activities:For the complete list of pharmacy education programs offered by ACPE-accredited

providers, visit their website at:http://www.acpe-accredit.org/pharmacists/programs.asp

Providing Continuing Education for Pharmacists

To provide CPEs for pharmacists and pharmacy technicians in HIV education, it is helpful topartner with the local or state pharmacy associations. Many of these associations obtain CE creditsfrom ACPE providers or from the State Board of Pharmacy. Sometimes local chapters of stateassociations are seeking topics, speakers and sponsorship of educational programs for theirmembership. State pharmacy associations typically have annual or semi-annualconferences/meetings/seminars that are planned at least 6 months in advance. Contact these groups

early to discuss adding HIV training for their membership. Also, CE application packets may beobtained from the ACPE providers. At times there may be an early submission deadline (i.e., 45 or60 days notice).

ACPE providers:For the complete list of ACPE-accredited providers, visit:

http://www.acpe-accredit.org/pharmacists/providers.asp



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Conclusion

Pharmacists play a significant role in the care and treatment of HIV-infected patients. With rapidlychanging information in the field of HIV, successful pharmacy training programs should addressthese changes as well as the core competencies needed by pharmacists.

AETC Training Levels provide the framework for developing training programs for pharmacists andother healthcare providers. As outlined in this Guide, there are several methods for developingpharmacy training programs. Creating a needs assessment survey is an effective starting point. Byproviding several program development strategies, marketing tips and other helpful resources in onecomprehensive document, this Guidecan be used as a tool when developing effective AETCpharmacy training programs.

References

Accreditation Council for Pharmacy Education. Accreditation Standards for Continuing PharmacyEducation.Retrieved on June 09, 2008 from http://www.acpe-accredit.org/pdf/CPE_Standards_Final_092107.pdf

Accreditation Council for Pharmacy Education.Revised ACPE Definition of Continuing Educationfor the Profession of Pharmacy. Retrieved on June 09, 2008 from http://www.acpe-accredit.org/pdf/CE_Definition_Pharmacy_Final_CoverMemo2007.pdf

AIDS Education and Training Centers, National Resource Center. AETC Training Principles.Retrieved on August 04, 2008 from http://www.aidsetc.org/aidsetc?page=tr-29-00

Hardy, Helene (2005). Adherence to antiretroviral therapy: the emerging role of HIVpharmacotherapy specialists.Journal of Pharmacy Practice,18(4)247-263.

New York State Department of Health. Pharmacists: partners in health care for HIV-infectedpatients. New York (NY): New York State Department of Health; 2006 Jan. 28. Retrieved onAugust 03, 2008 fromhttp://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=10974&nbr=5754



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Abbreviations

The following abbreviations have been used in this Guide:

AETC AIDS Education and Training Centers

ACPE Accreditation Council for Pharmacy EducationADAP AIDS Drugs Assistance Program

ARV Antiretroviral

CBO Community-Based Organization

CE Continuing Education

CPE Continuing Pharmacy Education

HIPAA Health Insurance Portability and Accountability Act

LPS Local Performance Site

NP Nurse Practitioner

OTC Over The Counter

PA Physicians Assistant

TA Technical Assistance



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List of Helpful Resources

AIDS Education and Training Center (AETC)Web link: www.aidsetc.org

Academy of Managed Care Pharmacy (AMCP)Web link: www.amcp.org

Accreditation Council for Pharmacy Education (ACPE)Web link: http://www.acpe-accredit.org

American Association of Colleges of Pharmacy (AACP)Web link: www.aacp.org

American College of ApothecariesWeb link: www.americancollegeofapothecaries.com

American College of Clinical Pharmacy (ACCP)Web link: http://www.accp.com

American Pharmacists Association (APhA)Web link: http://www.pharmacist.com

American Society of Consultant Pharmacists (ASCP)Web link: http://www.ascp.com

American Society of Health-System Pharmacists (ASHP)Web link: http://www.ashp.org

National Association of Boards of Pharmacy (NABP)

Web link: http://www.nabp.net

National Community Pharmacists Association (NCPA)Web link: http://www.ncpanet.org

National Alliance of State Pharmacy Associations (NASPA)Web link: http://www.ncspae.org/

National HIV/AIDS Clinicians Consultation Center (NCCC)Web link: http://www.nccc.ucsf.edu/



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PPENDIXA: NTIRETROVIRAL DRUG INTERACTIONSWORKSHOP

OBJECTIVE:

To review HIV antiretroviral and related opportunistic infection medication drug interactions.

