With improvements in antiretroviral therapy (ART) and its widespread use, the survival of people living with HIV (PLWH) has progressively improved, now resembling that of uninfected people. However, significant challenges remain in the area of HIV infection, such as improving prevention, early diagnosis of infection, and management of chronic conditions or sexually transmitted infections. Other issues that may appear less health-related, but are critically important, such as ending stigma and discrimination toward PLWH, also need to be addressed.

Given the varying levels of complexity and needs of different PLWH, stratification tools need to be developed and implemented to enable care to be tailored to each person living with HIV, leading to improvements in care and optimisation of resources. Their use is expected to have a positive impact on both the quality of life of PLWH and the sustainability of the health system. During this development and implementation process, it is important to focus on the usefulness of these stratification tools: they should have a clear purpose and respond to a real need, which should always be the starting point. Both complexity and the lack of it need to be diagnosed, stratified, and managed using a health-based rather than a disease-based approach for PLWH, where routine interventions add little value and have a negative impact on their personal and working lives. Without a comprehensive approach and clear objectives, these stratification tools are likely to fail; stratification should be a tool, a means to an end, and not an end in itself.

In this issue of Farmacia Hospitalaria, Dr. Morillo et al. present an interesting article analysing the concordance between two stratification models developed by the Spanish Society of Hospital Pharmacy with the aim of optimising and tailoring pharmaceutical care for PLWH. The first model was developed and published in 20171 and the simplified version in 2022.2 Both models classify PLWH into three strata, showing a good level of concordance. Therefore, the current simpler, multidisciplinary version is likely to be more applicable.

At present, we have little data on the implementation and use of these tools, and it is vital that efforts in this area of research and dissemination are stepped up in the coming years.

We often witness the failure to implement strategies and tools that are a priori necessary. There are likely many reasons for this situation. These include the heavy and complex workloads of healthcare professionals as well as high turnover rates, which can occur without adequate knowledge transfer. Another notable issue is the need to automate and integrate many processes within information systems, as Dr. Morillo acknowledges. These realities are likely familiar to healthcare professionals, yet there are other aspects that are sometimes overlooked, but which I believe are crucial for understanding the barriers to implementation. These include the need to change the mindset of healthcare professionals (where we evaluate and change everything that we consider unnecessary) as well as overcoming the inertia of “business as usual” and resistance to change. In other words, we need to make care models and the way we work more flexible, adapting them to a current model that is more patient-centred and value-based, and less focused on traditional outcome indicators.

In general terms, it is preferable to implement stratification tools using a bottom-up approach rather than a top-down approach; no one knows what is needed better than healthcare professionals. Implementing stratification tools that do not respond to the real needs of users and health professionals sets the strategy up for failure. It also transforms the work of healthcare professionals into purely administrative tasks in which they do not see themselves as participants, which they do not find useful, and which have a high risk of failure.

Stratification tools should not be rigid, but rather should take into account the dynamics and changes experienced by PLWH, encompassing not only health aspects, but also social, employment, and other issues. People living with HIV may face access barriers that hinder their adherence to programmes or treatments. Nevertheless, these circumstances are dynamic and can change over time. Therefore, tools need to be developed, implemented, and evaluated with this dynamism in mind; otherwise, they risk becoming static “snapshots” that do not accompany PLWH as they navigate the system, and will become outdated, losing their usefulness.

It should be recalled that the traditional model of monitoring PLWH in hospitals is rigid, disease-based, and primarily focuses on the early detection of events associated with severe immunosuppression, virological failure, or significant pharmacological toxicities. Fortunately, these targets are now considered outdated and therefore no longer apply to the vast majority of PLWH in follow-up. Thus, this model, once deemed successful, no longer meets the needs of PLWH today and is no longer efficient. Stratification tools can be very useful in designing tailored pathways for different groups of PLWH with shared needs. Only through multidisciplinary work will it be possible to address the fourth UNAIDS indicator, which focuses on quality of life.

In Spain, successful pilot schemes have been conducted using unconventional strategies, such as providing ART in remote centres, home delivery services, non-face-to-face follow-up of PLWH, and even developing self-monitoring models for certain PLWH.3–5

In addition to the models developed by the Spanish Society of Hospital Pharmacy (which form the basis of the article published in the current issue of Farmacia Hospitalaria), the GESIDA stratification model has been developed within the framework of the Spanish National Policy project. This model involves significant multidisciplinary work, and includes the perspectives of non-healthcare professionals and PLWH. This model classifies PLWH into 7 strata identified by colour, identifies the needs for each stratum, proposes a care portfolio, and calculates the complexity of PLWH.6

It is crucial that the different scientific societies that bring together healthcare professionals—in this case those working with PLWH—are able to work together toward the same goal, creating more useful tools and synergies, leading to much more cohesive and efficient work teams, ultimately enhancing satisfaction for both users and professionals. Hopefully, we will move toward more flexible care models that are focused and organised around processes rather than services. In the case of care for PLWH, this entails aligning the work of medical, pharmaceutical, and nursing professionals around the same goals and indicators, and in close association with other key healthcare and non-healthcare professionals.

The authors declare that they have received no specific support from any public or private entity.

The authors declare that they have no conflicts of interest.

Álvaro Mena: Writing – original draft.