- Email: [email protected]
Pharmacists’ perspectives on HIV testing in community pharmacies
RESEARCH
Pharmacists’ perspectives on HIV testing in community pharmacies Priscilla T. Ryder, Beth E. Meyerson, Kelsey C. Coy, and Christiana D.J. von Hippel
Received December 12, 2012, and in revised form April 24, 2013. Accepted for publication May 5, 2013.
Abstract Objective: To assess the feasibility, readiness, and acceptability of offering rapid human immunodeficiency virus (HIV) testing in community pharmacies. Design: Qualitative study. Setting: Community pharmacies in Indiana from May to September 2012. Participants: 17 licensed community pharmacists. Intervention: Semistructured interviews among a convenience sample of community pharmacists. Main outcome measures: Community pharmacists’ self-reported attitudes toward rapid HIV testing in community pharmacies, perceptions of peer acceptability, and opinions about readiness for implementation of the practice in community pharmacies. Results: Participants accepted the idea of pharmacy-based HIV testing, describing it as accessible, convenient, and nonstigmatizing. Acceptability was closely linked to positive patient relationships and pharmacist comfort with consultation. Identified challenges to pharmacy-based HIV testing included staffing issues, uneasiness with delivering positive test results, lack of information needed to link patients to care, insufficient consulting space, and need for additional training. Participants indicated that peer beliefs about the acceptability of pharmacist-based HIV testing would vary but that more recently trained pharmacists likely would be more accepting of the practice. Conclusion: Most participants felt that offering HIV testing was a reasonable addition to the evolving role of the community pharmacist, pending resolution of personal and institutional barriers.
Priscilla T. Ryder, MPH, PhD, is Assistant Professor of Pharmacy Practice, College of Pharmacy and Health Sciences, Butler University, Indianapolis, IN. Beth E. Meyerson, MDiv, PhD, is Assistant Professor of Health Policy & Management, School of Public Health, Indiana University, Bloomington. Kelsey C. Coy is a graduate, College of Liberal Arts & Sciences, Butler University, Indianapolis, IN. Christiana D.J. von Hippel, MPH, is a graduate, School of Public Health, Indiana University, Bloomington. Correspondence: Beth E. Meyerson, MDiv, PhD, School of Public Health, Indiana University, 1025 E. 7th St., Bloomington, IN 46405. Fax: 812-855-3936. E-mail: [email protected] Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Acknowledgments: To the Indiana Pharmacists Alliance, Purdue University Medication Safety Research Network of Indiana (Rx-SafeNet), and Butler University College of Pharmacy for recruitment assistance. Funding: ICTSI NIH/NCRR grant no. TR000006. Published online ahead of print at www. japha.org on October 4, 2013.
Keywords: Community pharmacy, human immunodeficiency virus, pharmacy services, qualitative research, Indiana. J Am Pharm Assoc. 2013;53:595–600. doi: 10.1331/JAPhA.2013.12240
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ommunity pharmacy practice has changed considerably in the previous 20 years. In addition to overseeing the dispensing of medications, community pharmacists now evaluate medications, educate and immunize, and are full-fledged health care partners.1,2 Community pharmacies increasingly are becoming public health settings, as they offer preventive and treatment services. The expansion of pharmacy-based diagnostic services, for example, has increased the opportunity for screening and control of chronic and infectious diseases.3–5 This is particularly important for human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), because in the United States, 40% of people testing positive for HIV do so late in the disease process6 and 20% of people living with HIV are unaware of their condition.7 Evidence indicates that despite availability of effective treatment, HIV is not controlled in approximately 850,000 of the 1.2 million people with HIV in the United States.8 Early detection and treatment of HIV can reduce transmission of the disease drastically.9 Pharmacists are highly trained, highly trusted10 health professionals, located in almost every community. With the observed success of offering medication
At a Glance Synopsis: Interviews with a sample of pharmacists from Indiana revealed that all participants considered pharmacy-based human immunodeficiency virus (HIV) testing to be acceptable and important as a public health service. Pending removal of personal and institutional barriers, most participants felt that HIV testing could be added as a community pharmacy service. Acceptability of the practice was closely linked to positive patient relationships and pharmacist comfort with consultation. Staffing issues, uneasiness with delivering positive test results, lack of information needed to link patients to care, insufficient consulting space, and need for additional training were identified as challenges. Analysis: Although pharmacists recognized the importance of and their potential role in linking patients to care, most talked about it in simplistic terms, as if a well-functioning referral system existed for getting patients into treatment. This finding needs to be explored further, as it may affect pharmacist perceptions of feasibility if they practice in communities in which linkage to HIV treatment is problematic. To implement HIV testing, comprehensive training curricula must address multiple issues, including stigmatization and modes of transmission for HIV, counseling techniques, and test mechanics.
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therapy management,11,12 immunizations,13,14 and other preventive services in community pharmacy settings, the integration of HIV testing may be a natural extension of the role of community pharmacists. Pharmacist opinion about pharmacy-based HIV screening has been explored in high-prevalence areas for HIV and in highly specialized pharmacy settings.4 Perceptions among injection drug users regarding pharmacy provision of HIV prevention services, including HIV testing, also has been explored in high-prevalence areas.15 Although these studies help to establish an understanding of HIV testing in pharmacies among specialized pharmacists or high-risk populations in highprevalence areas, little is known about issues of feasibility, acceptability, and readiness for HIV screening from the perspective of a general population of community pharmacists and in moderate-prevalence areas. This is a crucial gap in the literature, as pharmacies are particularly important sources of health care and information in rural communities and communities with low medical resources.16
Objective We sought to examine perceptions of feasibility, acceptability, and readiness for pharmacy-based HIV testing among a general population of community pharmacists in a midwestern state with a moderate prevalence of HIV.