GOALS:During this session, pharmacists will be able to:

1) Review a patients drug profile and identify potential drug interactions.2) List the expected outcome/consequences of the interaction.3) Formulate a counseling strategy and pharmaceutical care plan for handling the drug

interaction

INSTRUCTIONS:The following activity uses case scenarios to review antiretroviral drug interactions.You are a pharmacist performing a dispensing shift at your local community orhospital outpatient pharmacy.

You will be broken up into small groups and provided with easel paper and markers. Please readyour case and then discuss with your group. References on drug interactions will be provided. Onyour paper, create a chart with the following headings:

1. Drug Interaction2. Expected Outcome of Drug Interaction3. Pharmaceutical Care Plan4. Patient Counseling Points

Complete the chart with the pertinent fields from your case. At the end of the allotted time, we willreview your findings and care plans in the larger group.

There are seven cases that have been provided in this workshop.



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ARV Drug Interactions Workshop: CASE 1

Drs Office12345 Medication LaneSan Francisco, CA 94143(415) 911-4111

Patients Name ___Homer Simpson_______________________________________

Date: ___________6/20/08_______________________________________

Rx:

Clarithromycin 500mg PO BID #60, 5 refillsEthambutol 400mg PO QD #90, 5 refillsRifabutin 300mg, PO QD #30, 5 refillsMethadone 10mg PO BID #120, 0 refills

Signature:_____________Dr. Doe__________________________________________

Conversation at the pharmacy counter: Hi! Im here to refill my prescriptions. I think there are 7 of them. I alsohave these new ones (hands you the prescription) from Dr. Doe.

When you ask him how he has been lately he says

Ive been doing just ok. Dr. Doe keeps giving me all these medications. My back has been killing me more thanit has been in a long time. Especially over the last month. Maybe I should ask Dr. Payne if I can try a newmedicine.



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ARV Drug Interactions Workshop: CASE 1 (contd)Patient Homer J. SimpsonAddress 128 Donut Lane,Gender MaleInsurance Cover-all insurance

PATIENT PROFILE

Drug Name COMBIVIR 300mg/150mg TABS Orignal Rx 3/18/08Sig Take one tablet by mouth twice daily Last Filled 5/20/08Quantity 60 Physician Dr. DoeRefills left 3

Drug Name INVIRASE 500mg TABS Original Rx 3/18/08Sig Take two tablets by mouth twice

dailyLast Filled 5/20/08

Quantity 120 Physician Dr. DoeRefills left 3

Drug Name NORVIR 100mg TABS Original Rx 3/18/08Sig Take 1 capsule by mouth twice daily Last Filled 5/20/08Quantity 60 Physician Dr. DoeRefills left 3

Drug Name Buspirone 15mg TABS Original Rx 2/20/08Sig Take 1 tablet by mouth daily Last Filled 5/20/08Quantity 30 Physician Dr. PsychRefills left 2

Drug Name Methadone 10mg TABS Original Rx 5/20/08

Sig Take 2 tablets by mouth twice daily Last Filled 5/20/08Quantity 120 Physician Dr. PayneRefills left 0

Drug Name Stavudine 30mg TABS Original Rx 5/20/08Sig Take 1 capsule by mouth twice daily Last Filled 5/20/08Quantity 60 Physician Dr. NewhouseRefills left 4

Drug Name EPIVIR 150mg TABS Original Rx 5/20/08Sig Take 1 tablet by mouth twice daily Last Filled 5/20/08Quantity 60 Physician Dr. Newhouse

Refills left 4

Drug Name Digoxin 0.125mg TABS Original Rx 3/20/08Sig Take 1 tablet by mouth twice daily Last Filled 5/20/08Quantity 60 Physician Dr. HartRefills left 5



