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Background: Pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) prevention is highly effective. Pharmacists can increase PrEP accessibility through pharmacist prescribing. This study aimed to determine pharmacists’ acceptance of a pharmacist PrEP prescribing service in Nova Scotia. Methods: A triangulation mixed methods study consisting of an online survey and qualitative interviews was conducted with Nova Scotia community pharmacists. The survey questionnaire and qualitative interview guide were underpinned by the 7 constructs of the Theoretical Framework of Acceptability (affective attitude, burden, ethicality, opportunity costs, intervention coherence, perceived effectiveness and self-efficacy). Survey data were analyzed descriptively and with ordinal logistic regression to determine associations between variables. Interview transcripts were deductively coded according to the same constructs and then inductively coded to identify themes within each construct. Results: A total of 214 community pharmacists completed the survey, and 19 completed the interview. Pharmacists were positive about PrEP prescribing in the constructs of affective attitude (improved access), ethicality (benefits communities), intervention coherence (practice alignment) and self-efficacy (role). Pharmacists expressed concerns about burden (increased workload), opportunity costs (time to provide the service) and perceived effectiveness (education/training, public awareness, laboratory test ordering and reimbursement). Conclusion: A PrEP prescribing service has mixed acceptability to Nova Scotia pharmacists yet represents a model of service delivery to increase PrEP access to underserved populations. Future service development must consider pharmacists’ workload, education and training as well as factors relating to laboratory test ordering and reimbursement.

Polypharmacy is prevalent among long-term care (LTC) residents and can cause significant morbidity. In 2018, we concluded a deprescribing pilot study that reduced potentially inappropriate medication use among LTC residents.We sought to understand the experience and views of physicians, nurses, pharmacists, LTC residents and family members who participated in the pilot study.Qualitative semi-structured interviews were conducted with residents and families, a physician, pharmacist and pharmacy student, and licensed-practical nurses. Interviews were audio recorded, transcribed, and analyzed using an inductive thematic analysis approach.Interviews with 13 participants yielded themes in 3 categories: (1) views about medication use in LTC and willingness to engage in deprescribing, (2) perceived barriers and enablers for deprescribing, and (3) impact of participating in deprescribing study. Participants were willing to engage in deprescribing; residents were motivated by physician suggestions, and family members prioritized quality of life in decision-making and wanted to be part of the decision-making process. Solutions to overcome barriers included assigning responsibility to identify deprescribing opportunities to pharmacists, scheduling rounds to enable face-to-face team discussions, and consulting families to provide missing medical history to inform deprescribing decisions. Participating in a deprescribing intervention resulted in improved healthcare professional (HCP) confidence and interprofessional collaboration, and caused continued practice change after the study.Residents, families, and HCPs are concerned about problems associated with polypharmacy in LTC and are willing to consider deprescribing. Barriers to deprescribing in LTC exist but are not insurmountable. Results provide valuable insight into strategies to optimize deprescribing interventions within LTC.

Background: Advances in treatment have turned HIV from a terminal illness to a more manageable condition. Over the past 20 years, there have been considerable changes to HIV treatment guidelines, including changes in preferred antiretrovirals and timing of initiation of combination antiretroviral therapy (cART). Objective: To examine real-world trends in cART utilization, viral control, and immune reconstitution among people living with HIV in Canada. Methods: Data were obtained from the Canadian Observational Cohort (CANOC). CANOC participants were eligible if they were antiretroviral therapy–naive at entry and initiated 3 or more antiretrovirals on or after January 1, 2000; if they were at least 18 years of age at treatment initiation; if they were residing in Canada; and if they had at least 1 viral load determination and CD4 count within 1 year of CANOC entry. Baseline and annual mean CD4 counts were categorized as less than 200, 200–350, 351–500, and more than 500 cells/mm3. Annual mean viral loads were reported as suppressed (