Methods Data were collected during semistructured interviews among a convenience sample of community pharmacists located in Indiana. Key informant interviewing allowed exploration of complex and sensitive17 issues that are largely unstudied.18,19 An interview guide containing 12 questions was informed by thorough literature review and evaluation of extant instruments exploring pharmacist attitudes about several topics (not limited to HIV).3,4,14,20–25 Currently licensed Indiana community pharmacists were recruited through personal networks, pharmacy school faculty contacts, and state pharmacy organizations. A total of 45 individuals were suggested as possible participants, and 17 interviews were completed. Contact information was unavailable for 2 individuals, 3 declined to participate, and interest in participating could not be confirmed for the remaining 23. Recorded interviews lasting 20 to 60 minutes were conducted in person and by telephone between May and September 2012. A hybrid approach of thematic analysis and didactic, a priori template coding based on the research questions was used.26,27 This means that a codebook defined by the research questions was applied to the data for organization, paired with an approach that allowed themes to emerge inductively from the data. Theoretical saturation was reached with this sample.28 Three investigators independently coded transcripts to Journal of the American Pharmacists Association
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ensure that themes could be reproducible and therefore verifiable. In qualitative research, this is a method of ensuring interrater reliability.18,29 The study protocol was approved by the institutional review boards at Indiana University and Butler University.
Results Characteristics of participants and the pharmacies in which they work are shown in Table 1. The median age of participants was about 38 years (range 21–55), and they had worked an average of 13 years as community pharmacists. Acceptability of pharmacy-based HIV testing In general, pharmacists accepted the idea of pharmacybased HIV testing as a service that pharmacies could offer to the public. The benefits identified by participants were accessibility, convenience, and the trusting relationships that pharmacists had with patients for consultation and linkage to care. As described below, pharmacists accepted the concept of HIV testing in pharmacy settings and raised several important issues to inform implementation of the practice. Accessibility and convenience. Some pharmacists emphasized the importance of HIV testing in pharmacies because of the access they provide, specifically in rural communities. One pharmacist said, “There are some rural areas that might have a pharmacy in that small town but not have a physician’s office.” Pharmacist opinion about accessibility was most often expressed in terms of convenience. Participants felt that community pharmacy settings might be viewed by patients as “quicker” than a clinic or physician office visit. One pharmacist said, “[In a pharmacy], you could be waiting in the waiting room and no one would know what you’re waiting for. ... We’re kind of a one-stop shop, so it’s more private.” Pharmacist–patient relationship. The pharmacist– patient relationship was a prominent factor when participants discussed advantages to HIV testing in pharmacies. Participants framed both advantages and challenges to pharmacy-based HIV testing in terms of their own professional consultative relationship with their patients. As stated by one pharmacist, “I have a personal relationship with my patients, and I really enjoy that. Whatever I could do to help them in whatever type of situation that they’re in, I would certainly do.” In knowing their patients, pharmacists recognized that some people might not want to take an HIV test in their local pharmacy precisely because they would not be anonymous. One respondent used sildenafil (Viagra— Pfizer) to illustrate patients’ desire for anonymity: “There are people that will come to me and buy Viagra because I don’t know them. And I think some of my customers, because they don’t want people to know they’re taking Viagra, probably go to other pharmacies [to get Viagra].” Journal of the American Pharmacists Association
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Table 1. Characteristics of pharmacists interviewed regarding perceived feasibility, acceptability, and readiness of offering rapid HIV testing in community pharmacies Characteristic n Age (years) mean ± SD Gender (men) PharmD degree Years since first licensed <1 1–4 5–9 10–19 ≥20 Pharmacy setting Community chain Other chaina Community independent Pharmacy location Urban Suburban Large townb Small townc Rural Pharmacy serves HIV-positive patients Pharmacy has private consulting room
No. (%) 17 37.9 ± 9.7 9 (52.9) 11 (64.7) 1 (5.9) 3 (17.6) 3 (17.6 6 (35.3) 4 (23.5) 8 (47.1) 4 (23.5) 5 (29.4) 9 (52.9) 1 (5.9) 2 (11.8) 4 (23.5) 1 (5.9) 7 (43.8) 10 (62.5)
Abbreviations used: HIV, human immunodeficiency virus; PharmD, doctor of pharmacy. a Grocery or mass merchandiser setting. b Large town: population center with ≥25,000 residents. c Small town: population center with at least 2,500 but fewer than 25,000 residents.
