In this systematic review, we evaluated the impact of HIV pharmacists on HIV clinical outcomes, health utilization measures, ARV modifications, and other descriptive variables. In all but one study,18
the involvement of an HIV pharmacist in patient care was associated with clinically and statistically significant improvements in ARV adherence. The majority of reviewed studies also indicated that HIV pharmacist’s care was associated with greater viral load suppression. Evidence of any influence of pharmacists on immunologic outcomes was unclear and attenuated, which may have been due to lack of reporting of CD4+
cell count in many studies, insufficient duration of follow-up to observe substantial changes, the lack of an effect, or the more erratic nature of this outcome measure.
Several study-related factors limited the depth of our review. The most crucial limitation of several studies was the lack of reporting and/or adjustment for baseline demographics and confounders. The absence of reporting of clinical outcomes data in many studies and methodological constraints, such as reporting adherence as dichotomous or categorical variables or other methods, precluded a meta-analysis. Other common limitations included small sample size, short duration of study follow-up, incomplete description of the pharmacist’s role or the complexity of multicomponent interventions, and the use of unconventional methods of adherence calculation. Lastly, as with any systematic review, there is the potential for positive publication bias influencing the aggregate results.
The reviewed studies provide a broad spectrum of HIV pharmacist activities. It is noteworthy that the majority of the reviewed studies were conducted in HIV ambulatory care or inpatient medical center settings. HIV pharmacists practicing in community pharmacies are increasingly called upon to provide ARV adherence training, patient education, and drug information, yet outcome data from such activities are not well-represented in the literature. This may be due to the under-recognized value of these services or the challenges associated with gaining combined access to laboratory medical record and community pharmacy data.
We found a plethora of descriptive studies on ARV-related errors identified and resolved by the pharmacist and the degree of acceptance of pharmacist-related activities, as well as observational studies on the consistent evidence of a positive impact of HIV clinical pharmacists on ARV adherence. Therefore, future mixed methods research, including qualitative and quantitative studies should examine the pharmacist–patient relationship, focus on determining crucial pharmacist functions which have the most impact on adherence, and test these findings in randomized controlled trials with large sample sizes. Additionally, studies should examine cost-effectiveness of pharmacists (including cost savings associated with improvements in clinical markers, as well as other outcomes, such as reductions in extraneous physician visits, emergency room visits, length of hospitalization, medication errors, etc). Further research should also expand to include HIV pharmacist responsibilities that are beyond the “traditional” functions (ie, assessment of ARV accuracy, identification of drug interactions, adherence counseling, patient/provider education, etc). These roles may include the involvement of pharmacists in conducting clinical trials, performance of motivational interviewing, interpretation of drug resistance tests and prescription of ARVs, methods of tailoring adherence-enhancing tools based on individual reasons for nonadherence, and impact on HIV prevention (eg, through offering pre- or post-exposure prophylaxis).
It is evident in this review that research on the impact of pharmacists in HIV clinical care has evolved since the first reports in 1992. This progression includes the use of more sophisticated study designs and more complex research questions. Continued research on HIV pharmacists’ impact on the clinical care of HIV-positive individuals is underway. In ClinicalTrials.gov and the US National Institute of Health Research Portfolio Online Reporting Tools database there are currently several ongoing studies examining the role of pharmacists in HIV clinical care. Four of these studies pertain to HIV prevention by assessing and expanding the pharmacist’s role in services related to intravenous drug users purchasing syringes.42
Another project is assessing factors related to the receipt of pharmacist-provided adherence counseling and the impact of a counseling session based on the information–motivation–behavioral skills model46
on HIV treatment outcomes.49
A randomized controlled trial is examining the impact of pharmacist care on ARV adherence.49
Lastly, economic outcomes of an intervention comparing methods of offering pharmacist services are also under study.50