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Patients Name ___Marge Simpson_______________________________________

Date: ___________6/20/08_______________________________________

Rx:

Rifampin 300mg ii PO daily #60, 5 refillsIsoniazid 300mg PO daily #30, 5 refillsPyrazinamide 500mg ii PO daily #60, 1 refillEthambutol 400mg iii PO QD #90, 1 refillsEpivir HBV 100mg PO daily, #30, 5 refills

Signature:_____________Dr. I. Diseases_____________________________________

Conversation at the pharmacy counter: I cant believe I got TB and hepatitis from my trip to Asia! Here are myprescriptions. I think I also need refills on my other meds too.



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ARV Drug Interactions Workshop: CASE 2 (contd)Patient Marge SimpsonAddress 128 Donut Lane,Gender FemaleInsurance Lotsa insurance

PATIENT PROFILE

Drug Name COMBIVIR 300mg/150mg TABS Orignal Rx 2/18/08Sig Take one tablet by mouth twice daily Last Filled 5/20/08Quantity 60 Physician Dr. DoeRefills left 1

Drug Name KALETRA 200/50mg TABS Original Rx 2/18/08Sig Take two tablets by mouth twice


Quantity 120 Physician Dr. DoeRefills left 1

Drug Name ADVAIR DISCUS 100/50mg Original Rx 1/18/08Sig 1 inhalation twice daily Last Filled 5/20/08Quantity 1 Physician Dr. GeneralRefills left 0

Drug Name Phenytoin 300 CAPS Original Rx 1/20/08Sig Take 1 capsule by mouth daily Last Filled 5/20/08Quantity 30 Physician Dr. GeneralRefills left 1

Drug Name CRESTOR 5mg TABS Original Rx 5/20/08

Sig Take 1 tablets by mouth daily Last Filled 5/20/08Quantity 30 Physician Dr. GeneralRefills left 2



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Patients Name ___Moe Beers_______________________________________

Date: ___________6/20/08_______________________________________

Rx:

Migranal nasal spray 4mg/mL: Instill 1 spray in each nostril. Repeat in 15 min.

Signature:_____________Dr. General_____________________________________

Conversation at the pharmacy counter: Ugh. I thought I was supposed to be starting to feel better now! Thats thewhole reason I agreed to starting antivirals is to give me more energy. But Im feeling awful! Ive got this terribleheadache, and my body and muscles really ache! I hope this migraine medicine does the trick. I never thought I hadmigraines before, but maybe it will at least get rid of my headache. Maybe some of these supplements will help too.

Brings to the counter for purchase: a pack of gum, cigarettes a bottle of SAM-E and St. Johns Wort.



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ARV Drug Interactions Workshop: CASE 3 (contd)Patient Moe BeersAddress 911 Drinking Lane,Gender MaleInsurance Kindasorta insurance

PATIENT PROFILE

Drug Name EPZICOM 300mg/600mg TABS Orignal Rx 5/01/08Sig Take one tablet by mouth daily Last Filled 5/01/08Quantity 30 Physician Dr. InfectiousRefills left 0

Drug Name EPZICOM 300mg/600mg TABS Orignal Rx 6/01/08Sig Take one tablet by mouth daily Last Filled 6/01/08Quantity 30 Physician Dr. InternalRefills left 5

Drug Name LEXIVA 700mg TABS Original Rx 5/01/08Sig Take one tablet by mouth twice daily Last Filled 5/01/08Quantity 60 Physician Dr. InfectiousRefills left 0

Drug Name Famciclovir 500mg TABS Original Rx 6/01/08Sig Take one tablet by mouth twice daily Last Filled 6/01/08Quantity 60 Physician Dr. InternalRefills left 5

Drug Name Simvastatin 40mg TABS Original Rx 6/01/08Sig Take one tablet at bedtime Last Filled 6/01/08

Quantity 30 Physician Dr. GeneralRefills left 5

Drug Name WELLBUTRIN XL 300 TABS Original Rx 1/20/08Sig Take 1 tablet by mouth daily Last Filled 6/01/08Quantity 30 Physician Dr. GeneralRefills left 1



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Patients Name ___Lisa Simpson_______________________________________

Date: ___________6/20/08_______________________________________

Rx:Mevacor 10mg po at bedtime #30; 5 refills

Signature:_____________Dr. Cardio_____________________________________

Conversation at the pharmacy counter: Sigh. Isnt San Francisco so grey in the summer? And now Dr. Cardiosays I might have clogged arteries! It just figures that I have a broken heart. I thought I was doing so well, startingmy meds and all. But Ive been feeling so blah lately and I dont have any energy. Do I have to wait long for thisprescription? I just want to go home, go back to bed, and stay there forever.