Barriers to testing. Participants identified several barriers to pharmacy-based HIV testing, including staffing issues, unfamiliarity or discomfort with the task of delivering results to patients, lack of existing training, and issues of reimbursement. Participants felt that appropriate training could mitigate challenges because consultation was already part of the contemporary pharmacist role. One pharmacist said, “For the more recent [pharmacy] graduates, and I’m 15 years out now, consultation is the norm. They think of consultation as their primary occupation. For the ones older than me, often it was order accuracy and counting and making sure the label is correct and all that stuff.” Expansion of community pharmacist role. Pharmacists reported that the evolution of pharmacy practice included increased consultation, immunization, and health screening. Comfort with increased patient interaction and success with expanded pharmacy practice duties were considered likely facilitators of pharmacist acceptance of HIV testing in pharmacy settings. One pharmacist stated, “We didn’t even vaccinate 5 years ago, and now we’re doing vaccinations and health j apha.org
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screens. ... I would hope that my peers would embrace it as just another opportunity. ... It can be sensitive material for someone, but there are other issues we deal with that are sensitive as well, so it’s just another challenge. But again, if you can help someone get more access to health care, I think it would be a positive.” Although most participants described themselves as patient consultants, some felt that standard pharmacy training would not be sufficient for counseling regarding HIV test results. Participants recognized the potentially life-changing importance of consultation after a test. One pharmacist said, “It’s not like you’re being diagnosed with ... high blood sugar here.” The sensitive nature of giving someone HIV test results, especially when positive, was a concern for many participants. A few pharmacists explained this as the emotional aspect of test consultation. “Typically, a pharmacist doesn’t deal with giving patients horrible news,” said one pharmacist. One participant stated, “How do you counsel them? Not only on their results, but if asked, ‘How do I tell my partner?’ ‘How do I trace this back?’ ... I would be crying with them.” Despite some reservations, no pharmacist expressed that HIV testing would be unacceptable or inappropriate in community pharmacy settings. Feasibility of pharmacy-based HIV testing. Professional practice adjustment and models to operationalize testing were raised when participants reflected on the feasibility of pharmacy- based HIV testing. Several participants likened the inclusion of testing to the inauguration of pharmacy immunizations. Practice change regarding immunizations was not as difficult as initially anticipated. One pharmacist said, “We were able to work through that [practice change]. Now, there were a lot of people who were skeptical, and when they came in for [immunization] training, they just knew, ‘Okay, it’s going that way. I’m going to have to do this.’ ... And after going through the training and experiencing it; it was like, ‘Wow, that wasn’t as big a deal as I thought it was going to be.’” Although all participants viewed the practice adjustment as feasible, especially if handled similar to immunizations requests in the pharmacy, important differences were noted, including the duration of the visit and space for privacy. Challenges also included the balance of productivity with counseling and other services, as illustrated by the following comment: “I think that the challenge would be ... that a person has psyched themselves up and might want the test. ... I can think of nothing that would be more important than having good counseling based on the results of that test. It would be horrible to have someone get that news and feel like they’re rushed and not be able to have a health care professional discuss next steps with them and implications.” Privacy and confidentiality. Participants generally felt that offering testing in settings with private consulta598 JAPhA | 5 3:6 | NOV/DEC 2013
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tion rooms to ensure confidentiality and privacy would be feasible. However, some pharmacies do not have a physical layout that allows for closed-door consultation, while others might have a door that closes off to the public but not to the pharmacy space. Participants felt that pharmacies increasingly were offering private areas for counseling but that this was not a universal practice. Staffing issues. Staffing issues were frequently mentioned as a challenge. Several participants felt that HIV testing should occur only when more than one pharmacist was on duty. One pharmacist said, “I think in our store it would be pretty feasible because we’re a busy enough store that we also have pharmacist overlap. ... Problem you’re going to run into is that slower stores, they’re either (a) not going to have the clinic, like we do here, and (b) they’re not going to have any pharmacist overlap. So it’s a challenge if it’s something that is going to be time consuming, especially if you imagine someone having a positive result.” Training needs. Training was repeatedly identified as a fundamental need before HIV testing could take place. Suggested training topics included delivering results and counseling patients, referral to HIV treatment for those who test positive, and basics such as the mechanics of performing tests and general training on HIV issues such as modes of transmission and treatment. Pharmacists expressed differing opinions about how training should be delivered. Some thought that it should be treated as any other continuing education topic, through journal articles or classroom-based training. Others expressed strong feelings that training should take place face-to-face with experienced trainers, whereas others felt that online training, perhaps including video scenarios, would be preferable. Several participants felt that training should include pharmacy technicians and interns, focusing on confidentiality procedures and ensuring that staff have sufficient knowledge to respond appropriately to patients. Even with Health Insurance Portability and Accountability Act–required health information training for pharmacy technicians, a few participants expressed concerns about privacy among technicians. Readiness of pharmacy-based HIV testing. Participants expressed that readiness to implement HIV testing might be determined by pharmacy experience with other public health services, such as health behavior consultation, diagnostics, and immunizations. Staggered implementation, starting with interested pharmacies or pharmacies in communities with higher HIV prevalence, was recommended. Two participants indicated that their pharmacies sometimes offered HIV testing on specific dates, hosting a community-based organization (CBO) that provided testing and counseling on site. One pharmacist admired the CBO’s ability to counsel and link patients to care: “If I were to do HIV testing at my store, [I would] include [name of CBO] as Journal of the American Pharmacists Association
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the reference point for this person, so to set up an appointment for them at [CBO] to kind of bridge that gap between ‘Okay, you test positive here, now’ and ‘What do you do now?’” Most participants expressed that with sufficient training and support, they could offer testing services. Some participants expressed doubts about the readiness of their pharmacist peers. It was suggested that some pharmacists would not be comfortable with aspects of testing, such as counseling, preparing kits, or working with samples. A few participants expressed that peers may feel an exaggerated fear of acquiring HIV from patients based on a lack of knowledge about the test or about HIV. One pharmacist stated, “It can be a complicated disease state in the fact that there are different regimens and different classes of medication. So I think that if you ask the typical pharmacist, they wouldn’t be comfortable counseling or talking to a patient. And I also feel like it’s a disease state that is evolving quickly, so I think that they might also feel like, ‘Ooh, I might not be giving the most up-to-date recommendations or suggestions. ... You kind of just steer away from it.’”
