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.

Patient satisfaction with chronic HIV care provided through an innovative pharmacist/nurse-managed clinic and a multidisciplinary clinic.

BACKGROUND: Pharmacist/nurse-led clinics are an established model for many chronic diseases but not yet for HIV. At our centre, patients with HIV are seen by a multidisciplinary team (physician, nurse, pharmacist, social worker) at least yearly. Some attend an HIV-specialist pharmacist/nurse clinic (or "nonphysician clinic," NPC) for alternate biannual visits. Our objective was to assess patient satisfaction with care received through both clinics. METHODS: The Patient Satisfaction Survey for HIV Ambulatory Care (assesses satisfaction with access to care, clinic visits and quality of care) was administered by telephone to adults who attended either clinic between January and July 2014. Descriptive statistics described patient characteristics and satisfaction scores. Fisher's exact test compared satisfaction scores between the NPC and multidisciplinary clinic (MDC). Multivariate logistic regression examined associations between overall satisfaction with care and clinic type and patient characteristics (e.g., age, disease duration). RESULTS: Respondents were very satisfied with the overall quality of HIV care in both the NPC and MDC (89% vs 93%, respectively, p = 0.6). Patients from both clinics expressed satisfaction with access to care, treatment plan input, their provider's knowledge of the newest developments in HIV care and explanation of medication side effects, with no significant differences noted. Significantly more MDC patients reported being asked about housing/finances, alcohol/drug use and whether they needed help disclosing their status. Patient characteristics were not significantly associated with satisfaction with overall quality of care. CONCLUSION: Patients are satisfied with both clinics, supporting NPC as an innovative model for chronic HIV care. Comparison of outcomes between clinics is needed to ensure high-quality care.

Clinical impact of a pharmacist-led inpatient anticoagulation service: a review of the literature.

BACKGROUND: Anticoagulant therapies provide management options for potentially life-threatening thromboembolic conditions. They also carry significant safety risks, requiring careful consideration of medication dose, close monitoring, and follow-up. Inpatients are particularly at risk, considering the widespread use of anticoagulants in hospitals. This has prompted the introduction of safety goals for anticoagulants in Canada and the USA, which recommend increased pharmacist involvement to reduce patient harm. The goal of this review is to evaluate the efficacy and safety of pharmacist-led inpatient anticoagulation services compared to usual or physician-managed care. METHODS: This narrative review includes articles identified through a literature search of PubMed, Embase, and International Pharmaceutical Abstracts databases, as well as hand searches of the references of relevant articles. Full publications of pharmacist-managed inpatient anticoagulation services were eligible if they were published in English and assessed clinical outcomes. RESULTS: Twenty-six studies were included and further divided into two categories: 1) autonomous pharmacist-managed anticoagulation programs (PMAPs) and 2) pharmacist recommendation. Pharmacist management of heparin and warfarin appears to result in improvements in some surrogate outcomes (international normalized ratio [INR] stability and time in INR goal range), while results for others are mixed (time to therapeutic INR, length of stay, and activated partial thromboplastin time [aPTT] measures). There is also some indication that PMAPs may be associated with reduced patient mortality. When direct thrombin inhibitors are managed by pharmacists, there seems to be a shorter time to therapeutic aPTT and a greater percentage of time in the therapeutic range, as well as a decrease in the frequency of medication errors. Pharmacist recommendation services have generally resulted in a greater time in therapeutic INR range, greater INR stability, decreased length of stay, and reduced major drug interactions, with no significant differences in safety outcomes. CONCLUSION: Pharmacist-led inpatient anticoagulation management seems to result in superior outcomes, as compared to usual or physician-managed care. This conclusion is limited by small, poorly designed studies lacking statistical power, focusing mainly on surrogate outcomes.