Our study, based on a random sample of community-based pharmacies in an urban high HIV prevalence region of India, has several important findings. First, 35% of surveyed pharmacies stocked ARVs and an additional 18% ordered them upon individual requests, showing that at the time of our survey the treatment was relatively widely available in community-based pharmacies. Second, we identified a lack of adequate knowledge regarding HIV and ART among pharmacists, including among those who stocked ARVs. While not being able to list ARV names and side effects may have been expected amongst those respondents whose pharmacy did not stock ARVs, less than one-third knew that ARVs can never completely cure HIV. Furthermore, only 6% respondents were aware that it is inappropriate to administer AZT with d4T and only 1% knew that efavirenz was not recommended during pregnancy. This lack of awareness raises concern about the qualification and ability of the respondents to distribute ARVs, particularly if this distribution is linked with advice given to the patient. We therefore identified significant knowledge gaps and need for targeted training for pharmacies, particularly those dispensing ARVs in the community.
Encouragingly, we found in a majority of pharmacy respondents a sense of professional obligation to provide medication to persons with HIV/AIDS. In addition, 95% reported that they did not worry about HIV exposure when dispensing medications to an HIV-infected person. Therefore, there appears to be a willingness to care for and provide ARVs to HIV-infected persons. Nevertheless, stigma towards HIV patients remains high with nearly two thirds of respondents believing that patients are responsible for their illness and 54% reporting that HIV patients have looser sexual morals and cannot adhere to ARV regimens. Such provider-based stigma can be a significant barrier to health care seeking and treatment for HIV-infected patients, and is associated with reduced quality of life and health outcomes[13
]. Therefore, there is continued need to combat stigmatizing attitudes of pharmacists and other HCP towards persons living with HIV/AIDS.
Despite the fact that only 26% of those surveyed felt that pharmacy staff play a role in how patients take ARV drugs, a majority (81%) felt pharmacy employees should receive specific training on HIV treatment. Only 3% of respondents stated they had ever received training on HIV and only 1% had training on ARV drugs specifically. As has been seen with pharmacists treating tuberculosis, there is a willingness to provide treatment and advice to patients despite not having formal training[10
]. Training for pharmacists in India is needed to increase knowledge of safe practices and regimens, including drug names, side effects, and dosages, but also to dispel certain cultural notions that lead to stigma amongst treatment providers. The administration of an educational or training intervention would likely be best achieved through an alliance between the public and private sectors, as private providers have been shown to not follow the regulations put in place by the public sphere alone[4
]. However whether incentives or mandatory regulation would be optimal to implement an effective training intervention needs to be investigated[4
It appears to be common practice for pharmacists in India to sell loose medications and partial prescriptions [9
]. In our study, we found 65% of respondents of pharmacies which stock ARVs have sold 10 or less ARV tablets or capsules to a patient at one time. While this is often done to accommodate the patient's financial ability to pay for drug, with HIV, such practices can be potentially dangerous and lead to unanticipated treatment interruptions and increase the risk of drug resistance, treatment failure and disease progression. Furthermore, 25% of respondents felt that some patients may be using the same prescription and not visiting their doctor regularly. Therefore, there is a need and opportunity for the pharmacy to serve as a check point to ensure that patients are receiving appropriate prescriptions, instructions about drug safety, and regular treatment from registered HCP. They should dispense drugs only after receiving a valid prescription written by an authorized physician. In addition, pharmacies can also serve as important checkpoints for medication adherence as pharmacy records of drug dispensing have been used effectively for estimating adherence to ART[17
]. In high-income settings, almost all pharmacies have computerized databases, which greatly facilitate patient prescription tracking, appropriate drug combinations, and adherence monitoring[18
]. While only 46% respondents reported having a computer on site and only 10% reported having internet access, the use of computers and internet is spreading rapidly in India. Therefore strategies using computerized pharmacy databases should be explored and incentivized in India, as these are likely to yield great benefits over time.
Our study had a few limitations. We likely had some degree of social desirability bias, which may have impacted responses related to pharmacy practices, such as the verification of prescriptions. Use of mock clients, who present symptoms and requests to pharmacists who are unaware that they are being examined could be a technique used for future studies[19
]. We conducted the survey in an urban and peri-urban setting in a high HIV prevalence state of India during a time when less costly or free ART was not widely available. Therefore, our results may not necessarily be generalizable to other regions and settings in India, such as rural areas or states with lower prevalence, where there may be a decreased HIV awareness. Furthermore, our survey consisted of largely small, private pharmacies, so the results may not directly reflect the situation of very large or public hospital pharmacies. Nevertheless, the study was conducted on a sizable population and used a rigorous method of mapping and random sampling to obtain a representative sampling of community-based pharmacies in the Pune area. Since most of the ART scale-up in India since 2004 has occurred in the public government ART pharmacies, there may have been some changes in private pharmacy practices, however this would need to be confirmed. By and large, even with an expansion in the Government supported ART roll-out program in India since 2004, the accessibility to ART has not reached beyond 25% of those in need of ART [11
] and some patients continue to obtain ARVs, including second line ARV drugs, from pharmacies such as those included in our study. Thus, our findings have a major relevance even today.
The coupling of patient support and counseling with the distribution of treatment in licensed pharmacies could provide a much needed resource, particularly in settings where stigma may affect patients' quality of life and willingness to access treatment. Such a model has already been used in India, with the conception of a pharmacy run by persons living with HIV/AIDS for the specific provision of ART at a subsidized cost. However such a model cannot be a solution for every pharmacy in India, which provides medicines for HIV or co-infections.