Around 200 patients come in and out of care at the University of California, San Francisco (UCSF) Women’s HIV Program clinic, where Jennifer Cocohoba, PharmD, MAS, AAHIV-P, is a Clinical Pharmacist.
As a fledgling pharmacist, Cocohoba encountered a memorable patient—also a woman of color—and discovered that she didn’t just want to help people with HIV, she wanted to serve people with HIV. “This particular incident with this woman is one of those proverbial lightbulb moments that you have,” Cocohoba recalled in an interview with Pharmacy Today. “[I was] grateful that I was able to provide even a small amount of light in her very troubled life at that time.”
Today, Cocohoba provides her patients at the clinic with one-on-one medication therapy management (MTM) consults and runs a treatment adherence program. For clinicians, she provides drug information and antiretroviral resistance testing consultation. She’s also taken on the role of assisting with quality improvement in the clinic, especially in medication prescribing practices.
On top of her clinic job, Cocohoba is also an academic. As Health Sciences Associate Clinical Professor of Pharmacy in the UCSF Department of Clinical Pharmacy, she teaches classes, mentors student pharmacists, and writes research grants.
Most pharmacists know the basics about HIV; according to Cocohoba, a lot of pharmacy schools, with packed curriculums, may devote 6 or 7 hours to HIV therapy, tops. “But by the time you get out of school, things have changed already,” she said. “Truthfully, it’s very difficult to keep up with all of the trends in HIV treatment because the field—it moves so quickly. There’s always new drugs, new ways of combining them, new things not to do with HIV treatments.”
One trend in HIV treatment is “a huge decrease in pill burden” because of the advent of fixed-dose combination tablets, which combine multiple medications into fewer tablets, Cocohoba said. The offset to that is how the medications used to treat the adverse effects, and other chronic diseases that HIV patients get, add up. “Although a person may only take three pills for their HIV, they may also have to add to that the blood pressure medicines, diabetes medicines, cholesterol medicines; medicines for nausea, for diarrhea, on top of that,” she explained. “So the list can still be long, even if maybe HIV therapy is shrinking.”
For the clinic’s MTM program, Cocohoba has individualized one-on-one appointments with patients. The patients are referred by their provider, or they can self-refer. “Oftentimes, patients will just drop in and say, ‘Hey, can you help me with my medicines?’” she said.
In her flexible MTM protocol, Cocohoba makes sure patients’ medication therapy is efficacious and reviews their medication therapies, looking for key items such as medications without an indication and medication interactions.
Cocohoba often ends up making recommendations to help streamline patients’ regimens because they have to take so many medications for HIV and other disease states. “Patients will come to me and say, ‘Do I really need to be taking all of these?’” she said. “We’ll sit together, one on one, and talk about why they’re taking each of the medicines, and look at some of the medicines they might not need to be taking, to try to make life easier for them.”
HIV care is a model for pharmacists caring for patients with other chronic diseases because the HIV pharmacist has a very special place on the health care team. First, many HIV pharmacy practices are rooted in interdisciplinary care. For example, Cocohoba’s own team has physicians, including a psychiatrist and an obstretrician/gynecologist; nurses; case managers; and therapists. The team is a one-stop shop, and its members look at the pharmacist as the medication expert.
Second, Cocohoba’s team has created a collaborative interdisciplinary practice protocol. She can prescribe medications under protocol, order laboratory tests under protocol, and “provide high-level consultations such as resistance testing and regimen selection that really utilizes all of the clinical skills that a pharmacist learns while in pharmacy school,” she said.
Third, “HIV is one of those disease states that really allows the pharmacist to learn all they can about the medications,” Cocohoba continued. Once a patient is stable on his or her HIV regimen, there’s a lot of tinkering with medications for adverse effects, dose suggesting, other medications for other chronic diseases, keeping an eye on the regimen to make sure it’s still working, and appropriate laboratory results being drawn to monitor the HIV.