Background Injection drug use is the primary mode of transmission of hepatitis C virus (HCV) infection in the developed world and guidelines recommend screening individuals with current or history of injection drug use for HCV; however, the majority of those living with HCV in Canada are not aware of their positive status. This low level of HCV status awareness suggests that screening is not effective with current testing strategies. The aim of this review is to determine what barriers and enablers people who inject drugs (PWID) experience surrounding testing for HCV to help inform the development of an appealing testing strategy. Methods Comprehensive literature searches were conducted using Medline, Embase and CINAHL. Included studies investigated the barriers and enablers to testing for HCV in PWID and the experiences of PWID in testing for HCV. Studies were included if they involved people with current injection drug use or those with a history of injecting drugs, were written in the English language and set in the community. Studies were compared and common themes were coded and analyzed Results Nine studies were included most studies focused on barriers instead of enablers. Common barriers included self-perception of low risk for HCV, fear of diagnosis, stigma associated with IV drug use and HCV, antipathy in relation to mainstream health care services, limited knowledge about HCV, lack of rapport with provider, lack of motivation or competing priority of drug use, and limited awareness of new treatment options. Common enablers to testing included increasing awareness of HCV testing and treatment and providing positive narratives around HCV care, positive rapport with provider, accessible testing options and personalized care. Conclusion This scoping review determined that there has been some research in this area over the past decade though it has not been focused to specifically address this research question. Nevertheless, some common barriers and enablers to testing for HCV were observed across the available research.

The clinical and demographic characteristics that predict antiretroviral efficacy among patients co-infected with HIV and hepatitis B virus (HBV) remain poorly defined. We evaluated HIV virological suppression and rebound in a cohort of HIV-HBV co-infected patients initiated on antiretroviral therapy.A retrospective cohort analysis was performed with Canadian Observation Cohort Collaboration data. Cox proportional hazards models were used to determine the factors associated with time to virological suppression and time to virological rebound.HBV status was available for 2,419 participants. A total of 8% were HBV co-infected, of whom 95% achieved virological suppression. After virological suppression, 29% of HIV-HBV co-infected participants experienced HIV virological rebound. HBV co-infection itself did not predict virological suppression or rebound risk. The rate of virological suppression was lower among patients with a history of injection drug use or baseline CD4 cell counts of199 cells per cubic millimetre. Low baseline HIV RNA and men-who-have-sex-with-men status were significantly associated with a higher rate of virological suppression. Injection drug use and non-White race predicted viral rebound.HBV co-infected HIV patients achieve similar antiretroviral outcomes as those living with HIV mono-infection. Equitable treatment outcomes may be approached by targeting resources to key subpopulations living with HIV-HBV co-infection.Les caractéristiques cliniques et démographiques prédictives de l’efficacité antirétrovirale chez les patients co-infectés par le virus de l’immunodéficience humaine (VIH) et le virus de l’hépatite B (VHB) demeurent mal définies. Les chercheurs ont évalué la suppression et le rebond virologiques du VIH dans une cohorte de patients co-infectés par le VIH et le VHB chez qui on avait entrepris un traitement antirétroviral.Les chercheurs ont réalisé une analyse rétrospective de cohorte à l’aide des données de laLes chercheurs ont obtenu le statut de VHB de 2 419 participants. Au total, 8 % étaient co-infectés par le VHB, dont 95 % présentaient une suppression virologique. Après la suppression virologique, 29 % des participants co-infectés par le VIH et le VHB ont subi un rebond virologique du VIH. En elle-même, la co-infection par le VHB n’était pas prédictive de la suppression virologique ou du risque de rebond. Le taux de suppression virologique était plus faible chez les patients ayant des antécédents de consommation de drogues injectables ou une numération des cellules CD4 de référence de moins de 199 cellules par millimètre cube. Un ARN du VIH de référence bas et les hommes ayant des relations sexuelles avec des hommes étaient associés de manière significative avec un taux plus élevé de suppression virologique. La consommation de drogues injectables et les races non blanches étaient prédictives d’un rebond viral.Les patients atteints du VHB co-infectés par le VIH obtenaient des résultats antirétroviraux semblables à ceux qui étaient seulement infectés par le VIH. On peut anticiper des résultats cliniques équitables des traitements en ciblant les ressources vers les sous-populations atteintes d’une co-infection par le VIH et le VHB.

