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Using Home-Delivery Pharmacy Triples Odds of Viral Control in Cleveland Group
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IDWeek 2016, October 26-30, 2016, New Orleans
Mark Mascolini
People using a pharmacy home-delivery service had three times higher odds of HIV suppression than people who picked up antiretrovirals at their pharmacy, according to results of a 320-person Cleveland analysis [1]. Among people who picked up their antiretrovirals, living closer to the pharmacy did not improve chances of viral suppression.
Research links race, income, and other factors to viral suppression in people with HIV. Outside the HIV field, research has weighed the impact of pharmacy proximity on adherence to medications for hypertension, diabetes, and high cholesterol. Investigators at Cleveland's Case Western Reserve University and MetroHealth Hospital conducted this study to determine whether pharmacy accessibility affects virologic suppression rates in a contemporary HIV population.
The study focused on HIV-positive people living in Cleveland zip codes with a median household income below $30,000. All study participants made clinic visits, had an antiretroviral prescription, and had HIV lab work in 2012. The research team reviewed patient charts to learn whether each person used a drug home-delivery service or made in-store pickups, to record the pharmacy address for in-store pickups, and to determine HIV load. For the in-store group, the researchers calculated distance to the pharmacy, public transit routes required, and time traveled from home to the pharmacy. Viral suppression meant HIV RNA below 200 copies. The investigators calculated viral suppression rates for January-June 2012, July-December 2012, and throughout 2012.
Among 320 study participants, 222 (69%) were black, 237 (74%) were men, and 299 (93%) had insurance. The study group included 166 people (52%) who used home delivery and 154 (48%) who made in-store pickups. In the year-long viral suppression analysis, 230 people (72%) sustained viral suppression and 90 (28%) did not. The suppressed group did not differ significantly from the unsuppressed group in age, gender, insurance status, or distance traveled, time taken, or route used for in-store pickup.
Multivariate analysis of year-long viral suppression determined that home delivery (versus in-store pickup) more than tripled the odds of viral control (adjusted odds ratio [aOR] 3.430, 95% confidence interval 1.935 to 6.080). Nonblack race independently doubled the odds of viral suppression (aOR 1.957, 95% CI 1.049 to 6.080). A higher number of prescribed antiretrovirals halved odds of viral suppression (aOR 0.476, 95% CI 0.352 to 0.642).
Viral suppression rate improved from the first half-year to the second half-year among people making in-store pickups (64% to 75%). But viral suppression remained more likely in the home-delivery group compared with the in-store group both in the first half-year (aOR 5.011, 95% CI 2.723 to 9.220) and the second half-year (aOR 2.404, 95% CI 1.323 to 4.369). Lower number of antiretrovirals prescribed remained an independent predictor of viral suppression in both half-years, but black race did not. Again, distance traveled, time taken, or route used for in-store pickups did not affect viral suppression outcome.
The researchers noted that home-delivery services such as Exact Care and CVS Caremark are highly accessible and involve no additional copay. But the investigators observed that some HIV patients may not have a reliable pickup location, may not be home when a delivery arrives, or may fear disclosing their HIV status if someone inappropriately accepts their delivery. They suggested that improved viral suppression in the second half-year with in-store pickups "could be attributed to nonsuppressed patients in half-year 1 being more likely to be suppressed in half-year 2 when using the same pharmacy throughout the year."
The Cleveland team called for more research on these issues in other income brackets and other cities.
Reference
1. Pham N, Lewis S, Avery A. Evaluation of impact of pharmacy proximity on HIV viral suppression. IDWeek 2016, October 26-30, 2016, New Orleans. Abstract 1550.
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