ASSESSMENT OF THE ROLE OF COMMUNITY PHARMACISTS IN MANAGEMENT OF HIV-POSITIVE INDIVIDUALS IN THE SOUTHERN REGION OF NIGERIA

Mgbahurike A. Amaka*1image, Amadi Nwadiuto Cecilia2image

1Department of Clinical Pharmacy & Management, Faculty of Pharmaceutical Sciences, University of Port Harcourt, Rivers State, Nigeria.

2Department of Pharmacology & Toxicology, Faculty of Pharmaceutical Sciences, University of Port Harcourt, Rivers State, Nigeria.

ABSTRACT 

Background: The long- recognized challenges to HIV care remained relevant as newer challenges emerge. Pharmacists’ role has evolved and expanded to help patients and other healthcare providers to achieve the core goals of HIV management. 

Objectives: this study assessed the role/services community pharmacists play/offer in the management of HIV patients in Rivers State, Southern region of Nigeria, and evaluated the perception of community pharmacists towards management of HIV infected patients.

Method: A cross-sectional study was carried out among three hundred and seventy four community pharmacist owned pharmacies spread across Rivers State. Data were collected using pre-tested structured questionnaire. The structure comprises demographic information, services offered to HIV infected patients and perception towards community pharmacists’ involvement in management of HIV. Data were analyzed with SPSS version 16 and statistical significance taken at p<0.05. 

Results: Out of 374 (100%) community pharmacist-owned pharmacies only 30 (8%) were involved in the management of HIV patients. 22(73.3%) were male and 8(26.7%) were female. While 23(76.7%) had B.Pharm degree; 2(6.7%) had Pharm D. 18(70%) had 11–20 yrs practice experience as 7(23%) had over 20 yrs experience. 23(76.6%) had special HIV training program while 3(10%) self-acquired information on HIV. The Likert scale to measure perception is biased towards agreement, Likert scale 3.89, that community pharmacists are knowledgeable and well positioned to play role in the management of HIV infected patients. 

Conclusion: Very few 30(8%) of registered community pharmacists are involved in the management of HIV patients. Although the services offered cut across the guidelines for management of HIV infected patients, there is still need for improvement and regular update on HIV training for community pharmacists. These steps would help to involve more community pharmacists, decongest hospitals and reduce workload on hospital pharmacists. 

Keywords: Community pharmacists, HIV-patients, services/roles, Southern Nigeria.

 

INTRODUCTION

 

While the long-recognized challenges to successful HIV care remained relevant (such as lack of early diagnosis, insufficient linkage and retention of care, poor adherence to antiretrovirals, stigma and perception, as well as disparities in accessing care for disadvantaged populations or socially marginalized, newer challenges to successful HIV care and prevention emerge, such as HIV in the elderly population, the application of new preventive methods such as pre-exposure prophylaxis, the optimal timing to start  antiretroviral therapy (ART), and management of special groups of infected patients1,2,3. As the HIV epidemic evolves and new challenges to successful care and prevention emerge, healthcare providers, including pharmacists, are expanding their roles to ensure optimal patient care4,5. Pharmacists have long been recognized as essential members of the HIV patient care team, and their involvement in managing HIV infected patients has been associated with improved outcomes. Pharmacists’ activities such as helping the team in selecting individualized HIV treatment regimens, providing patient counseling, monitoring for treatment responses and adverse effects, evaluating regimens for potential drug-drug interactions, and identifying opportunities for regimen simplification, are associated with better viral load reduction and CD+ T-lymphocytes responses, improved ART adherence, simpler regimens, and reductions in medication errors6,7,8,9,10. To address these emerging challenges, pharmacists will need to apply their traditional expertise within an interdisciplinary healthcare framework in multiple practice settings (i.e. inpatient, community, and ambulatory care) as well as identify and establish new roles in evolving area of HIV care, including HIV testing and diagnosis, medication therapy management, transition of care, patient retention, acute HIV treatment, pre-exposure prophylaxis (PrEP) and initiation of ART in key populations such as those with acute opportunistic infections, hepatitis co-infections, and solid organ transplantation. In developing these roles, it’s essential for pharmacists to remain highly engaged in the rapidly changing field of HIV using reliable resources such as https://aidsinfo.nih.gov; the US Department of Health and Human Services (US DHHS), HIV management guidelines, as well as other resources.

