Expanding access to HIV testing through Canadian community pharmacies: findings from the APPROACH study.

BACKGROUND: There is a need for acceptable and feasible HIV testing options to ensure people living with HIV know their status so they can access care. Pharmacist-provided HIV point-of-care testing (POCT) may overcome testing barriers, including privacy concerns, testing wait times, and improve accessibility. In the APPROACH study, we aimed to develop and assess an HIV POCT program in community pharmacies for future scale up and evaluation. This paper describes the program uptake, participant and pharmacist experiences, and implementation factors. METHODS: A pharmacist-provided HIV POCT program was offered in 4 pharmacies in two Canadian provinces. A mixed methods design incorporated self-report questionnaire data, participant telephone interviews, pharmacist focus groups, workload analysis, and situational analysis to assess the uptake, acceptability and feasibility of the HIV POCT program. RESULTS: Over the 6-month pilot, 123 HIV tests were performed. One new case of HIV was identified; this participant was linked with confirmatory testing and HIV care. Participants were predominantly male (76%), with a mean age of 35 years. This was the first HIV test for 27% participants, and 75% were at moderate to very high risk of undiagnosed HIV infection, by Denver HIV Risk Score. Questionnaires and telephone interviews showed participants were very satisfied with the program; 99% agreed HIV POCT should be routinely offered in pharmacies and 78% were willing to pay for the service. Participants felt the pharmacy was convenient, discreet, and that the pharmacist was supportive and provided education about how to reduce their future risk. Pharmacists felt prepared, confident, and expressed professional satisfaction with offering HIV POCT. Community and public health supports, clear linkage to care plans to refer participants with positive HIV POCT results, and provision of counselling tools were important enabling factors for the program. Pharmacist remuneration, integration with existing healthcare systems, and support for ongoing promotion of HIV POCT availability in pharmacies were identified as needs for future scale-up and sustainability. CONCLUSIONS: A successful model of pharmacy-based POCT, including linkage to care, was developed. Further research is needed to determine the effectiveness and cost-effectiveness of this approach in finding new diagnoses and linking them with care. TRIAL REGISTRATION: Retrospectively registered with clinicaltrials.gov (NCT03210701) on July 6, 2017.

Adaptation of POCT for pharmacies to reduce risk and optimize access to care in HIV, the APPROACH study protocol: examining acceptability and feasibility.

BACKGROUND: Approximately 1 in 5 Canadians with HIV are unaware of their status. In many provinces and especially rural communities, barriers to HIV testing include lack of access, privacy concerns, and stigma. The availability of HIV point-of-care testing (POCT) is limited across Canada. Pharmacists are well positioned to address barriers by offering rapid HIV POCT and facilitating linkage to care. METHODS: We will use a type-2 hybrid implementation-effectiveness design to assess a pilot HIV POCT model in one urban and one rural pharmacy in each of two Canadian provinces over 6 months. In this feasibility trial the research aims include developing and assisting pharmacies in implementing the model, evaluating processes/determinants of program implementation, evaluating the model's effects on client outcomes, preferences, and testing satisfaction. Using a community-based research approach, the research team will engage community stakeholders in each province including individuals with lived experience to inform the development of the pharmacy-based HIV testing model and support the research team throughout the study. A multipronged promotion campaign will be used to promote the study and facilitate recruitment. The pharmacy-based testing model will include pre/post-test counseling and linkage to care plans in addition to pharmacist-administered HIV POCT. Pharmacists will complete a comprehensive training program prior to implementing the testing model. Client demographics and satisfaction will be assessed by surveys and interviews. Pharmacists will document time required for testing and participate in a post-study focus group to discuss barriers/enablers. Implementation will be assessed qualitatively and quantitatively. The process of developing and implementing the model will be described using qualitative data and a logic model. Acceptability and barriers/enablers will be examined qualitatively based on survey responses. A preliminary costing assessment will consider the client, pharmacy, and government perspectives. DISCUSSION: The results of this pilot will inform modifications to the HIV POCT model to optimize effectiveness and increase scalability. The study has national importance, providing valuable information on improving access to HIV testing. Future applications of this research may expand the role of pharmacists in offering POCT for other sexually transmitted/bloodborne infections as tests become available in Canada. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03210701.

Sexually dimorphic effects of postnatal treatment on the development of activity-based anorexia in adolescent and adult rats.

Hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis is a marked feature of anorexia nervosa. Using a modified version of the activity-based animal model of anorexia nervosa, we examine whether factors known to affect HPA axis activity influence the development of activity-based anorexia (ABA). Male and female rats were subjected to maternal separation or handling procedures during the first two postnatal weeks and tested in a mild version of the ABA paradigm, comprised of 2-hr daily running wheel access followed by 1-hr food access, either in adolescence or adulthood. Compared to handled females, maternally separated females demonstrated greater increases in wheel running and a more pronounced running-induced suppression of food intake during adolescence, but not in adulthood. In contrast, it was only in adulthood that wheel running produced more prolonged anorexic effects in maternally separated than in handled males. These findings highlight the interplay between early postnatal treatment, sex of the animal, and developmental age on running, food intake, and rate of body weight loss in a mild version of the ABA paradigm.

Early maternal separation increases symptoms of activity-based anorexia in male and female rats.

Running activates the hypothalamic-pituitary-adrenal (HPA) axis, increasing the release of stress hormones known to exert anorexic effects. HPA axis reactivity is strongly influenced by early postnatal manipulations, including removal of pups from the dam for short (handling) or prolonged (maternal separation) durations during the preweaning period. The authors examined the effects of handling and maternal separation on food intake, body weight loss, and running rates of young adult male and female rats in the activity-based anorexia (ABA) paradigm. Postnatal treatment did not affect adaptation to a 1-hr restricted feeding schedule before the introduction of wheel running. During the ABA paradigm, maternally separated animals lost weight faster, ate less, ran more, and required fewer days to reach removal criterion compared with handled rats. Females were particularly vulnerable. These findings indicate that early postnatal treatment and sex influence ABA.

Variations in maternal care influence vulnerability to stress-induced binge eating in female rats.

Binge eating disorder (BED) is characterized by intermittent, discrete periods of uncontrollable consumption during which huge quantities of high-fat food are eaten. The onset of BED occurs most frequently in adolescent or young adult females and is often associated with a history of dieting and psychological stress. Animal research suggests the importance of two synergistic factors in the aetiology of binge eating: a history of restriction-refeeding cycles (i.e., "yo-yo" dieting) and exposure to acute stress. In the rat, natural variations in maternal licking and grooming (LG) of pups during the first week of life are associated with long-lasting individual differences in offspring sensitivity to stress. The current set of experiments examined the effects of restriction--refeeding--footshock cycles on intake of highly palatable (HP) food in adolescent and adult female offspring of Low, Mid, and High LG dams. Following cycles of food restriction or unlimited food access, sated rats were exposed to footshock and their intake of HP food and chow was measured at 2, 4, and 22 h post-shock. Adolescent offspring of Low LG mothers displayed shock-induced binge eating, regardless of food-restriction history. In contrast, adolescent female offspring of Mid and High LG mothers failed to exhibit shock-induced increases in food intake. We saw no evidence of binge eating when shock was introduced in adulthood. The data suggest that low levels of maternal care in early life are associated with greater vulnerability to the later development of stress-related binge eating and further that this heightened vulnerability manifests during the adolescent period.

Responding for sucrose and wheel-running reinforcement: effects of sucrose concentration and wheel-running reinforcer duration.

Six male albino rats were placed in running wheels and exposed to a fixed-interval 30-s schedule of lever pressing that produced either a drop of sucrose solution or the opportunity to run for a fixed duration as reinforcers. Each reinforcer type was signaled by a different stimulus. In Experiment 1, the duration of running was held constant at 15 s while the concentration of sucrose solution was varied across values of 0, 2.5. 5, 10, and 15%. As concentration decreased, postreinforcement pause duration increased and local rates decreased in the presence of the stimulus signaling sucrose. Consequently, the difference between responding in the presence of stimuli signaling wheel-running and sucrose reinforcers diminished, and at 2.5%, response functions for the two reinforcers were similar. In Experiment 2, the concentration of sucrose solution was held constant at 15% while the duration of the opportunity to run was first varied across values of 15, 45, and 90 s then subsequently across values of 5, 10, and 15 s. As run duration increased, postreinforcement pause duration in the presence of the wheel-running stimulus increased and local rates increased then decreased. In summary, inhibitory aftereffects of previous reinforcers occurred when both sucrose concentration and run duration varied; changes in responding were attributable to changes in the excitatory value of the stimuli signaling the two reinforcers.