Impact of Pharmacy Setting on Pharmacist Provision of Clinical Pharmacy Services to Persons Living With HIV

OBJECTIVE: At present, over a million Americans are living with HIV. The population of persons living with HIV (PLWH) is increasing, and people are living longer and ageing with the disease. Long-term consistent adherence to antiretroviral therapy (ART) is crucial for effective management of HIV disease and high quality of life for PLWH. As medication experts, pharmacists, are well positioned to help PLWH adhere consistently to their regimen. Despite evidence of the cost-effectiveness of pharmacist interventions in clinical trials, little is known about pharmacists’ adherence promotion activities in real-world settings. We examine if specialty pharmacists provide more adherence promotion activities (APA) than nonspecialty pharmacists.

METHODS: We used generalized linear modelling (GLM). Factor analysis was used to generate 4 APA indices: 1) 9-item adherence assessments (e.g. prescription refill history) index (AAI); 2) 22-item customized interventions (e.g., patient counseling) index (CII); 3) 4-item monitoring activities (e.g., call reminders) index (MAI); and 4) 35-point all activities index (APAI).

RESULTS: We surveyed 225 pharmacists from 41 U.S. states. Pharmacists were mostly female (63%), Caucasian (66%), and >30 years (67%). Most had an HIV certification (68%); 31% worked in specialty-only and 21% in traditional-only pharmacies. Only 26% of pharmacists reported APA-related reimbursements. We found that 65% reported all AAI activities, 52% all MAI activities, only 18% all CC1 activities, and 15% all APAI activities. Interestingly, specialty pharmacy impacted only MAI activities (OR_{_MAI}: 1.665 p<.001). Pharmacies with mostly private insurance patients were more likely to have MAI (OR_MAI 2.408: p<0.001), and public insurance more AAI activities (OR_AAI 1.96; p<0.001) compared to uninsured patients. HIV certification was a significant predictor of CII (OR_CII: 1.798 p<.001). The most significant predictor of APA types was HIV-related organization membership (OR_AAI: 3.079 p<0.001; OR_CCI: 3.142 p<0.001; OR_MAI: 1.917 p<0.01). Surprisingly, prescription volume was significant for MAI only at 10% (OR_MAI: 1.357 p<0.10). Neither pharmacist age nor post-licensure experience significantly impact APA.

CONCLUSION: For many PLWH struggling with ART adherence, access to specialty pharmacies and to HIV-certified pharmacists actively engaged in HIV-related organizations determines if they receive adherence monitoring services. Pharmacies that invest in employee HIV certifications and memberships contribute significantly to the quality of pharmaceutical care received by PLWH. However, the low levels of customized interventions suggested missed opportunities to promote ART, and therefore potential targets for pharmacists-based interventions. Not surprising, non-reimbursement for adherence promotion does not preclude many pharmacists from providing high-quality pharmaceutical care to PLWH in community-based settings.