Previous studies11,12 support the potential role that pharmacists can play in improving HIV self-management. In a meta- analysis of 14 randomized -controlled trials investigating the effect of pharmacists’ intervention in patients with HIV across a number of countries, significant and clinically relevant improvements in glycemic control were observed13. Pharmacists’ interventions included non-pharmacological HIV education as well as pharmacological interventions such as medication-use counseling, (i.e. medication type and dosages). Traditionally, community pharmacists’ services are accessed till extended working hours. This is particularly valuable in parts of the world where multidisciplinary HIV care team are not yet well established. HIV education and support professionals such as HIV nurses and educators are scare in sub Saharan African region. In recent years, pharmacists’ roles have expanded from simply packaging and dispensing medications to working with other healthcare professionals and the public. The role of pharmacists in HIV management, including patient identification, assessment, education, referral, and monitoring, has been well established elsewhere in the world14. Given the ongoing evolution of HIV medicine, pharmacists must continue to evolve their roles as part of the healthcare team to identify and meet the future needs of HIV infected patients. This goal can be achieved through continuous assessment of the role of HIV pharmacists, the development and maintenance of HIV specialty pharmacist -training programs, and expert certification, and the continued collaboration with other healthcare providers, patients, activist groups, and professional HIV medicine and pharmacy organizations. Consequently, this study aimed to assess the role played/services provided by community pharmacists in management of patients with HIV and also evaluated their perception to managing HIV patients in Southern region of Nigeria.

 

METHOD

 

Study area

The study was carried out in Port Harcourt, Rivers State. Port Harcourt is located in the South East of Nigeria, in the Niger delta region within the South–South geo- political Zone of Nigeria. Rivers State has been reported to have the highest HIV prevalence of all the 36 states in Nigeria. Within Port Harcourt there are two local government areas: Obio-Akpor and Port Harcourt City (Phalga). Three hundred and seventy -four (374) registered community pharmacies are spread across the two local government areas as at the time of the study.

Sample size

All the registered pharmacists practicing within the community pharmacy in the State were the target population. At the time of this study, all the community pharmacists were targeted for the study. Preliminary investigation showed that of the 374 registered community pharmacies in Rivers State (record from Rivers State Ministry of Health), only 30 registered and licensed pharmacist manage HIV infected patients in their pharmacy. This figure was also confirmed with a list obtained from the Association of Community Pharmacists of Nigeria (ACPN) Rivers Sate branch. Thus, a total of 30 community pharmacists were recruited into this study.

Study design/data collection

The study was a cross-sectional study using structured questionnaire to collect relevant data from the community pharmacists within the study area. The questionnaire was structured into three parts: demographic data; services offered by the pharmacist; and perception questions relating to the services.  Demographic data section included: gender; year of practice; as well as educational qualification. The second part assessed services offered by the community pharmacist in the pharmacy, including medication refill, monitoring of patient’s blood pressure and blood glucose level, education of patients on HIV disease, referral to laboratory for relevant tests, counseling on adherence to therapy, interpretation of test results, monitoring for adverse drug reaction, identification and referral for patients’ failing therapy, referral for drug resistance testing, and assessment of potential drug interaction. The third part assessed community pharmacists’ perception towards management of HIV patients in terms of knowledge base, position, and added value to both patient and the pharmacist. The Likert scale was used to analyze the perception of respondents towards HIV management. A total of 30 questionnaire were distributed and all retrieved

Data analysis 

The data obtained were analyzed using statistical package for social sciences (SPSS) version 16, for both descriptive and inferential statistics. The statistical significance difference was taken at p<0.05. Chi square was used for comparative analysis.

 

RESULTS

 

Out of the three hundred and seventy- four (374) community pharmacies, only thirty (30) were involved in the management of HIV infected patients. The thirty pharmacists in the pharmacies were targeted. The questionnaires were distributed accordingly to the pharmacists and retrieved. A 100% respond was recorded. The demographic data of the respondents is shown in Table 1. 

 

The data showed 22(73.3%) male and 8(26.7%) female. For years of practice experience, 10(33.3%) had 5-10 yrs experience while 5(16.7%) had more than 20yrs practice experience. 

Most of the pharmacists, 23(76.7%) had special HIV training program while, 2(6.7%) got their training experience through mandatory continuing education program development (MCPD), and 3(10%) was through self- acquired information on HIV. 

2. The result showed that all the respondents, 30(100%) offer medication to the patients. 24(80%) counsel the patients on adherence to their medications, while none was involved in HIV testing. The different points at which community pharmacists recommends change/switch of regimen is shown in Table 3. The result showed that most respondents, 28(93%) recommend switch in treatment when patient cannot tolerate adverse drug reaction of the regimen and when the viral load is increased. Meanwhile, 15(50%) of the respondents recommend switch of treatment regimen when patient’s compliance is poor, but only 2(6.7%) recommend change of regimen when there is drug interaction with other medications in the regime. 