Background There is a need for acceptable and feasible HIV testing options to ensure people living with HIV know their status so they can access care. Pharmacist-provided HIV point-of-care testing (POCT) may overcome testing barriers, including privacy concerns, testing wait times, and improve accessibility. In the APPROACH study, we aimed to develop and assess an HIV POCT program in community pharmacies for future scale up and evaluation. This paper describes the program uptake, participant and pharmacist experiences, and implementation factors. Methods A pharmacist-provided HIV POCT program was offered in 4 pharmacies in two Canadian provinces. A mixed methods design incorporated self-report questionnaire data, participant telephone interviews, pharmacist focus groups, workload analysis, and situational analysis to assess the uptake, acceptability and feasibility of the HIV POCT program. Results Over the 6-month pilot, 123 HIV tests were performed. One new case of HIV was identified; this participant was linked with confirmatory testing and HIV care. Participants were predominantly male (76%), with a mean age of 35 years. This was the first HIV test for 27% participants, and 75% were at moderate to very high risk of undiagnosed HIV infection, by Denver HIV Risk Score. Questionnaires and telephone interviews showed participants were very satisfied with the program; 99% agreed HIV POCT should be routinely offered in pharmacies and 78% were willing to pay for the service. Participants felt the pharmacy was convenient, discreet, and that the pharmacist was supportive and provided education about how to reduce their future risk. Pharmacists felt prepared, confident, and expressed professional satisfaction with offering HIV POCT. Community and public health supports, clear linkage to care plans to refer participants with positive HIV POCT results, and provision of counselling tools were important enabling factors for the program. Pharmacist remuneration, integration with existing healthcare systems, and support for ongoing promotion of HIV POCT availability in pharmacies were identified as needs for future scale-up and sustainability. Conclusions A successful model of pharmacy-based POCT, including linkage to care, was developed. Further research is needed to determine the effectiveness and cost-effectiveness of this approach in finding new diagnoses and linking them with care. Trial registration Retrospectively registered with clinicaltrials.gov (NCT03210701) on July 6, 2017.

BackgroundHepatitis B (HBV) and Human Immunodeficiency Virus (HIV) share common risk factors for exposure. Co-infected patients have an increased liver-related mortality risk and may have accelerated HIV progression. The epidemiology and demographic characteristics of HIV-HBV co-infection in Canada remain poorly defined. We compared the demographic and clinical characteristics and factors associated with advanced hepatic fibrosis between HIV and HIV-HBV co-infected patients.MethodsA retrospective cohort analysis was conducted using data from the Canadian Observational Cohort (CANOC) Collaboration, including eight sites from British Columbia, Quebec, and Ontario. Eligible participants were HIV-infected patients who initiated combination ARV between January 1, 2000 and December 14, 2014. Demographic and clinical characteristics were compared between HIV-HBV co-infected and HIV-infected groups using chi-square or Fisher exact tests for categorical variables, and Wilcoxon’s Rank Sum test for continuous variables. Liver fibrosis was estimated by the AST to Platelet Ratio Index (APRI).ResultsHBV status and APRI values were available for 2419 cohort participants. 199 (8%) were HBV co-infected. Compared to HIV-infected participants, HIV-HBV co-infected participants were more likely to use injection drugs (28% vs. 21%,p = 0.03) and be HCV-positive (31%, vs. 23%,p = 0.02). HIV-HBV co-infected participants had lower baseline CD4 T cell counts (188 cells/mm3, IQR: 120–360) compared to 235 cells/mm3in HIV-infected participants (IQR: 85–294) (p = 0.0002) and higher baseline median APRI scores (0.50 vs. 0.37,p p = 0.03). HIV-HBV co-infected participants had a higher mortality rate compared to HIV-infected participants (11% vs. 7%,p = 0.02).ConclusionThe prevalence, demographic and clinical characteristics of the HIV-HBV co-infected population in Canada is described. HIV-HBV co-infected patients have higher mortality, more advanced CD4 T cell depletion, and liver fibrosis that improves in conjunction with ARV therapy. The high prevalence of unknown HBV status demonstrates a need for increased screening among HIV-infected patients in Canada.

Background In Newfoundland and Labrador (NL), people living with HIV (PLHIV) primarily receive care through an interdisciplinary HIV specialty clinic, however, HIV care has been transitioning to primary healthcare elsewhere. Developing a comprehensive cohort of PLHIV to help improve healthcare has long been the vision of researchers, clinicians and decision makers. The objective of this study was to develop a de-identified cohort of PLHIV in NL, to be used to inform policy and prioritize healthcare system changes to optimize HIV healthcare in NL and to address gaps in care for PLHIV. Methods Data was collected from a number of different databases and PLHIV were identified as having HIV from three sources: 1. NL Public Health Laboratory data; 2. HIV Clinic data; 3. Medical Administration data. Results The finalized dataset included 317 people who had been diagnosed with HIV in NL as of 1994 and 251 were still alive at the end of data collection. The final database contained a total of 178 variables describing PLHIV health and health care utilization. Only 7% of PLHIV were identified by all three sources suggesting no single provincial HIV data custodian captures all those living with HIV in the province. Conclusion It is important that policy be implemented to merge siloed data sources in order to provide researchers, clinicians and decision makers with the accurate and complete data that is required to conduct sound and precise research, provide appropriate care and allocate resources to health initiatives that can improve the quality of life for PLHIV. Disclosure No significant relationships.