Discussion All participants felt that pharmacy-based HIV testing was acceptable and important as a public health service. One pharmacists said, “There’s so much evidence towards ... being diagnosed early, and treatment possibilities that it would just be hard not to provide that service.” The value of immunization experience as a potential basis for community pharmacist acceptance and sense of feasibility about pharmacy-based HIV testing is congruent with the work of Amesty et al.4 They found that among specialty pharmacy staff in New York City, those who supported pharmacy-based vaccination were more likely to support in-store HIV testing. Although pharmacists recognized the importance of linkage to care and their potential role related to it, most talked about linkage to care in simplistic terms, as if a well-functioning referral system existed for getting people into treatment. This needs to be explored further, as it may affect pharmacist perceptions of feasibility if they practice in communities in which linkage to HIV treatment is problematic. However, this would be precisely the reason for pharmacy-based HIV testing, consultation, and linkage to care because the pharmacy would be filling an important public health service gap as safety net provider. Participants provided thoughtful guidance for professional development. To implement HIV testing, comprehensive training curricula must address multiple issues, including stigmatization and modes of transmission for HIV, counseling techniques, and test mechanics. This could be accomplished in several ways. Continuing education programs are a natural way to educate pharJournal of the American Pharmacists Association
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macists, and new programs will need to be developed to help pharmacists gain confidence in providing comprehensive screening services. The interviews described in the current work provided tremendous insight into the complexity of issues surrounding HIV testing in community pharmacies. The willingness of pharmacists to address several difficult issues, including sexual transmission, stigma, and selfawareness, indicated that these pharmacists were highly aware of the social dimensions around HIV. Indiana is a midwestern state where HIV stigma is still experienced and reported,30 and these participants were aware of the importance of testing in nonstigmatized venues. Compassion and empathy were universally expressed toward patients and reflected elements in the Oath of a Pharmacist: welfare of humanity, keeping abreast of developments, and embracing and advocating change.31
Limitations As is standard with qualitative research, this study used nonprobability sampling.32 As such, the participants may not be fully representative of the universe of licensed community pharmacists in Indiana. This study was an important contribution to the literature because to date, no studies have been conducted in communities with a moderate prevalence of HIV or among nonspecialized pharmacists. A total of 17 participants were interviewed. This number is typical in qualitative research, and theoretical saturation of major themes was reached. The near unanimity of expressed attitudes about acceptability may be a result of sampling and response issues. For example, pharmacists who were negative about offering HIV services may have actively or passively declined to participate. Positive attitudes could be explained in part by sampling and not, as findings would suggest, by the relatively recent pharmacy school training of many participants or by experiences in expanded public health pharmacy practice. Future studies should explore acceptability, readiness, and feasibility among a larger and more representative sample of community pharmacists.
Conclusion Although challenges exist to offering rapid HIV testing in community pharmacy settings, this study of midwestern community pharmacists demonstrates that pharmacists are interested in talking about expanding pharmacy practice to include HIV testing, consultation, and linkage to care. Issues of feasibility and readiness require training and changes in pharmacy infrastructure and management support. Before HIV testing can be implemented, pharmacists require training, primarily in delivering test results and in linking patients to resources. This study is an important step in our national discussion of expanding nonclinical access to HIV testing. Pharmacies are important public health settings. j apha.org
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References 1. Abramowitz PW. The evolution and metamorphosis of the pharmacy practice model. Am J Health Syst Pharm. 2009;66(16):1437–46. 2. Meyerson BE, Ryder PT, Richey-Smith C. Achieving pharmacy-based public health: a call for public health engagement. Public Health Rep. 2013;128(3):140–3. 3. Snella KA, Canales AE, Irons BK, et al. Pharmacy- and communitybased screenings for diabetes and cardiovascular conditions in highrisk individuals. J Am Pharm Assoc. 2006;46(3):370–7. 4. Amesty S, Blaney S, Crawford ND, et al. Pharmacy staff characteristics associated with support for pharmacy-based HIV testing. J Am Pharm Assoc. 2012;52(4):472–9. 5. Potter MB, Gildengorin G, Wang Y, et al. Comparative effectiveness of two pharmacy-based colorectal cancer screening interventions during an annual influenza vaccination campaign. J Am Pharm Assoc. 2010;50(2):181–7. 6. Centers for Disease Control and Prevention. Late HIV testing: 34 states, 1996–2005. MMWR Morb Mortal Wkly Rep. 2009;58(24):661–5. 7. Centers for Disease Control and Prevention. HIV in the United States 2011. www.cdc.gov/hiv/resources/factsheets/PDF/us.pdf. Accessed March 18, 2012. 8. Gardner EM, McLees MP, Steiner JF, et al. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52(6):793–800. 9. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493–505. 10. Gallup. Honesty/ethics in professions: 2011. www.gallup.com/ poll/1654/honesty-ethics-professions.aspx. Accessed November 3, 2012. 11. Hirsch JD, Rosenquist A, Best BM, et al. Evaluation of the first year of a pilot program in community pharmacy: HIV/AIDS medication therapy management for Medi-Cal beneficiaries. J Manag Care Pharm. 2009;15(1):32–41.