“Because HIV is so medicine-centric, it provides a great opportunity for pharmacists really to be the expert. And I think there are various other chronic disease states that have this same medication-centric focus,” noted Cocohoba. “When it’s all about medication management, the pharmacist can really play an important role.”
One of the most basic medication-related problems that pharmacists often have to solve is simply getting HIV medications covered by insurance. Most insurance companies are mandated to cover HIV medications, but there are still hoops that health care systems have to jump through to get those medications into patients’ hands—and patients may not understand their insurance, according to Cocohoba.
For the pharmacist, the solution can be as simple—or as complicated—as calling the patient’s insurance, trying to figure out what the appropriate forms are, figuring out how much HIV medication they can get—say, a 1-month or a 3-month supply—and troubleshooting problems. “It’s a significant amount of time spent serving as a liaison between the patient and their insurance,” she added. “Someone who’s savvy about all those [insurance plans] can really aid patients in getting their medicines in a timely manner. And that is really important for patients with HIV because if they miss doses, they’re at risk for getting resistance to their regimen.” Even a paperwork delay of 5 to 7 days “can put a patient at risk for losing that particular regimen.”
Another type of medication-related problem—at the top end of the license—is medication resistance. A pharmacist who is well trained in HIV therapy can be an expert on HIV-resistance mutations. If the patient’s problem is that the medication regimen is not working any more, an HIV specialist pharmacist may be able to order a genotype or phenotype test, interpret that test, figure out what the mutations mean, determine what next best regimen should be suggested for the patient, and communicate those recommendations to the patient’s provider.
Maintaining high adherence to an antiretroviral regimen is essential for anyone living with HIV/AIDS to receive full immunologic benefit. “This may not seem very different from any other chronic disease medication, but the challenge with HIV antiretrovirals is that if they are not adhered to properly, drug resistance emerges and future treatment options become limited for that patient,” Cocohoba said. “On a public health level, resistant strains of HIV can also be transmitted to others, which limits the pool of available medications for other patients as well.”
Research interests emerge organically from clinicians’ investment in a field. “It’s wonderful to provide service. And I think the next natural question is: … What can we do to make our interactions with patients even more effective?” That question fueled Cocohoba’s desire to start a research program centered on HIV pharmacists, adherence counseling, and pharmacy interventions. “Research allows us to not only capture and share what all of these incredible [HIV] pharmacists do, but it also raises the bar for us to say: What can we do that’s even better?” she said. “And I think that’s how you move the field forward.”
Research interests change over time as new questions arise. Right now, Cocohoba is very interested in HIV community pharmacists—the future cornerstone of HIV pharmacy care, given changes in the health care system such as the Affordable Care Act. One research interest, therefore, is in looking at interventions and programs that HIV pharmacists can implement to contribute to the health of HIV patients. Another research interest revolves around adherence counseling: how pharmacists perform adherence counseling, how effective they are, and ways that pharmacists can be taught to counsel on adherence to HIV medications to make sure that patients are getting the full benefits of their antiretroviral therapy.
A native of San Diego, Cocohoba is the sole pharmacist in a whole family of nurses. Her decision to become a pharmacist grew out of a love of chemistry, and a love of the idea of medicines and their effect on the body. What solidified her desire to go into pharmacy was her excitement at the idea of the pharmacist as the most accessible health care provider.
Cocohoba completed her PharmD degree, did a postgraduate year (PGY)1 general practice residency, and then did a PGY2 specialized residency in HIV ambulatory care. “There are many career paths to get to where you want to be,” she said. “I do feel that that second-year residency really increased my confidence and knowledge to care for HIV patients.” Several years after earning her PharmD, Cocohoba went back to school to get a master’s degree in advanced studies and clinical research. “That, I think, has really helped build a strong platform for me to conduct large research studies and really understand the ins and outs of study design.”
The key piece of advice that Cocohoba would give aspiring HIV pharmacists is to network with working HIV pharmacists. “A lot of the things that I practice with and use everyday are things that I’ve learned from mentors and other people who have come before me in the field of HIV and blazed the trail,” she said. “You can learn a lot from people who’ve been there before and model what you want your future practice to be.”