Background Approximately 1 in 5 Canadians with HIV are unaware of their status. In many provinces and especially rural communities, barriers to HIV testing include lack of access, privacy concerns, and stigma. The availability of HIV point-of-care testing (POCT) is limited across Canada. Pharmacists are well positioned to address barriers by offering rapid HIV POCT and facilitating linkage to care. Methods We will use a type-2 hybrid implementation-effectiveness design to assess a pilot HIV POCT model in one urban and one rural pharmacy in each of two Canadian provinces over 6 months. In this feasibility trial the research aims include developing and assisting pharmacies in implementing the model, evaluating processes/determinants of program implementation, evaluating the model’s effects on client outcomes, preferences, and testing satisfaction. Using a community-based research approach, the research team will engage community stakeholders in each province including individuals with lived experience to inform the development of the pharmacy-based HIV testing model and support the research team throughout the study. A multipronged promotion campaign will be used to promote the study and facilitate recruitment. The pharmacy-based testing model will include pre/post-test counseling and linkage to care plans in addition to pharmacist-administered HIV POCT. Pharmacists will complete a comprehensive training program prior to implementing the testing model. Client demographics and satisfaction will be assessed by surveys and interviews. Pharmacists will document time required for testing and participate in a post-study focus group to discuss barriers/enablers. Implementation will be assessed qualitatively and quantitatively. The process of developing and implementing the model will be described using qualitative data and a logic model. Acceptability and barriers/enablers will be examined qualitatively based on survey responses. A preliminary costing assessment will consider the client, pharmacy, and government perspectives. Discussion The results of this pilot will inform modifications to the HIV POCT model to optimize effectiveness and increase scalability. The study has national importance, providing valuable information on improving access to HIV testing. Future applications of this research may expand the role of pharmacists in offering POCT for other sexually transmitted/bloodborne infections as tests become available in Canada. Trial registration Clinicaltrials.gov, NCT03210701

Background: Pharmacist/nurse-led clinics are an established model for many chronic diseases but not yet for HIV. At our centre, patients with HIV are seen by a multidisciplinary team (physician, nurse, pharmacist, social worker) at least yearly. Some attend an HIV-specialist pharmacist/nurse clinic (or “nonphysician clinic,” NPC) for alternate biannual visits. Our objective was to assess patient satisfaction with care received through both clinics. Methods: The Patient Satisfaction Survey for HIV Ambulatory Care (assesses satisfaction with access to care, clinic visits and quality of care) was administered by telephone to adults who attended either clinic between January and July 2014. Descriptive statistics described patient characteristics and satisfaction scores. Fisher’s exact test compared satisfaction scores between the NPC and multidisciplinary clinic (MDC). Multivariate logistic regression examined associations between overall satisfaction with care and clinic type and patient characteristics (e.g., age, disease duration). Results: Respondents were very satisfied with the overall quality of HIV care in both the NPC and MDC (89% vs 93%, respectively, p = 0.6). Patients from both clinics expressed satisfaction with access to care, treatment plan input, their provider’s knowledge of the newest developments in HIV care and explanation of medication side effects, with no significant differences noted. Significantly more MDC patients reported being asked about housing/finances, alcohol/drug use and whether they needed help disclosing their status. Patient characteristics were not significantly associated with satisfaction with overall quality of care. Conclusion: Patients are satisfied with both clinics, supporting NPC as an innovative model for chronic HIV care. Comparison of outcomes between clinics is needed to ensure high-quality care.