16. Radford A, Richardson I, Mason M, Rutledge S. The key role of sole community pharmacists in their local healthcare delivery systems. www.shepscenter.unc.edu/rural/pubs/finding_brief/FB88.pdf. Accessed January 18, 2013. 17. Remler DK, Van Ryzin GG. Research methods in practice: strategies for discription and causation. Thousand Oaks, CA: Sage; 2011. 18. Golafshani N. Understanding reliability and validity in qualitative research. The Qualitative Report. 2003;8(4):597–607. 19. Morse JM, Barrett M, Mayan M. Verification strategies for establishing reliability and validity in qualitative research. International Journal of Qualitative Methods. 2002;1(2):13–22. 20. Chandra A, Malcolm N 2nd, Fetters M. Practicing health promotion through pharmacy counseling activities. Health Promot Pract. 2003;4(1):64–71. 21. Raine TR, Harper CC, Rocca CH, et al. Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs: a randomized controlled trial. JAMA. 2005;293(1):54–62. 22. Roberts AS, Benrimoj SI, Chen TF, et al. Practice change in community pharmacy: quantification of facilitators. Ann Pharmacother. 2008;42(6):861–8. 23. O’Loughlin J, Masson P, Déry V, Fagnan D. The role of community pharmacists in health education and disease prevention: a survey of their interests and needs in relation to cardiovascular disease. Prev Med. 1999;28(3):324–31. 24. Grabenstein JD. Pharmacists as vaccine advocates: roles in community pharmacies, nursing homes, and hospitals. Vaccine. 1998;16(18):1705–10. 25. Phokeo V, Sproule B, Raman-Wilms L. Community pharmacists’ attitudes toward and professional interactions with users of psychiatric medication. Psychiatr Serv. 2004;55(12):1434–6. 26. Crabtree BF, Miller WF. A template approach to text analysis: developing and using codebooks. In: Crabtree BF, Miller WF, Eds. Doing qualitative research. Newbury Park, CA: Sage; 1999:163–77.
12. Bunting BA, Smith BH, Sutherland SE. The Asheville Project: clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia. J Am Pharm Assoc. 2008;48(1):23–31.
27. Boyatzis R. Transforming qualitative information: thematic analysis and code development. Thousand Oaks, CA: Sage; 1998.
13. Hogue MD, Grabenstein JD, Foster SL, Rothholz MC. Pharmacist involvement with immunizations: a decade of professional advancement. J Am Pharm Assoc. 2006;46(2):168–79.
29. Saldana J. The coding manual for qualitative researchers. London: Sage; 2009.
14. Weitzel KW, Goode JV. Implementation of a pharmacy-based immunization program in a supermarket chain. J Am Pharm Assoc. 2000;40(2):252–6. 15. Lutnick A, Case P, Kral AH. Injection drug users’ perspectives on placing HIV prevention and other clinical services in pharmacy settings. J Urban Health. 2012;89(2):354–64.
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28. Creswell JW. Qualitative inquiry and research design: choosing among five traditions. Thousand Oaks, CA: Sage; 1998.
30. Meyerson BE, Perez A, Goode A. HIV secret shopper? Indiana’s community participatory research model. Abstract D05-1501. National HIV Prevention Conference, August 14–17, 2011, Atlanta, GA. 31. American Pharmacists Association. Oath of a pharmacist. www.pharmacist.com/oath-pharmacist. Accessed April 24, 2013. 32. Green J, Thorogood N. Qualitative methods for health research. 2nd ed. London: Sage; 2009.
Journal of the American Pharmacists Association
Pharmacists’ perspectives on HIV testing in community pharmacies Priscilla T. Ryder, Beth E. Meyerson, Kelsey C. Coy, and Christiana D.J. von Hippel
Received December 12, 2012, and in revised form April 24, 2013. Accepted for publication May 5, 2013.
Abstract Objective: To assess the feasibility, readiness, and acceptability of offering rapid human immunodeficiency virus (HIV) testing in community pharmacies. Design: Qualitative study. Setting: Community pharmacies in Indiana from May to September 2012. Participants: 17 licensed community pharmacists. Intervention: Semistructured interviews among a convenience sample of community pharmacists. Main outcome measures: Community pharmacists’ self-reported attitudes toward rapid HIV testing in community pharmacies, perceptions of peer acceptability, and opinions about readiness for implementation of the practice in community pharmacies. Results: Participants accepted the idea of pharmacy-based HIV testing, describing it as accessible, convenient, and nonstigmatizing. Acceptability was closely linked to positive patient relationships and pharmacist comfort with consultation. Identified challenges to pharmacy-based HIV testing included staffing issues, uneasiness with delivering positive test results, lack of information needed to link patients to care, insufficient consulting space, and need for additional training. Participants indicated that peer beliefs about the acceptability of pharmacist-based HIV testing would vary but that more recently trained pharmacists likely would be more accepting of the practice. Conclusion: Most participants felt that offering HIV testing was a reasonable addition to the evolving role of the community pharmacist, pending resolution of personal and institutional barriers.
Priscilla T. Ryder, MPH, PhD, is Assistant Professor of Pharmacy Practice, College of Pharmacy and Health Sciences, Butler University, Indianapolis, IN. Beth E. Meyerson, MDiv, PhD, is Assistant Professor of Health Policy & Management, School of Public Health, Indiana University, Bloomington. Kelsey C. Coy is a graduate, College of Liberal Arts & Sciences, Butler University, Indianapolis, IN. Christiana D.J. von Hippel, MPH, is a graduate, School of Public Health, Indiana University, Bloomington. Correspondence: Beth E. Meyerson, MDiv, PhD, School of Public Health, Indiana University, 1025 E. 7th St., Bloomington, IN 46405. Fax: 812-855-3936. E-mail: [email protected] Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Acknowledgments: To the Indiana Pharmacists Alliance, Purdue University Medication Safety Research Network of Indiana (Rx-SafeNet), and Butler University College of Pharmacy for recruitment assistance. Funding: ICTSI NIH/NCRR grant no. TR000006. Published online ahead of print at www. japha.org on October 4, 2013.