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ARV Drug Interactions Workshop: CASE 4 (contd)Patient Lisa SimpsonAddress 8220 Jazzy LaneGender FemaleInsurance Smartypants Insurance

PATIENT PROFILE

Drug Name EPZICOM 300mg/600mg TABS Orignal Rx 2/01/08Sig Take one tablet by mouth daily Last Filled 6/01/08Quantity 30 Physician Dr. ViralRefills left 2

Drug Name PREZISTA 600mg TABS Original Rx 2/01/08Sig Take one tablet by mouth twice daily Last Filled 6/01/08Quantity 60 Physician Dr. ViralRefills left 2

Drug Name NORVIR 100mg CAPS Original Rx 2/01/08Sig Take one capsule by mouth twice


Quantity 60 Physician Dr. ViralRefills left 2

Drug Name ISENTRESS 400mg TABS Original Rx 2/01/08Sig Take one tablet by mouth twice daily Last Filled 6/01/08Quantity 60 Physician Dr. ViralRefills left 2

Drug Name Lorazepam 1mg TABS Original Rx 4/20/08

Sig Take - 1 tablet by mouth atbedtime as needed for sleep

Last Filled 6/01/08

Quantity 30 Physician Dr. PsycheRefills left 1

Drug Name Paroxetine 20mg TABS Original Rx 12/20/08Sig Take 1 tablet by mouth daily Last Filled 6/01/08Quantity 30 Physician Dr. PsycheRefills left 6

Drug Name ORTHO CYCLEN 7/7/7 TABS Original Rx 12/20/08Sig Take 1 tablet by mouth daily Last Filled 6/01/08Quantity 84 Physician Dr. BabyRefills left 1

Drug Name Vitamin C 500mg TABS Original Rx 12/20/08Sig Take 1 tablet by mouth daily Last Filled 6/01/08Quantity 30 Physician Dr. BabyRefills left 1



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Patients Name ___Sideshow Bob_______________________________________

Date: ___________6/20/08_______________________________________

Rx:

Viagra 100mg Sig: Take - 1 tablet 30 minutes prior to sex. #30 0 Refills

Signature:_____________Dr. Internal_____________________________________

Conversation at the pharmacy counter: I am just loving life! I need this prescription and refills on my Reyataz andTruvada, please.



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ARV Drug Interactions Workshop: CASE 5 (contd)Patient Sideshow BobAddress 1092 Bigtop LaneGender MaleInsurance CircusCircus Insurance

PATIENT PROFILE

Drug Name TRUVADA 300mg/200mg TABS Orignal Rx 1/01/08Sig Take one tablet by mouth daily Last Filled 3/01/08Quantity 30 Physician Dr. NT ViralRefills left 2

Drug Name Didanosine 400mg CAPS Original Rx 1/01/08Sig Take one capsule by mouth daily Last Filled 3/01/08Quantity 30 Physician Dr. NT ViralRefills left 2

Drug Name NORVIR 100mg CAPS Original Rx 1/01/08Sig Take one capsule by mouth daily Last Filled 3/01/08Quantity 30 Physician Dr. NT ViralRefills left 2

Drug Name REYATAZ 300mg CAPS Original Rx 1/01/08Sig Take one capsule by mouth daily Last Filled 3/01/08Quantity 30 Physician Dr. NT ViralRefills left 2

Drug Name COMBIVENT INH Original Rx 1/20/08Sig 2 inhalations four times daily Last Filled 2/01/08

