Ryan Haumschild, PharmD, MS, MBA: I like the journey between where we’ve come from and where we’re at, recognizing that multidrug-resistant patients may have additional pill burdens or complexities. How do we meet them where they are, for part of their treatment journey? Part of that is the clinical outcomes, but there are economic impacts as well to make sure they’re successful. Dr Lopes, total cost of care is a term you brought up, and it’s important. If a patient isn’t doing well, there’s a higher cost of care even outside the medication. What are some important total cost-of-care considerations for patients who have multidrug-resistant HIV vs those treated or managed with traditional regimens? What are the cost-of-care implications for that treated vs nontreated patients with HIV who are multidrug resistant?

Maria Lopes, MD, MS: It goes back to whether they’re immunosuppressed vs if their CD4 counts are higher and they’re not experiencing opportunistic infections. What does that mean? What’s the time horizon in which you’re going to end up in the ED [emergency department] or hospital or have further complications that end up costing more than the medication regimen? It’s important to highlight that. HIV medications have been a huge success in terms of prolonging good quality of life through simplification. The convenience issue has made a dramatic difference in adherence as well.

As we look at more complex regimens that are added to the background standard of care, it’s important to keep in mind that background but also how much of an impact it’s making on adherence and viral suppression. In the end, payers are looking at direct costs: out-of-the-hospital ED, doing well from a CD4 count. You can correlate how adherence is making an impact, in terms of CD4 counts, in the relationship to being immunocompromised. Once you’re immunocompromised, the risk of associated costs will be beneficial. It’s always a little challenging if you’re fully responsible for pharmacy-only costs because you may see drug costs and not see the total cost of care with the hospitalizations, ED visits, and complications. That’s where published literature, real-world data, and even a change in guidelines will hopefully allow us to think differently about which combinations have value and our relationship to shared decision support.

Ryan Haumschild, PharmD, MS, MBA: Payers can play an important role when thinking about the total cost of care but also the patient overall. Mr Driffin, what are some ways that payers can minimize barriers that we’ve discussed in obtaining optimal therapy for multidrug-resistant HIV? If you could, talk about utilization-management barriers, such as step therapies or preauthorizations, that can get in the way of patients starting therapy.

Daniel Driffin, BS, MPH: I’ve had some run-ins with prior authorizations a time or 2, or even just the pharmacy ensuring that the patient-assistance card is going through. If there are any barriers around cost, that increases the likelihood of nonadherence and drug resistance. [We need to] sit down and ensure that all systems and clinical centers are having the same conversation in terms of optimal health for the patient we’re seeing. If there’s a barrier to care in any line of service delivery, [we need to] think about how to remove this to ensure that our patients are healthy. It’s often driven by cost, but this is public health also. It should be centered on quality of life. If we can improve the lives of patients we’re taking care of, then it’s our duty to ensure that health is being achieved.

Ryan Haumschild, PharmD, MS, MBA: You need that promotion of health. You need that support from the payer. You need that support from the clinician. Dr Lopes, as you think about it more holistically across a number of covered lives in a plan, how can clinicians best support patient buy-in for optimal medication adherence with patients? As a payer, if you’re covering expensive therapy, it’s important that patients stay adherent to it because we want to make sure they sustain treatment, that they reduce any type of resistance, and ultimately get the desired effects of the therapy you’re paying for. What can clinicians do to best support patient buy-in for this adherence?

Maria Lopes, MD, MS: The medical home and the multidisciplinary approach are important. We haven’t talked about the role of specialty pharmacy, but these are expensive drugs. Specialty pharmacy has clinicians, clinical pharmacists, social workers, and case managers who can interact with a physician. We don’t want to be overly burdensome, but there are frequent contacts with a patient. At the end of the day, it’s about dispensing high-cost drugs. How can we ensure patients are taking them? How can we also look at reasons for nonadherence and try to connect patients to services, reminders, or personalization that gets back to what are patients taking? Can we do a drug inventory and look at proportion days covered and see if they’re renewing their prescription? From a pharmacy perspective, sometimes it looks like they’re not. Then when we’re interacting with a physician, we find out they’re virally suppressed. There’s some opportunity for better coordination, in particular, how can we link patients to the appropriate services or timely education that can overcome some of the barriers to nonadherence in a personalized manner?

Transcript edited for clarity.