The results of the respondents’ perception towards community pharmacists’ management of HIV patients is shown in Table 4, while Table 5 illustrated with Likert scale, values and group frequency on the sub -unit of the perception scale. The four perception questions represented with A, B, C, and D as shown in Table 4 indicates diverse scores on a Likert scale as shown in Table 5. It was observed that none of the respondents strongly disagreed with the general statement on perception of community pharmacists’ knowledge and positioning to manage HIV infected patients. The general trend on the Likert scale is biased towards 4 (agree). The tail end of the Likert scale i.e. 1 (strongly disagree) and 2 (disagree) had the least scores generally. 

image

H=Sum of frequency of community pharmacists’ response on each four sub unit score, ranging from strongly disagree to strongly agree, of the Likert scale.

I=The total sum of frequency of community pharmacists responding to a particular sub scale.

Average Likert scale=

image

The general trend on the Likert scale is a bias towards agreement (3.89 approximately 4) with the general statement on perception towards community pharmacists’ management of HIV patients. Gender effect on the services offered to HIV infected patients by community pharmacists is shown in Figure 1. 

The result showed that all the respondents both male and female refill medications for the patients. But more female offered other services, such as documentation of patients’ medication history, referral to tests, education on HIV prevention, and counseling on medication adherence, than the male. The result of effect of years of experience on the services offered to HIV infected patients by community pharmacists is given in Figure 2. Analysis of the results as shown in Table 6 and Table 7 indicate that there is no significant difference (p> 0.05) in the services offered by the various categories of community pharmacists with different years of practice experiences, as well as in gender difference.  The overall services scores were classified as: (1) acceptable (when services offered is ≥ 75%, (2) partially acceptable (if services offered is within 60-74%, and unacceptable (if services< 60%).

DISCUSSION

 

Only thirty community pharmacists owned pharmacies out of three hundred and seventy four registered pharmacies in Rivers State were involved in the management of HIV infected individuals despite the fact that pharmacists’ involvement in the care of HIV infected individuals has been associated with improved patient outcomes6,7,8.  Although the services offered to HIV infected patients by the community pharmacists, cut across the guidelines on the role of community pharmacists in caring for patients with HIV, this study identified that there is still need for improvement in almost all the areas of services offered. While all the respondents 30(100%) were involved in medication refill and blood pressure monitoring, only 15(50%) document information on patients’ medication history. This may be attributed to lack of emphasis on the importance of documentation in the course of training. There have been numerous advances in HIV therapy, with 6 drug classes comprising 24 individual antiretroviral agents now available. Patients who are adherent with their therapy and have undetectable viral load level, HIV has become a chronic, manageable disease in an aging and genetically diverse population. The core goals of management remain maximal suppression of viral replication and promotion of immune reconstitution through combination antiretroviral therapy. Secondary goals of therapy include promoting long term adherence, avoidance of drug interaction, minimizing toxic effects of drugs, simplifying treatment regimens, decreasing drug costs, managing co-morbid conditions, and preventing transmission of HIV by achieving undetectable viral load15,16. Consequently, the pharmacist’s role has evolved and expanded to help patients and other health care providers to achieve these goals. Pharmacists are recognized as established and integral members of HIV health care teams across Canada and United States17. Pharmacists’ involvement in the care of HIV infected patients has been associated with improved patient outcomes, including enhanced adherence6, reduced pill burden, and dosing frequency, greater increases in CD4+ cell counts, higher rates of viral suppression7,8, and decreases in medication errors9,10. The current guideline points out pharmacists’ role in many aspects of caring for patients with HIV/AIDS, including selecting and reviewing therapy, tailoring treatment for specific populations, counseling patients, monitoring response to therapy guiding transition of care, and undertaking scholarly and professional activities. In this study, all the respondents were involved in the refill of antiretroviral medications for the patients. Most, 28(93%), exhibited good knowledge on decision -making point to change/switch treatment regimen, when patients cannot tolerate adverse drug reaction, and when viral load increases. This may be attributed to a good knowledge of drugs and disease pathophysiology. However, a good number, 15(50%), identified patients’ poor compliance as a decision-making point to change regimen. Most treatment failures are the result of non- adherence, pharmacokinetic complications, and antiretroviral resistance. Pharmacists, especially those with specialized training in adherence assessment, interventions, and motivational interviewer, can help determine which of these reasons may have contributed to valid antiretroviral therapy failure. Many factors lead to non-adherence, including medication intolerance and adverse effects, depression, substance use, psychosocial factors, lack of social support, housing insecurity or homelessness, and patients’ beliefs. The pharmacist should work with the patients to assess and resolve any barriers to antiretroviral adherence. Strategies for improving adherence include utilizing an inter- professional team approach, establishing a rapport with the patient, proactively identifying adherence barriers prior to regimen initiation, assessing patients for medication intolerance and adverse effects, providing mental health and social resources for the patients, assessing adherence at every pharmacy visit, involving the patient in regimen selection, providing adherence aids such as pill boxes and calendars, and assisting the patient in setting reminders through cell phone alerts or text messages18. However, this study identified that 24(80%) of respondents counsel patients on medication adherence. This positive measure can certainly improve patient compliance to treatment regimen.