Background: Pharmacists are consistently ranked among the most trusted professionals, and research shows high levels of satisfaction with pharmacist services. Studies have also shown that the public is generally unaware of the full range of roles and responsibilities of a pharmacist. The purpose of this study was to explore the public’s knowledge and attitudes regarding the role of the community pharmacist and to determine their likelihood of using expanded pharmacist services. Methods: Adults across Newfoundland and Labrador were surveyed by telephone. Survey questions addressed how frequently participants visited the pharmacy, understanding of duties undertaken by pharmacists, perceptions and attitudes regarding pharmacists as health care professionals, likelihood of using expanded pharmacist services and participant demographics. Comparisons were made between responses from urban and rural participants and frequent versus nonfrequent pharmacy users, to determine if there were any differences. Results: The majority of participants were generally aware of what pharmacists do when filling prescriptions; those who visited the pharmacy more frequently appeared to be more informed. Participants indicated they would take advantage of the expanded services suggested, with greatest interest in receiving advice for minor ailment management and prescription refills from pharmacists. Results support the prevailing view that pharmacists are trusted health professionals who should have access to patients’ health information to provide best care. Conclusion: The public is aware of aspects of the pharmacist’s role, but opportunities exist to better educate the public on the knowledge, skills and unique professional abilities of pharmacists to support uptake of expanded pharmacist services.

Background: Strong working relationships between pharmacists and physicians are needed to optimize patient care. Understanding attitudes and barriers to collaboration between pharmacists and physicians may help with delivery of primary health care services. The objective of this study was to capture the opinions of family physicians and community pharmacists in Newfoundland and Labrador (NL) regarding collaborative practice. Methods: Two parallel surveys were offered to all community pharmacists and family physicians in NL. Surveys assessed the following: attitudes and experience with collaborative practice, preferred communication methods, perceived role of pharmacists, areas for more collaboration and barriers to collaborative practice. Results for both groups were analyzed separately, with comparisons between groups to compare responses with similar questions. Results: Survey response rates were 78.6% and 7.1% for pharmacists and physicians, respectively. Both groups overwhelmingly agreed that collaborative practice could result in improved patient outcomes and agreed that major barriers were lack of time and compensation and the need to deal with multiple pharmacists/physicians. Physicians indicated they would like more collaboration for insurance approvals and patient counselling, while pharmacists want to assist with identifying and managing patients’ drug-related problems. Both groups want more collaboration to improve patient adherence. Conclusion: Both groups agree that collaborative practice can positively affect patient outcomes and would like more collaboration opportunities. However, physicians and pharmacists disagree about the areas where they would like to collaborate to deliver care. Changes to reimbursement models and infrastructure are needed to facilitate enhanced collaboration between pharmacists and physicians in the community setting.

Objective: To review the clinical features, risk factors, diagnosis, and management of abacavir hypersensitivity reaction (HSR). Data Sources: A MEDLINE (1950–October 2007) and EMBASE (1980–October 2007) search using key words abacavir, HIV, human immunodeficiency virus, hypersensitivity reaction, HLA-B*5701, and patch tests was conducted. Conference abstracts and article bibliographies were reviewed to identify relevant studies. Study Selection and Data Extraction: Studies that investigated the clinical and immunogenetic risk factors for abacavir hypersensitivity and the benefit of genetic screening, as well as articles that focused on the clinical presentation, assessment, and management of abacavir HSR, were considered for this review. Data Synthesis: Abacavir hypersensitivity is an immune-mediated reaction that typically occurs within the first 6 weeks of therapy. Signs and symptoms of abacavir HSR are nonspecific, which makes the diagnosis challenging, particularly in medically complex patients. Patch testing may improve the diagnosis and confirmation of abacavir HSR, but it remains experimental. Clinical management is aimed at supportive therapy and discontinuation of abacavir. Rechallenge with abacavir is contraindicated due to the risk of precipitating a life-threatening reaction. Appropriate patient education and a clear communication plan are essential for the safe use of this medication. Identification of patients at risk of developing abacavir hypersensitivity through routine genetic screening for human leukocyte antigen (HLA) HLA-B*5701 represents a significant advance in the field of pharmacogenomics, with an apparent 100% negative predictive value when used to screen for abacavir HSR. Preliminary data suggest that pharmacogenetic testing for HLA-B*5701 is cost effective. However, until routine testing is available, pharmacovigilance is necessary for the safe and effective use of abacavir. Conclusions: Serious adverse events associated with the use of abacavir can be avoided by appropriate recognition and management of the HSR. Screening patients for HLA-B*5701 prior to initiation of abacavir represents a tool to further decrease the risk of HSRs as well as unnecessary discontinuation of this drug.

