December is HIV/AIDS Awareness Month and the college wants to remind you of the important role pharmacists play in treating people living with HIV/AIDS. Pharmacotherapy Associate Professor Rustin Crutchley teaches many topics at the Yakima extension, including Therapeutics of Special Populations and Integrated Pharmacology. However, his passion is illuminating the various breakthrough therapies for people living with HIV/AIDS. Crutchley will resume a six-week rotation to Cape Town, South Africa in May 2023 where he educates student pharmacists about the treatment and prevention of HIV/AIDS.
Can you tell us more about your background with treating patients living with HIV and how you became interested in helping those patients?
I grew up in Cape Town, South Africa during most of my childhood. Having witnessed the devastating effects of AIDS on the South African population, this sparked in me a deep passion to pursue a career that encompassed care for people living with HIV. Fortunately, I was able to build on my interests in antiretroviral pharmacology and clinical expertise in HIV through pharmacy school at the University of North Carolina Chapel Hill and my PGY2 HIV Specialty residency in SUNY-Buffalo (State University of New York – Buffalo) under worldwide leadership and mentoring of Drs. Angela Kashuba and Gene Morse, respectively. I then worked as an HIV clinical pharmacist in both pediatric and adult HIV populations with worldwide experts Drs. Mary Paul and Joseph Gathe for 9 years in Houston, Texas.
During the last few years of my appointment at University of Houston I became more interested in pharmacogenomics since I observed first-hand the benefits it had on some of my patients with HIV who had other medical problems such as depression. Having also worked some time as a pharmacogenomist in Houston this further gave me a greater appreciation of the field. Therefore, I created a new PGY2 HIV Ambulatory Care/Clinical Pharmacogenetics residency program to train future HIV practitioners with a skillset in pharmacogenomics to be able to provide comprehensive care for the HIV population.
While at Washington State University, my work in HIV has come full circle, where I created an HIV/Precision Medicine APPE rotation that is offered annually to WSU students in Cape Town, South Africa. The first offering of this rotation was in 2019. Unfortunately, because of COVID I was unable to take students since then but am looking forward to taking a group of six students in May 2023.
Can you share what students will be doing in May 2023 during their rotation to Cape Town, South Africa?
This program is a blend of academic and ambulatory care/inpatient experiences in HIV, internal and precision medicine. This 3-week experience in Cape Town, South Africa offers students a broad array of opportunities ranging from comprehensive care of people living with HIV (i.e. prevention of mother-to-child transmission, pediatric, and adult care) at Helderberg Community Health Clinic to general medication management in an internal medicine inpatient setting at both Helderberg and New Somerset Hospitals. Opportunities are also available for students interested in mental health at Strand Clinic. Students will engage regularly with University of Western Cape Masters in Clinical Pharmacy students across these clinical facilities including participation in pharmacogenomics/precision medicine teachings. This is an excellent opportunity for sharing of best practices with regards to medication management of people living with HIV. Students will observe how pharmacogenetic analyses are performed in state-of-the-art laboratory facilities at the University of Cape Town and how these data are used to inform prescribing recommendations for patients under care of providers at various institutions. Overall, this program will equip students with a unique global perspective on comprehensive care of people living with HIV and a greater appreciation and understanding of delivery of health care in South Africa. They will have multiple opportunities to engage in South African culture and explore the extravagant beauty of Cape Town, too.
December is AIDS Awareness Month. What sort of information do you think the public needs to know about HIV? What’s the most common misconception about HIV?
A common misconception about HIV that used to have some weight was that having HIV/AIDS is a death sentence. However, development of newer antiretrovirals including recent long-acting injectable antiretrovirals has transformed this disease state to a very manageable chronic disease state with life expectancy no different to people who do not have HIV. Furthermore, the availability and development of oral daily pre-exposure prophylaxis (PrEP) options such as Truvada® and Descovy® including long-acting injectable antiretroviral PrEP such as Apretude® has helped to curb the HIV epidemic with an overall decreased incidence of new HIV infections in the US.
Can you give us some context of what a day in a life of a patient who is living with HIV? How do pharmacists play a role in helping these patients?
As alluded to earlier, people living with HIV worldwide nowadays have an advantage of being able to take one tablet once daily fixed dose antiretroviral combinations. This is critical for promoting life-long adherence to treatment. Furthermore, there are also opportunities for people living with HIV to now simplify to long-acting injectable antiretroviral treatment with Cabenuva® dosed every two months. Additional long-acting antiretroviral options such as lenacapavir should be approved relatively soon which will also provide opportunities for people living with HIV to take treatment even less frequently. Since people living with HIV are living longer due to improved accessibility and availability of potent and tolerable antiretroviral therapy, focus on patient care has shifted increasingly to optimization of medication management of comorbidities such as cardiovascular disease and diabetes. Pharmacists are well positioned to also serve as accessible resources for provision of PrEP, especially, as prescriptive authority is improving for those working in community pharmacy.
What information/knowledge do you try to impart on your students when you are teaching about HIV?
I find that using case examples from prior experiences working with various age groups of people living with HIV from different parts of the world helps to reinforce important concepts of teaching for students. Having worked in the field for more than 15 years, I have been able to observe significant changes in the landscape of antiretroviral treatment of people living with HIV. Fortunately, antiretroviral treatment has improved significantly over time with the availability of potent and tolerable antiretroviral therapy including long-acting injectable treatment. These provide exciting opportunities for pharmacists who are interested in pursuing a career in HIV as well as the increased prevalence of an aging HIV population, which gives pharmacists numerous opportunities for engaging in other aspects of HIV patient care such as primary care. The future management of HIV looks very promising as newer antiretroviral classes with less frequent administration are on the horizon. Furthermore, I find it important to relay to students that working in this field is incredibly rewarding as people living with HIV can now live normal lives with comparable lifespans to those without HIV. Pharmacists are also well positioned to serve as accessible resources for providing counseling on PrEP to help end the HIV epidemic.
What role does pharmacogenomics play in treating patients living with HIV?
Pharmacogenomics, a budding field of personalized medicine, is the study of how genes influence an individual’s response to treatment with medications. Major therapeutic areas involving these medications include oncology, psychiatry, cardiology, and pain which are also commonly represented in the HIV population. Pharmacogenomics can help to remove the trial-and-error approach by providing health care professionals with informative guidance from the very beginning of treatment to prevent toxicity and improve overall effectiveness of medication use. Abacavir, which is used for treatment of HIV is a well-established example of using pharmacogenomic testing to decrease the risk for developing a hypersensitivity reaction. The FDA-approved label for abacavir states that genetic testing for the HLA-B*5701 allele is required prior to initiating treatment. This testing is commonly performed by providers before prescribing abacavir in the US. However, this testing is not routinely done in other areas such as in sub-Saharan Africa since the prevalence of this allele is not as common in the populations in this area and is not financially feasible. As greater clinical uptake of pharmacogenomic testing and consumerism is anticipated to grow exponentially in the future, the role of using precision medicine in treatment of comorbidities and coinfections in the HIV population is also needed. Gaining this knowledge and insight could help to tailor appropriate selection of medications and dosing necessary for ensuring optimal medication management and maximizing long-term benefits for the HIV population.