Perception of community pharmacists towards management of HIV infected patients: The result of this study showed that the average Likert scale value for respondents’ perception towards community pharmacists’ involvement in management of HIV infected patients was biased towards agreement, 3.89 (approximately 4). This finding agreed with previous studies19,20, where majority of community pharmacists showed positive disposition to use their practice site, and willingness to extend access for differentiated HIV care21. The result further confirmed the research reports that evaluated views of pharmacists and other stakeholders regarding integration of community pharmacies into primary care pathway22. Community pharmacists occupy unique positions within the community such that accessibility and availability of health services can be assured. Community pharmacists as the most accessible healthcare professional to the public have been adjudged to be better positioned for early detection and management of chronic diseases together with other health care professional. Chronic diseases screening, counseling on the appropriate use of medicines, life style changes advocacy, working with other healthcare professionals and general provision of pharmaceutical care services to these patients are some of the identified areas where community pharmacists could help improve the quality of life patients with chronic diseases8. HIV/AIDS is a chronic disease of concern because of its high morbidity and mortality. Early detection of HIV and timely initiation of antiretroviral therapy is crucial in achieving the vision of controlling the virus which will help prevent transmission and HIV/AIDS associated deaths23. Achieving this primarily hinged on ensuring universal access to lifesaving medications and access to other HIV prevention services24, including counseling and testing. Hence, the use of more peripheral health professional settings including community pharmacists could be optimally utilized to improve and enhance access to HIV care and services.

Association between demographic variables of respondents with Perception of community pharmacists; management of HIV infected patients: This study showed that considerable associations between services offered by community pharmacists and demographic variables such as gender, educational level, years of practice experience and source of training experience on HIV, exist. The study showed there is statistical difference in the services provided by respondents and level of education attained (X2 =14.875, p=0.005) and source of training experience on HIV (X2=15.708, p=0.005). Generally, the respondents with special training on HIV management had significantly highest acceptable (87%) level of services offered. This further emphasizes the importance of special training for community pharmacists on HIV management. Guidelines and position statements on the role of the pharmacists in caring for patients with HIV/AIDS have been published by various national and international organizations4,5. Thus the need for community pharmacists to update their knowledge on those guidelines will not be over emphasized. Furthermore, the result showed no statistical significance difference (X2=3.986, p>0.05) in the overall services offered by both male and female respondents. This may be attributed to the fact that neither the services nor the training is gender based. 

 

CONCLUSION

 

The study identified that only thirty (30) community pharmacists out of three hundred and seventy -four (374) registered community pharmacists were involved in the management of HIV infected patients in Rivers State. The services offered by the community pharmacists cut across the guidelines, but there a great need for improvement. The perception of community pharmacists towards involvement in management of HIV infected patients is biased towards agreement that community pharmacists are well positioned, knowledgeable, and accessible to play role in management of HIV patients, and to give a wider coverage for management of HIV patients. Pharmacists in particular are uniquely capable of contributing to all components of HIV care by being highly accessible to both patients and care providers in a variety of health care settings. Their expert drug therapy knowledge and clinical skills provide an avenue for proficient clinical consultation with other health care providers as well as effective patient interactions through counseling and education.

AUTHOR’S CONTRIBUTION

 

This research work is part of the project done for a Pharm D program. The authors collected the data, revised and edited. The corresponding author designed and supervised work.

 

ACKNOWLEDEMENTS

 

The authors would like to appreciate the Rivers State Ministry of Health for their support and help with information. We also thank the Association of Community Pharmacists of Nigeria, Rivers State and their Zonal Coordinators for their cooperation

 

CONFLICT OF INTEREST

 

No conflict of interest exists with this work

 

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