Human immunodeficiency virus (HIV) infection has become a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Metabolic complications such as dyslipidemia, insulin resistance, diabetes mellitus, obesity, and fat distribution abnormalities are associated with increased risk of cardiovascular disease. Cardiovascular disease is now a leading cause of death among HIV-infected patients. Lipid abnormalities, now often characteristically seen with HIV infection, include elevated triglycerides and low elevated total cholesterol (TC), and low high-density lipoprotein (HDL) levels of total and HDL cholesterol. Many antiretroviral drugs are associated with lipid abnormalities, which commonly include hypertriglyceridemia and increased total and low-density lipoprotein cholesterol levels. The management of dyslipidemia includes lifestyle modifications, lipid-lowering therapy, and switching antiretroviral therapy (ART). The increased prevalence of insulin resistance, impaired glucose tolerance, and diabetes is multifactorial in etiology. Management and goals of diabetes should follow the same practice guidelines in non-HIV-infected patients. Drug interactions and switching ART are additional management measures in diabetic HIV-infected patients. Since the treatment of lipodystrophy is a challenge, its prevention by selecting appropriate ART is the key.

In a retrospective cohort study of salvage antiretroviral combination therapy including efavirenz, 60% of 51 patients were able to suppress HIV RNA by at least 1 log 10 or to less than 50 copies/ ml. A lack of the previous use of non-nucleoside reverse transcriptase inhibitors was the only factor predictive of response on multivariate analysis. No patient with a viral isolate with an increased IC 50 to efavirenz by virtual phenotype had a virological response.

Over the past decade, there have been numerous advances in HIV therapy, with 6 drug classes comprising 24 indivi dual antiretroviral agents now available. For patients who are adherent with therapy and who have an undetectable viral load, HIV has become a chronic, manageable disease in an aging and genetically diverse population. The core goals of management remain maximal suppression of viral replication and promotion of immune reconstitution through combination antiretroviral therapy. Secondary goals of therapy include promoting long-term adherence, avoiding drug interactions, minimizing toxic effects, simplifying treatment regimens, decreasing drug costs, managing comorbid conditions, and preventing transmission of HIV by achieving undetectable viral load. Consequently, the pharmacist’s role has evolved and expanded to help patients and other health care providers to achieve these goals. Pharmacists are recognized as established and integral members of HIV health care teams across Canada and the United States. Pharmacists’ involvement in the care of HIVpositive patients has been associated with improved patient outcomes, including enhanced adherence, reduced pill burden and dosing frequency, greater increases in CD4 cell counts, higher rates of viral suppression, and decreases in medication errors. Guidelines and position statements on the role of the pharmacist in caring for patients with HIV/AIDS have been published by various national and international organizations, but there have been no updates since combination antiretro viral therapy came into use, about a dozen years ago. This paper provides current guidelines for a pharmacist’s role in the many aspects of caring for patients with HIV/AIDS, including selecting and reviewing therapy, tailoring treatment for specific populations, counselling patients, monitoring response to therapy, guiding transitions of care, and undertaking scholarly and professional activities. The target audience for these guidelines includes new HIV pharmacy practitioners, pharmacists with an interest in HIV but limited experience or therapeutic knowledge in this area, and pharmacy students. This paper may also serve as a model of pharmacy practice for ambulatory care in other therapeutic areas. A literature search was conducted using the electronic databases MEDLINE and PubMed from 2000 to March 2012. The following search terms were used: HIV, antiretrovirals, adverse drug reactions, drug interactions, adherence, pediatric, perinatal transmission, therapeutic drug monitoring, pharmacist, hepatitis B, hepatitis C, seamless care, and medication reconciliation. In addition, conference abstracts were searched for relevant studies. Updated guidelines for treatment of HIV and related conditions, landmark studies, and comprehensive review articles were selected for inclusion.

BACKGROUND: Clinicians frequently consult HIV drug interaction Web sites of unknown quality. OBJECTIVE: To systematically review and identify HIV drug interaction Web sites of high quality and usefulness for healthcare professionals. METHODS: Relevant Web sites were identified through a structured search on commonly used search engines. An assessment tool containing 4 domains (content, reliability, access restrictions, ease of navigation) was developed. English and French Web sites were selected for review if they included HIV drug interaction information directed to healthcare professionals. Web sites were excluded if antiretroviral interaction data were not available or were out of date. Commercial online databases and sites that required payment were not included. Seventeen HIV pharmacists from across Canada participated in the review. The Web sites were ranked with total mean scores. Mean scores for each domain were then analyzed. Interrater agreement and ANOVA using the rater as a covariate were determined. RESULTS: Nine Web sites met the criteria for review. Web sites from Toronto General Hospital (Canada), HIVinSite (beta version) (US), and the University of Liverpool (UK) ranked highest for total mean scores and for content. Other Web sites were found to be reliable, accessible, and easy to navigate; however, they did not consistently include unpublished data or data on herbal preparations, recreational drugs, or multiple interactions. CONCLUSIONS: Three HIV interaction Web sites of high quality were identified that can be valuable tools for HIV and non-HIV healthcare professionals. Regular reviews are necessary in order to keep pace with the growing body of HIV interaction data and the constant evolution of Web sites.