Quantity 1 Physician Dr. InternalRefills left 3

Drug Name Albuterol MDI Original Rx 1/20/08Sig 1-2 inhalations every 4-6 hours as

needed for shortness of breathLast Filled 6/01/08

Quantity 1 Physician Dr. InternalRefills left 0

Drug Name Esomeprazole 40mg CAPS Original Rx 4/01/08Sig Take 1 capsule by mouth daily Last Filled 6/01/08Quantity 30 Physician Dr. Internal

Refills left 3

Drug Name CARDIZEM CD 120mg CAPS Original Rx 4/01/08Sig Take one capsule by mouth daily Last Filled 6/01/08Quantity 30 Physician Dr. InternalRefills left 1



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Patients Name ___ Guy Comicbook _______________________________________

Date: ___________6/20/08_______________________________________

Rx:

Loratidine 10mg i PO QD #30 5 refillsSudafed 30mg i PO QID PRN #100 0 refills

Signature:_____________Dr. House_____________________________________

Conversation at the pharmacy counter: I need refills on my Septra. Im already behind by a week. My doctor saidits going to prevent me from getting sick I dont want to get that sick again. Here, Ill buy this can of grapefruitjuice to wash my meds down with. And, by the way, I know its a little early, but can I also pick up my other meds?Not the methadone I know I need a special prescription for that one. I have an appointment coming up with Dr.Payne and Dr. Specialist on June 30th.



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ARV Drug Interactions Workshop: CASE 6 (contd)Patient Guy ComicbookAddress 28346 Fantasy Island StreetGender MaleInsurance Trekkie Insurance

PATIENT PROFILE

Drug Name TRUVADA 300mg/200mg TABS Orignal Rx 5/30/08

Sig Take one tablet by mouth daily Last Filled 5/30/08Quantity 30 Physician Dr. Specialist

Refills left 3

Drug Name VIRAMUNE 200mg TABS Original Rx 5/30/08Sig Take one tablet by mouth daily x 21

days then increase to one tablet twice

daily

Last Filled 5/30/08

Quantity 60 Physician Dr. SpecialistRefills left 3

Drug Name Methadone 10mg TABS Original Rx 5/30/08Sig Take 3 tablets orally three times daily Last Filled 5/30/08Quantity 270 Physician Dr. Payne

Refills left 0

Drug Name BACTRIM DS 800/160mg TABS Original Rx 5/26/08Sig Take 2 tablets by mouth three times

daily

Last Filled 5/26/08

Quantity 126 Physician Dr. Specialist

Refills left 0

Drug Name Azithromycin 600 mg TABS Original Rx 5/30/08

Sig Take two tablets by mouth once weekly Last Filled 5/30/08Quantity 8 Physician Dr. SpecialistRefills left 3

Drug Name VFEND 200 mg TABS Original Rx 5/26/08

Sig Take one tablets by mouth twice daily Last Filled 5/26/08Quantity 60 Physician Dr. Specialist

Refills left 2



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Patients Name ___ Joe Crabapple_______________________________________

Date: ___________6/20/08_______________________________________

Rx:

Atripla i po at bedtime, #30 5 refillsSelzentry 300mg i po twice daily #30

Signature:_____________Dr. Virology_____________________________________

Conversation at the pharmacy counter: Time to start these meds, huh? I guess things could be worse Im feelingpretty good, so I think Im up to it.



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ARV Drug Interactions Workshop: CASE 7 (contd)Patient Joe CrabappleAddress 6253 Schoolhouse StreetGender MaleInsurance University Insurance

PATIENT PROFILE

Drug Name Risperdal 1mg TABS Orignal Rx 2/30/08Sig Take one tablet by mouth twice daily Last Filled 5/30/08Quantity 60 Physician Dr. Hed CaseRefills left 1

Drug Name Doxycycline 100mg CAPS Original Rx 3/30/08Sig Take one capsule by mouth twice

daily until goneLast Filled 3/30/08


Drug Name Itraconazole 200mg CAPS Original Rx 3/30/08Sig Take one capsule by mouth daily x