Keywords: Community pharmacy, human immunodeficiency virus, pharmacy services, qualitative research, Indiana. J Am Pharm Assoc. 2013;53:595–600. doi: 10.1331/JAPhA.2013.12240
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ommunity pharmacy practice has changed considerably in the previous 20 years. In addition to overseeing the dispensing of medications, community pharmacists now evaluate medications, educate and immunize, and are full-fledged health care partners.1,2 Community pharmacies increasingly are becoming public health settings, as they offer preventive and treatment services. The expansion of pharmacy-based diagnostic services, for example, has increased the opportunity for screening and control of chronic and infectious diseases.3–5 This is particularly important for human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), because in the United States, 40% of people testing positive for HIV do so late in the disease process6 and 20% of people living with HIV are unaware of their condition.7 Evidence indicates that despite availability of effective treatment, HIV is not controlled in approximately 850,000 of the 1.2 million people with HIV in the United States.8 Early detection and treatment of HIV can reduce transmission of the disease drastically.9 Pharmacists are highly trained, highly trusted10 health professionals, located in almost every community. With the observed success of offering medication
At a Glance Synopsis: Interviews with a sample of pharmacists from Indiana revealed that all participants considered pharmacy-based human immunodeficiency virus (HIV) testing to be acceptable and important as a public health service. Pending removal of personal and institutional barriers, most participants felt that HIV testing could be added as a community pharmacy service. Acceptability of the practice was closely linked to positive patient relationships and pharmacist comfort with consultation. Staffing issues, uneasiness with delivering positive test results, lack of information needed to link patients to care, insufficient consulting space, and need for additional training were identified as challenges. Analysis: Although pharmacists recognized the importance of and their potential role in linking patients to care, most talked about it in simplistic terms, as if a well-functioning referral system existed for getting patients into treatment. This finding needs to be explored further, as it may affect pharmacist perceptions of feasibility if they practice in communities in which linkage to HIV treatment is problematic. To implement HIV testing, comprehensive training curricula must address multiple issues, including stigmatization and modes of transmission for HIV, counseling techniques, and test mechanics.
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therapy management,11,12 immunizations,13,14 and other preventive services in community pharmacy settings, the integration of HIV testing may be a natural extension of the role of community pharmacists. Pharmacist opinion about pharmacy-based HIV screening has been explored in high-prevalence areas for HIV and in highly specialized pharmacy settings.4 Perceptions among injection drug users regarding pharmacy provision of HIV prevention services, including HIV testing, also has been explored in high-prevalence areas.15 Although these studies help to establish an understanding of HIV testing in pharmacies among specialized pharmacists or high-risk populations in highprevalence areas, little is known about issues of feasibility, acceptability, and readiness for HIV screening from the perspective of a general population of community pharmacists and in moderate-prevalence areas. This is a crucial gap in the literature, as pharmacies are particularly important sources of health care and information in rural communities and communities with low medical resources.16
Objective We sought to examine perceptions of feasibility, acceptability, and readiness for pharmacy-based HIV testing among a general population of community pharmacists in a midwestern state with a moderate prevalence of HIV.
Methods Data were collected during semistructured interviews among a convenience sample of community pharmacists located in Indiana. Key informant interviewing allowed exploration of complex and sensitive17 issues that are largely unstudied.18,19 An interview guide containing 12 questions was informed by thorough literature review and evaluation of extant instruments exploring pharmacist attitudes about several topics (not limited to HIV).3,4,14,20–25 Currently licensed Indiana community pharmacists were recruited through personal networks, pharmacy school faculty contacts, and state pharmacy organizations. A total of 45 individuals were suggested as possible participants, and 17 interviews were completed. Contact information was unavailable for 2 individuals, 3 declined to participate, and interest in participating could not be confirmed for the remaining 23. Recorded interviews lasting 20 to 60 minutes were conducted in person and by telephone between May and September 2012. A hybrid approach of thematic analysis and didactic, a priori template coding based on the research questions was used.26,27 This means that a codebook defined by the research questions was applied to the data for organization, paired with an approach that allowed themes to emerge inductively from the data. Theoretical saturation was reached with this sample.28 Three investigators independently coded transcripts to Journal of the American Pharmacists Association
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ensure that themes could be reproducible and therefore verifiable. In qualitative research, this is a method of ensuring interrater reliability.18,29 The study protocol was approved by the institutional review boards at Indiana University and Butler University.