OBJECTIVE: To report a case of suspected extrapyramidal symptoms (EPS) in a patient initiated on ritonavir and indinavir while taking risperidone for a tic disorder. CASE SUMMARY: A 35-year-old white man with AIDS received risperidone 2 mg twice daily for treatment of a Tourette's-like tic disorder. Ritonavir and indinavir were initiated, and 1 week later, he experienced significantly impaired swallowing, speaking, and breathing, and worsening of his existing tremors. Ritonavir and indinavir were discontinued. On the same day, the patient increased the risperidone dosage to 3 mg twice daily. Symptoms continued to worsen over the next 3 days. All investigations and laboratory parameters were unremarkable, and vital signs were stable. Risperidone was discontinued and clonazepam initiated. Three days later, the patient's symptoms were significantly improved. DISCUSSION: The symptoms described herein are consistent with neuroleptic-induced acute dystonia and potentially neuroleptic-induced parkinsonism. We believe this adverse effect occurred as a result of a drug interaction between ritonavir/indinavir and risperidone. Based on the pharmacokinetics of these medications, we hypothesize that inhibition of CYP2D6 and CYP3A4 by ritonavir and indinavir may have resulted in an accumulation of the active moiety of risperidone, which may explain the occurrence of EPS in this patient. CONCLUSIONS: This is the second published case report describing a suspected drug interaction with ritonavir, indinavir, and risperidone. Caution is warranted when risperidone is prescribed with ritonavir/indinavir, and possibly with other antiretrovirals that inhibit the same pathways.

Background Influenza infection may be more serious in human immunodeficiency virus (HIV)-infected individuals, therefore, vaccination against seasonal and pandemic strains is highly advised. Seasonal influenza vaccines have had no significant negative effects in well controlled HIV infection, but the impact of adjuvanted pandemic A/California/07/2009 H1N1 influenza hemaglutinin (HA) vaccine, which was used for the first time in the Canadian population as an authorized vaccine in autumn 2009, has not been extensively studied. Objective Assess vaccine-related effects on CD4+ T cell counts and humoral responses to the vaccine in individuals attending the Newfoundland and Labrador Provincial HIV clinic. Methods A single dose of ArepanrixTM split vaccine including 3.75 μg A/California/07/2009 H1N1 HA antigen and ASO3 adjuvant was administered to 81 HIV-infected individuals by intramuscular injection. Plasma samples from shortly before, and 1–5 months after vaccination were collected from 80/81 individuals to assess humoral anti-H1N1 HA responses using a sensitive microbead-based array assay. Data on CD4+ T cell counts, plasma viral load, antiretroviral therapy and patient age were collected from clinical records of 81 individuals. Results Overall, 36/80 responded to vaccination either by seroconversion to H1N1 HA or with a clear increase in anti-H1N1 HA antibody levels. Approximately 1/3 (28/80) had pre-existing anti-H1N1 HA antibodies and were more likely to respond to vaccination (22/28). Responders had higher baseline CD4+ T cell counts and responders without pre-existing antibodies against H1N1 HA were younger than either non-responders or responders with pre-existing antibodies. Compared to changes in their CD4+ T cell counts observed over a similar time period one year later, vaccine recipients displayed a minor, transient fall in CD4+ T cell numbers, which was greater amongst responders. Conclusions We observed low response rates to the 2009 pandemic influenza vaccine among HIV-infected individuals without pre-existing antibodies against H1N1 HA and a minor transient fall in CD4+ T cell numbers, which was accentuated in responders. A single injection of the ArepanrixTM pandemic A/California/07/2009 H1N1 HA split vaccine may be insufficient to induce protective immunity in HIV-infected individuals without pre-existing anti-H1N1 HA responses.