12 weeks for toenailsLast Filled 5/30/08


Drug Name CIALIS 10mg TABS Original Rx 3/30/08Sig Take one tablet by mouth 30

minutes prior to sexLast Filled 3/30/08


Drug Name Atorvastatin 20 mg TABS Original Rx 3/30/08Sig Take one tablet by mouth at bedtime Last Filled 5/30/08Quantity 30 Physician Dr. HeartyRefills left 3

Drug Name Lorazepam 1mg TABS Original Rx 4/20/08Sig Take - 1 tablet by mouth at

bedtime as needed for sleepLast Filled 6/01/08

Quantity 30 Physician Dr. Hed CaseRefills left 1



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Appendix B: HIV Pharmacology Workshop Exercise

Exercise: Have posters around the room with the topic in the title section. Each table then hascolored cards (approximately 10) with names of antiretroviral medicines (generic and brand names).The cards then need to be placed on the appropriate poster. If place near top of poster, the group isSure the medicine belongs to that poster. Can place the card near the bottom of poster if lesssure it belongs there. If brand name is already on the poster, do not also place the generic namethere (and visa-versa). Groups can discuss with each other and use the references available in theirpacket (ARV tables from DHHS guidelines, ARV drug information sheet with pictures).

Co-formulated (combination) Products (>1 medicine in one pill)

Once daily dosing FDA approved

Avoid in Pregnancy (or avoid component if co-formulated)

Renal Dose Adjustments Recommended (or component if co-formlated)

Significant interactions with Proton-Pump Inhibitors

Should be taken on Empty Stomach

Rash and/or Allergic Reaction is Common & suggests special education

Activity against Hepatitis B (or component if co-formulated)

FDA approved after January 2005

Must Be Dispensed with Ritonavir

1. Co-formulated (combination) Products (>1 medicine in one pill)

Combivir (zidovudine/lamivudine)

Trizivir(abacavir/zidovudine/lamivudine)

Truvada (tenofovir/emtricitabine)

Kaletra (lopinavir/ritonavir)

Atripla(efavirenz/tenofovir/emtricatabine)

Epzicom (abacavir/lamivudine)

Teaching Points:

Some patients prefer lower bottle burden than pill burden.

Can affect co-pays (decrease cost).

Can increase confusion about names.

Need to recall individual components to educate/consider interactions and side-

effect issues.

2. Once daily dosing FDA approved

Atripla

(efavirenz/tenofovir/emtricitabine) Epzicom (abacavir/lamivudine)

Lamivudine (Epivir)

Viread (tenofovir)

Efavirenz (Sustiva)

Atazanavir/ritonavir (Reyataz/Norvir)

Emtricitabine (Emtriva)

Tenofovir/emtricitabine (Truvada)

Didanosine (Videx)



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Nave patients:

Kaletra (lopinavir/ritonavir)

Fosamprenavir/ritonavir (Lexiva/Norvir)

Reyataz (atazanavir)

Teaching Points: Can effectively combine once daily dosing of antiretrovirals.

Some ARV are used once daily, but not FDA-approved (not on this list, would beadded to chart during exercise).

Some once daily regimens are FDA-approved for use in ARV nave pts, but notARV experienced.

Review pharmacokinetic issues: Boosting of ritonavir what does that really mean? Forgivability of regimens what is the significance of missing a dose in a

once a day regimen vs. twice a day regimen?

Adherence rates differ between once daily vs. twice daily vs. three times daily

regimens. (In all chronic disease conditions, including HTN & DM)

3. Avoid in Pregnancy (or avoid component if co-formulated)

Efavirenz (Sustiva)

Viracept (nelfinavir)

Stavudine/didanosine (Zerit/Videx)

Atripla (efavirenz/tenofovir/emtricitabine)

Teaching Points:

Efavirenz isteratogenic especially if used early in pregnancy (Pregnancy Category D)

Women desiring pregnancy, and/or not using effective birth control, should avoidefavirenz.

Stavudine and didanosine is on this list due to increased risk of pancreatitis and lacticacidosis when used in pregnancy.

Pharmacokinetics of ARV can be affected by pregnancy, leading to some dosingadjustments or increased side-effects.

