Of 8 formulary HIV medications at our institution, 3 are no longer first line treatments. Agents unavailable on formulary are administered from a patient’s own supply. We examined the impact of availability of antiretroviral therapy (ART) on time to appropriate therapy among HIV positive inpatients.
Adult inpatients who received ART from 11/2015 – 10/2016 were included in this single-center review. Data were evaluated by encounter; individuals with multiple admissions were counted per admit. Descriptive statistics were used to evaluate the time from admission to ART order and administration. We noted discrepancies between ordered and home ART regimen, and any administration of partial therapy. Patients not taking ART prior to admission or without documentation of a home ART regimen were excluded from the outcomes analysis. A cost analysis was conducted to describe the financial impact of any recommended formulary changes.
36 patients with 55 inpatient encounters were evaluated; 46 (84%) had a documented home ART regimen. Mean age was 47.8 years, 67% were male, 36% met criteria for AIDS by CD4 cell count. Creatinine clearance was < 60 ml/min in 33% of subjects, 25% were admitted for an infectious issue. Median length of stay was 5 days. Half (49%) were taking nucleoside reverse transcriptase inhibitors, 22% integrase inhibitors, 19% protease inhibitors, 3% non-nucleoside reverse transcriptase inhibitors. In the 7 encounters (15%) with all ART on formulary, 100% received their full ART regimens as inpatients vs 69% of those with partial or no ART on formulary. Median time to therapy doubled in patients who had partial or no home ART on formulary: 25 hours (median of 1 missed dose) vs. 12 hours (median of 0 missed doses). Anticipated annual cost of formulary revisions, including addition of 4 agents, was $6016.37.
Having a complete ART regimen on formulary substantially increased likelihood of complete ART administration without delay. Adding an NRTI alternative to tenofovir was needed due to high rates of renal dysfunction; adding agents with higher barriers to resistance, dolutegravir and darunavir, were important as genotypes and viral loads are not always known at admit. Expanding the ART formulary provides a significant improvement in quality of care at a reasonable cost.