Results Characteristics of participants and the pharmacies in which they work are shown in Table 1. The median age of participants was about 38 years (range 21–55), and they had worked an average of 13 years as community pharmacists. Acceptability of pharmacy-based HIV testing In general, pharmacists accepted the idea of pharmacybased HIV testing as a service that pharmacies could offer to the public. The benefits identified by participants were accessibility, convenience, and the trusting relationships that pharmacists had with patients for consultation and linkage to care. As described below, pharmacists accepted the concept of HIV testing in pharmacy settings and raised several important issues to inform implementation of the practice. Accessibility and convenience. Some pharmacists emphasized the importance of HIV testing in pharmacies because of the access they provide, specifically in rural communities. One pharmacist said, “There are some rural areas that might have a pharmacy in that small town but not have a physician’s office.” Pharmacist opinion about accessibility was most often expressed in terms of convenience. Participants felt that community pharmacy settings might be viewed by patients as “quicker” than a clinic or physician office visit. One pharmacist said, “[In a pharmacy], you could be waiting in the waiting room and no one would know what you’re waiting for. ... We’re kind of a one-stop shop, so it’s more private.” Pharmacist–patient relationship. The pharmacist– patient relationship was a prominent factor when participants discussed advantages to HIV testing in pharmacies. Participants framed both advantages and challenges to pharmacy-based HIV testing in terms of their own professional consultative relationship with their patients. As stated by one pharmacist, “I have a personal relationship with my patients, and I really enjoy that. Whatever I could do to help them in whatever type of situation that they’re in, I would certainly do.” In knowing their patients, pharmacists recognized that some people might not want to take an HIV test in their local pharmacy precisely because they would not be anonymous. One respondent used sildenafil (Viagra— Pfizer) to illustrate patients’ desire for anonymity: “There are people that will come to me and buy Viagra because I don’t know them. And I think some of my customers, because they don’t want people to know they’re taking Viagra, probably go to other pharmacies [to get Viagra].” Journal of the American Pharmacists Association
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Table 1. Characteristics of pharmacists interviewed regarding perceived feasibility, acceptability, and readiness of offering rapid HIV testing in community pharmacies Characteristic n Age (years) mean ± SD Gender (men) PharmD degree Years since first licensed <1 1–4 5–9 10–19 ≥20 Pharmacy setting Community chain Other chaina Community independent Pharmacy location Urban Suburban Large townb Small townc Rural Pharmacy serves HIV-positive patients Pharmacy has private consulting room
No. (%) 17 37.9 ± 9.7 9 (52.9) 11 (64.7) 1 (5.9) 3 (17.6) 3 (17.6 6 (35.3) 4 (23.5) 8 (47.1) 4 (23.5) 5 (29.4) 9 (52.9) 1 (5.9) 2 (11.8) 4 (23.5) 1 (5.9) 7 (43.8) 10 (62.5)
Abbreviations used: HIV, human immunodeficiency virus; PharmD, doctor of pharmacy. a Grocery or mass merchandiser setting. b Large town: population center with ≥25,000 residents. c Small town: population center with at least 2,500 but fewer than 25,000 residents.
Barriers to testing. Participants identified several barriers to pharmacy-based HIV testing, including staffing issues, unfamiliarity or discomfort with the task of delivering results to patients, lack of existing training, and issues of reimbursement. Participants felt that appropriate training could mitigate challenges because consultation was already part of the contemporary pharmacist role. One pharmacist said, “For the more recent [pharmacy] graduates, and I’m 15 years out now, consultation is the norm. They think of consultation as their primary occupation. For the ones older than me, often it was order accuracy and counting and making sure the label is correct and all that stuff.” Expansion of community pharmacist role. Pharmacists reported that the evolution of pharmacy practice included increased consultation, immunization, and health screening. Comfort with increased patient interaction and success with expanded pharmacy practice duties were considered likely facilitators of pharmacist acceptance of HIV testing in pharmacy settings. One pharmacist stated, “We didn’t even vaccinate 5 years ago, and now we’re doing vaccinations and health j apha.org
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screens. ... I would hope that my peers would embrace it as just another opportunity. ... It can be sensitive material for someone, but there are other issues we deal with that are sensitive as well, so it’s just another challenge. But again, if you can help someone get more access to health care, I think it would be a positive.” Although most participants described themselves as patient consultants, some felt that standard pharmacy training would not be sufficient for counseling regarding HIV test results. Participants recognized the potentially life-changing importance of consultation after a test. One pharmacist said, “It’s not like you’re being diagnosed with ... high blood sugar here.” The sensitive nature of giving someone HIV test results, especially when positive, was a concern for many participants. A few pharmacists explained this as the emotional aspect of test consultation. “Typically, a pharmacist doesn’t deal with giving patients horrible news,” said one pharmacist. One participant stated, “How do you counsel them? Not only on their results, but if asked, ‘How do I tell my partner?’ ‘How do I trace this back?’ ... I would be crying with them.” Despite some reservations, no pharmacist expressed that HIV testing would be unacceptable or inappropriate in community pharmacy settings. Feasibility of pharmacy-based HIV testing. Professional practice adjustment and models to operationalize testing were raised when participants reflected on the feasibility of pharmacy- based HIV testing. Several participants likened the inclusion of testing to the inauguration of pharmacy immunizations. Practice change regarding immunizations was not as difficult as initially anticipated. One pharmacist said, “We were able to work through that [practice change]. Now, there were a lot of people who were skeptical, and when they came in for [immunization] training, they just knew, ‘Okay, it’s going that way. I’m going to have to do this.’ ... And after going through the training and experiencing it; it was like, ‘Wow, that wasn’t as big a deal as I thought it was going to be.’” Although all participants viewed the practice adjustment as feasible, especially if handled similar to immunizations requests in the pharmacy, important differences were noted, including the duration of the visit and space for privacy. Challenges also included the balance of productivity with counseling and other services, as illustrated by the following comment: “I think that the challenge would be ... that a person has psyched themselves up and might want the test. ... I can think of nothing that would be more important than having good counseling based on the results of that test. It would be horrible to have someone get that news and feel like they’re rushed and not be able to have a health care professional discuss next steps with them and implications.” Privacy and confidentiality. Participants generally felt that offering testing in settings with private consulta598 JAPhA | 5 3:6 | NOV/DEC 2013
