Pharmacy Gives Man Wrong HIV Meds for Six Months

Being diagnosed with HIV is tough, and sometimes getting the most appropriate medication can be difficult too. For Jack (not his real name) it was even worse. After Jack tested positive for HIV, his doctor prescribed Isentress and Truvada, two drugs that work together to reduce a person’s viral load. Like millions of other people, he filled the prescription at a nationwide pharmacy chain. And that’s where a significant error occurred.

Jack’s attorney, Anthony Ross, says when his client’s prescription was filled, the technicians correctly logged that he needed Truvada, but instead of giving him Isentress, they prescribed him pain medication.

“Because it was his initial diagnosis, and also because he was informed by his physician that he might receive generic drugs, he didn’t know he was being given the wrong drug,” Ross says. “He just assumed it was the generic version of what he’d been prescribed.”

The error went uncorrected for months. Jack had his prescription filled four times, and each time he was given the incorrect drug. And even though his doctor noticed that his viral load was not responding as expected to the drugs she prescribed, nothing was done to check Jack’s medication, Ross says. In fact, the only reason the error was caught was pure luck: Without any prompting, his medical insurance provider assigned him to a different pharmacy.

“They do that sometimes,” Ross says. “He hadn’t requested it, and there was no reason that he was aware of as to why that happened.”

Once the new pharmacy obtained his actual prescription, Jack came home one day with different-looking pills. He called his original pharmacy and asked the staff to check whether he had been receiving the right pills.

“That’s when they confirmed that he had indeed been given the wrong drug,” Ross says.

During those months that Jack was on the wrong medication, he felt ill and fatigued, and his immune system took a big hit. He developed a resistance to Truvada because he was taking it without the proper companion drug. And once he found out he was being incorrectly medicated, he took a psychological hit.

“As you can imagine, finding out you have HIV is one kick in the gut,” Ross says. “Then, six months later, finding out you weren’t even being treated properly for the HIV you were just diagnosed with is the second kick in the gut.”

Jack is one of the many people who have been exposed to pharmacy errors like this. According to the National Patient Safety Foundation, medication errors are incredibly common. In fact, a 2006 report by the Institute of Medicine estimated that 1.5 million Americans were harmed by medication errors annually, resulting in $3.5 billion in additional medical costs.

Joseph Zorek, who was a pharmacist with CVS/pharmacy (now CVS Health) for more than 30 years, filed a whistle-blower lawsuit in 2012 against the chain. In the suit Zorek said understaffing at the pharmacy created an environment where such careless mistakes could be made behind the counter.

Ross says in his research in Jack’s case, he found that many pharmacies run like banks or fast-food chains, where speed is incentivized over accuracy or safety. 

“A lot of big chain pharmacies have systems in place where they’re trying to move people through the pharmacy quickly,” he says. “If you’re in line for a certain number of minutes, we’ll give you 50 bucks or whatever. So there’s all these incentives — sometimes they’re on the consumer side, sometimes they’re on the employee side — to get people through quickly.”

Due to the agreement Ross’s client and the pharmacy reached earlier this year, the company could not be identified in this story, but it is one of the four largest drugstore chains in the U.S. When contacted for comment about the case, the company’s media representative said, “Because of privacy issues, we are unable to comment on the matter.”

In the meantime, to Ross’s knowledge, the pharmacy has done little to prevent further errors, so there is still a potential for harm to people who take all kinds of medications. But for now, he suggests that everyone make a visual confirmation of the medication they’re taking by checking online to see what their pill is supposed to look like and then making sure the pill in the bottle matches up.