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Mail-Order Pharmacy, Travel Time to Pharmacy Do Not Affect HIV Control
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IDWeek 2018, October 3-7, 2018, San Francisco
from Jules: in NYS HIV+ community was very unhappy about mail order pharmacy and it took several years of complaining to NYS to finally change the situation so that insurance companies COULD NOT mandate mail order, that HIV+ could opt out. In this case the reason it took so long is that every time NYS made a ruling against mandatory mail order the insurance companies found a way around it until finally mandating mail order was stopped, and it was banned, now HIV+ can opt out. This study looks at viral load suppression but there are many reasons HIV+ did not want mandatory mail order: privacy: medications could be left out in the open without face to face to delivery breaking anonymity; sometimes deliveries were not made on time endangering adherence; and many people liked the relationships they had with their local pharmacies.
Mark Mascolini
Using a mail-order pharmacy for antiretrovirals did not affect chances of HIV control in a comparison of 214 city dwellers using mail order and 214 using a brick-and-mortar pharmacy [1]. Distance to the pharmacy and travel time to the pharmacy did not predict viral load outcomes in this University of Chicago study. But age, race, and CD4 count did affect chances of viral suppression.
Researchers who conducted this study noted that pharmacy accessibility is one of many factors that may affect antiretroviral adherence. Although mail-order pharmacies work for chronic diseases like diabetes [2] and heart disease, their use by people with HIV is not well studied. A 200-person London comparison found that home delivery versus pharmacy pick-up of antiretrovirals did not affect adherence, viral load, or CD4 percent [3]. The University of Chicago team conducted this study to compare viral load response in 214 people who used a mail-order pharmacy and 214 who used a nearby in-person pharmacy.
The study included people at least 18 years old who received care during 2006-2015 at the University of Chicago HIV clinic. The researchers excluded people diagnosed with HIV within 1 year and those with no recorded viral load, home address, or pharmacy address. They calculated travel distance and time from home to an in-person pharmacy by ESRI StreetMap Premium geocoding. The primary outcome was HIV suppression, defined as a viral load at or below 200 copies. The investigators used logistic regression analysis to identify independent predictors of viral suppression.
Median age was similar in the mail-order and in-person groups (50 and 48.5), as were proportions of men (56.5% and 57%), blacks (85% and 89.3%), and whites (10.7% and 7.5%). Median CD4 count stood at about 485 in both groups and median income around $48,000. Insurance type was also similar in the mail-order and in-house groups: Medicaid (43% in both), Medicare (19.6% and 22%), private (27.6% and 24.8%), and self-pay or none (7% and 9.3%). The mail-order group had a significantly higher proportion of people infected with HIV while injecting drugs (6.1% versus 1.8%, P = 0.05).
Proportions of participants with a viral load at or below 200 copies did not differ between the mail-order group and the in-person group (78.5% and 79.4%, P = 0.81). In people who used in-person pharmacies, viral suppression did not differ by distance to the pharmacy (1.46 miles in virally suppressed versus 1.36 miles in unsuppressed, P = 0.75) or drive time to the pharmacy (7 minutes versus 6.6 minutes, P = 0.75).
Logistic regression analysis linked black or nonwhite race (versus white) to lower odds of viral suppression. Two factors favored viral suppression in this multivariate analysis: older age and higher nadir CD4 count. Neither gender nor insurance type affected chances of viral control.
The University of Chicago investigators concluded that pharmacy type, distance to pharmacy, or travel time to pharmacy does not predict HIV suppression in a largely black urban population that depends primarily on public insurance.
References
1. Choe J, Nguyen C, Pettit NN, Ridgway JP. Impact of mail order pharmacy use on viral suppression among HIV-infected patients. IDWeek 2018, October 3-7, 2018, San Francisco. Abstract 1904. Poster at https://idsa.confex.com/idsa/2018/webprogram/Paper70299.html
2. Schmittdiel JA, Karter AJ, Dyer WT, Chan J, Duru OK. Safety and effectiveness of mail order pharmacy use in diabetes. Am J Manag Care. 2013;19:882-887.
3. Castelino S, Miah H, Auyeung V, Vogt F. Determination of the influence of home delivery of HIV therapy on virological outcomes and adherence. Int J STD AIDS. 2015;26:93-97.
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