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tion rooms to ensure confidentiality and privacy would be feasible. However, some pharmacies do not have a physical layout that allows for closed-door consultation, while others might have a door that closes off to the public but not to the pharmacy space. Participants felt that pharmacies increasingly were offering private areas for counseling but that this was not a universal practice. Staffing issues. Staffing issues were frequently mentioned as a challenge. Several participants felt that HIV testing should occur only when more than one pharmacist was on duty. One pharmacist said, “I think in our store it would be pretty feasible because we’re a busy enough store that we also have pharmacist overlap. ... Problem you’re going to run into is that slower stores, they’re either (a) not going to have the clinic, like we do here, and (b) they’re not going to have any pharmacist overlap. So it’s a challenge if it’s something that is going to be time consuming, especially if you imagine someone having a positive result.” Training needs. Training was repeatedly identified as a fundamental need before HIV testing could take place. Suggested training topics included delivering results and counseling patients, referral to HIV treatment for those who test positive, and basics such as the mechanics of performing tests and general training on HIV issues such as modes of transmission and treatment. Pharmacists expressed differing opinions about how training should be delivered. Some thought that it should be treated as any other continuing education topic, through journal articles or classroom-based training. Others expressed strong feelings that training should take place face-to-face with experienced trainers, whereas others felt that online training, perhaps including video scenarios, would be preferable. Several participants felt that training should include pharmacy technicians and interns, focusing on confidentiality procedures and ensuring that staff have sufficient knowledge to respond appropriately to patients. Even with Health Insurance Portability and Accountability Act–required health information training for pharmacy technicians, a few participants expressed concerns about privacy among technicians. Readiness of pharmacy-based HIV testing. Participants expressed that readiness to implement HIV testing might be determined by pharmacy experience with other public health services, such as health behavior consultation, diagnostics, and immunizations. Staggered implementation, starting with interested pharmacies or pharmacies in communities with higher HIV prevalence, was recommended. Two participants indicated that their pharmacies sometimes offered HIV testing on specific dates, hosting a community-based organization (CBO) that provided testing and counseling on site. One pharmacist admired the CBO’s ability to counsel and link patients to care: “If I were to do HIV testing at my store, [I would] include [name of CBO] as Journal of the American Pharmacists Association
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the reference point for this person, so to set up an appointment for them at [CBO] to kind of bridge that gap between ‘Okay, you test positive here, now’ and ‘What do you do now?’” Most participants expressed that with sufficient training and support, they could offer testing services. Some participants expressed doubts about the readiness of their pharmacist peers. It was suggested that some pharmacists would not be comfortable with aspects of testing, such as counseling, preparing kits, or working with samples. A few participants expressed that peers may feel an exaggerated fear of acquiring HIV from patients based on a lack of knowledge about the test or about HIV. One pharmacist stated, “It can be a complicated disease state in the fact that there are different regimens and different classes of medication. So I think that if you ask the typical pharmacist, they wouldn’t be comfortable counseling or talking to a patient. And I also feel like it’s a disease state that is evolving quickly, so I think that they might also feel like, ‘Ooh, I might not be giving the most up-to-date recommendations or suggestions. ... You kind of just steer away from it.’”
Discussion All participants felt that pharmacy-based HIV testing was acceptable and important as a public health service. One pharmacists said, “There’s so much evidence towards ... being diagnosed early, and treatment possibilities that it would just be hard not to provide that service.” The value of immunization experience as a potential basis for community pharmacist acceptance and sense of feasibility about pharmacy-based HIV testing is congruent with the work of Amesty et al.4 They found that among specialty pharmacy staff in New York City, those who supported pharmacy-based vaccination were more likely to support in-store HIV testing. Although pharmacists recognized the importance of linkage to care and their potential role related to it, most talked about linkage to care in simplistic terms, as if a well-functioning referral system existed for getting people into treatment. This needs to be explored further, as it may affect pharmacist perceptions of feasibility if they practice in communities in which linkage to HIV treatment is problematic. However, this would be precisely the reason for pharmacy-based HIV testing, consultation, and linkage to care because the pharmacy would be filling an important public health service gap as safety net provider. Participants provided thoughtful guidance for professional development. To implement HIV testing, comprehensive training curricula must address multiple issues, including stigmatization and modes of transmission for HIV, counseling techniques, and test mechanics. This could be accomplished in several ways. Continuing education programs are a natural way to educate pharJournal of the American Pharmacists Association
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macists, and new programs will need to be developed to help pharmacists gain confidence in providing comprehensive screening services. The interviews described in the current work provided tremendous insight into the complexity of issues surrounding HIV testing in community pharmacies. The willingness of pharmacists to address several difficult issues, including sexual transmission, stigma, and selfawareness, indicated that these pharmacists were highly aware of the social dimensions around HIV. Indiana is a midwestern state where HIV stigma is still experienced and reported,30 and these participants were aware of the importance of testing in nonstigmatized venues. Compassion and empathy were universally expressed toward patients and reflected elements in the Oath of a Pharmacist: welfare of humanity, keeping abreast of developments, and embracing and advocating change.31
Limitations As is standard with qualitative research, this study used nonprobability sampling.32 As such, the participants may not be fully representative of the universe of licensed community pharmacists in Indiana. This study was an important contribution to the literature because to date, no studies have been conducted in communities with a moderate prevalence of HIV or among nonspecialized pharmacists. A total of 17 participants were interviewed. This number is typical in qualitative research, and theoretical saturation of major themes was reached. The near unanimity of expressed attitudes about acceptability may be a result of sampling and response issues. For example, pharmacists who were negative about offering HIV services may have actively or passively declined to participate. Positive attitudes could be explained in part by sampling and not, as findings would suggest, by the relatively recent pharmacy school training of many participants or by experiences in expanded public health pharmacy practice. Future studies should explore acceptability, readiness, and feasibility among a larger and more representative sample of community pharmacists.
Conclusion Although challenges exist to offering rapid HIV testing in community pharmacy settings, this study of midwestern community pharmacists demonstrates that pharmacists are interested in talking about expanding pharmacy practice to include HIV testing, consultation, and linkage to care. Issues of feasibility and readiness require training and changes in pharmacy infrastructure and management support. Before HIV testing can be implemented, pharmacists require training, primarily in delivering test results and in linking patients to resources. This study is an important step in our national discussion of expanding nonclinical access to HIV testing. Pharmacies are important public health settings. j apha.org
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