The number of new pharmacists entering the field has been growing at a remarkable rate since the mid-1980s, and even more pronounced since the mid-2000s. In 2020 alone, over 14,500 graduates received their first professional pharmacy degree.1 That said, the Bureau of Labor Statistics estimates only a 2% growth in jobs between 2021 and 2031, equating to about 13,600 new positions each year.2 As might be expected, the variance between new pharmacists applying for positions and the shortage of positions available leads to an extremely competitive market, requiring the development of skills attained outside the classroom.

The purveyors of HIV health, in all its parts, tend to be drawn to this work by some intrinsic driver, like shared experience or passion for advocacy, more so than by the science of disease. While passion is an excellent foundation to build a career, it is not all that’s needed for long-term career success, and rarely is it enough to make that optimal first impression. I have been practicing across the pharmacy space for just shy of 20 years now, with over 10 of those years rooted in the field of HIV care and prevention. Following is a smattering of the advice I have for pharmacists entering, or considering, the HIV field for the first time.

Knowledge of the medications is obvious. Learn the drugs. Read the studies. Be a pharmacist. The truth is, the medications we have in our toolbox now are amazingly effective, and with appropriate selection and quality adherence the vast majority of patients will be virally suppressed, with no risk of transmission and without notable side effects. Appropriate selection is the space where pharmacists can play a huge role, and the reason isn’t particularly HIV specific. According to data published by the National Institutes of Health, by 2030 over 70% of all people living with HIV and 18% of people newly diagnosed will be over the age of 50. This reinforces the approach to HIV management that has pivoted from a position of infectious disease to one more akin to a chronic geriatric condition.3

The effectiveness of today’s HIV medications make viral suppression the icing on the cake, as more and more patients seek medical care for their uncontrolled comorbidities, like diabetes, hypertension, depression, etc. As the population of people living with HIV continues to get older, pharmacists must place a stronger emphasis on understanding the comorbidities associated with aging, and the intersectionality of antiretroviral selection. Polypharmacy, especially in the occurrence of age or disease-related declining cognitive function, places individuals at higher risk for drug-drug interactions. Renal and hepatic disease, along with endocrine and metabolic changes, can cause significant alterations in drug metabolism. Malignancy, frailty and fall risk and cardiovascular incidence are all more likely to be experienced by senior individuals living with HIV than those without.

The other major piece of advice I have for new pharmacists entering the HIV care space is also associated with approach mindset, as opposed to clinical prowess. HIV was one of the first disease states to be evaluated under the lens of syndemic theory, which was developed by medical anthropologist Merrill Singer in the early 1990s, and essentially describes two or more concurrent, but seemingly unrelated, epidemics that actually have synergistic effects.4  In layman’s terms, it is impossible to separate the medical impact of HIV from other medical comorbidities or the social, racial, political and economic disparities affecting people living with HIV.

The concept of syndemics has been given a considerable increase in attention as we grapple with understanding the whys and hows of the COVID epidemic. The modeling that has developed in recent years has begun to be applied to other disease states, diabetes in particular, but the conceptualization began in the study of the HIV epidemic over 30 years ago. New pharmacists, or those entering the HIV space for the first time, should understand that not only do disparities in health exist, but that these disparities are not isolated points of data. They are symbiotic contributors, applying pressure to clinical and social outcomes, and must be addressed concurrently at the system and patient levels if we truly hope to end the HIV epidemic.

Dan Scales is director of Pharmacy Collaborative Care at Vivent Health.