Can use most of our ARV during pregnancy

4. Renal Dose Adjustments Recommended (or component if co-formulated)

Viread (tenofovir)

Lamivudine (Epivir)

Truvada (tenofovir/emtricitabine) Zidovudine (Retrovir)

Combivir (zidovudine/lamivudine)

Videx (didanosine)


Stavudine (Zerit)

Trizivir(abacavir/lamivudine/zidovudine)





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Teaching Points:

No Protease Inhibitors on this list

Dose adjustment due to renal dysfunction is different that having medications cause renaldysfunction.

Tenofovir is only one on this list that is associated with causing renal dysfunction.

Coformulated products often need to be separated for appropriate dose adjustment. Often medication errors are found when the dose is not adjusted for renal dysfunction.

Especially after renal function improves, if the dose is not adjusted accordingly, thiscould lead to subtherapeutic concentrations and resistance.

Atazanavir should not be administered to treatment experienced patients on hemodialysisand treatment nave patients need to be on boosted atazanavir. No adjustments required forpatients not on hemodialysis.

5. Significant interactions with Proton-Pump Inhibitors (PPIs)

Atazanavir (Reyataz)

Atazanavir/ritonavir (Reyataz/Norvir)

Teaching Points:

Atazanavir requires an acidic environment for absorption and PPIs will decreaseabsorption, even with boosted atazanavir.

A good drug history important, including over-the-counter medications, due toavailability of PPIs and H-2 antagonists OTC

See FDA-approved package insert for atazanavir for updated recommended dosingfor treatment experienced and treatment nave patients receiving PPIs or H2antagonists.

6. Should be taken on Empty Stomach

Videx (didanosine)

Efavirenz (Sustiva)

Indinavir (Crixivan)


Teaching Points:

Indinavir (rarely given anymore) was given Q 8 hrs on empty stomach for adequateabsorption, until started using with boosted RTV.

Didanosine, even in enteric-coated formulation, still has an empty stomach requirement,unless dosed with tenofovir. When given with tenofovir, the dose is reduced to 250mg

once daily and maybe given with food. Need to double check auxiliary labels from pharmacy, as they do not always take into

account co-administered meds.

The reason efavirenz is recommended on empty stomach is to avoid INCREASEDabsorption, which would lead to increased possible side-effects, not decreased efficacy. Soif patients can tolerate taking with food and improves adherence, the patient can do so.



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7. Rash and/or Allergic Reaction is Common & suggests special education

Abacavir (Ziagen)


Trizivir (abacavir/zidovudine/lamivudine)

Nevirapine (viramune)

Teaching Points:

HLA-B*5701 test is available which could help predict patients likely to haveabacavir hypersensitivity (ABC-HSR) reaction.

Discuss warning card dispensed with abacavir and abacavir-containing products.Patients should actually be advised NOT to stop their medications on their own.May often suggest for patients who have symptoms reported on the card to continuemedication for several days to determine if truly ABC-HSR or just early side-effectsfrom the new ARV regimen.

Early symptoms of ABC-HSR are not fatal. Restarting after stopping has had somelife-threatening reactions.

Nevirapine dose should be once daily for first 2 weeks, then every 12 hours toreduce incidence of rash.

If a nevirapine rash develops without other symptoms (flu-like, abdominal pain), maybe able to continue the medication. Rash often resolves within several days to weeks.

Severe rash and hepatitis is seen more often when nevirapine is used in men withCD4 > 400 and women with CD4 > 250. Should monitor Liver Function Tests(LFTs) every 2 weeks for first 8 weeks in all patients started on nevirapine.

Many other ARV can also cause rash, but do not necessarily need special education: Etravirine Fosamprenavir Efavirenz

Darunavir Tipranavir Nelfinavir



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8. Activity against Hepatitis B (or component if co-formulated)

Tenofovir (Viread)

Lamivudine (Epivir)


Truvada (tenofovir/emtricitabine)

Atripla (efavirenz/tenofovir/emtricitabine) Trizivir (abacavir/lamivudine/zidovudine)


Teaching Points:

Tenofovir, lamivudine and emtriciatabine which are available in several co-formulatedproducts, have activity against both HIV and Hepatitis B virus.

When treating co-infected individuals, both infections need to be treated concomitantly.(i.e., dont treat one without treating the other).

There is a warning not to stop these medications suddenly as a Hepatitis B flare up mayoccur.

9. FDA approved after January 2005


Raltegravir (Isentress)

Darunavir (Prezista)

Maraviroc (Selzentry)

Tipranavir (Aptivus)

Etravirine (Intelence)

Teaching Points:

Some of the medications that are newly approved are actually just new formulationsof old medicines (i.e., Atripla).

Some are new medicines in current classes of antiretrovirals (i.e., darunavir andtipranavir are new protease inhibitors). Data suggests activity against PI resistantvirus, especially for darunavir.

Like-sounding medications adds to the confusion of names (Intelence vs Isentress).

Most recently, there has been an approval for medicines that are novel targets againstHIV, such as CCR5 receptor antagonist and integrase inhibitor.

10. Must Be Dispensed with Ritonavir

Darunavir (Prezista)

Tipranavir (Aptivus)

Other Protease Inhibitors often boosted, but NOTALWAYS:

Atazanavir (Reyataz)

Fosamprenavir (Lexiva)

Saquinavir (Invirase)

Indinavir (Crixivan)



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Already Co-formulated with ritonavir, therefore does not need extra dispensing:

Lopinavir (coformulated as Kaletra)

Teaching Points:

Many Protease Inhibitors are used in combination with ritonavir, but many haveFDA-approved dosing without ritonavir.

The two above are the only protease inhibitors that have no approved dosing

without ritonavir

Efficacy of boosted protease inhibitors and forgivability is improved compared tounboosted protease inhibitors.

BID dosing of ritonavir can make for dispensing errors, as two or more bottles of100mg ritonavir are given to the patient.



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Appendix C: List of Common Training Topics for Pharmacists

Level 1 New Antiretroviral Medication Updates

Managing Adverse Reactions to HIV Medications Pharmacokinetics/Pharmacogenomics and Therapeutic Drug Monitoring

Medication Errors in HIV

Medicare Part D and access to HIV Medications

Level 2 Use of New Antiretroviral Medications

Adherence Counseling

Identifying and Managing Drug-Drug Interactions

Managing and Counseling HIV Adverse Drug Reactions

Providing Culturally Competent HIV Care

Role of the Community Pharmacist in the HIV Care Team

HIV 101: When to Start Antiretroviral Therapy and What to Start With

Level 3 For clinic/hospital-based preceptorships:

HIV Pharmacotherapy Update and Drug Interactions

Co-Management Approach to HIV Care

HIV Medical UpdateFor community pharmacy-based preceptorships:

Addressing HIV Drug Errors in the Retail Pharmacy Setting

Interactions between Common OTC Products and HIV Medications

Putting Theory into Practice: Medication Counseling with HIV Patients

Level 4 HIV regimen changes

Avoiding drug errors

Adherence counseling issues

Over-the-counter (OTC) product interactions with ARVs

How to handle physician communication problems



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Appendix D: Needs Assessment Survey forCommunit Pharmacists and Pharmac Staff

Purpose:The AIDS Education and Training Centers (AETCs) are a network of 11 regional centers that conduct targeted, multi-disciplinaryeducation and training programs for healthcare providers treating persons with HIV/AIDS.

The AETC within your region is interested in learning more about the educational needs of community pharmacists andpharmacy staff related to HIV/AIDS care and treatment. This needs assessment survey will be used to help the AETCs identifytopics of interest and the best ways to meet your educational needs. Your responses will be kept confidential.

State: ____________________ Zip Code: _________________

1. Are you familiar with your regional AIDS Education and Training Center? Yes No

2. Please indicate what type of pharmacy you work for (check all that apply):

O IndependentO Part of a small chainO Part of a large chain

O Mail orderO HIV Specialty PharmacyO Located in hospital/clinic

3. Please indicate your primary functional role.

O Pharmacy Manager/DirectorO Registered Pharmacist

O Pharmacy TechnicianO Pharmacy/Store Clerk

4. On average, how many HIV/AIDS-related prescriptions do

pharmte guidebook final

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