Our study offers a brief look at community pharmacist counseling in a cohort of women with HIV and women with high-risk HIV behaviors. Only a modest proportion of study participants (30%) self-reported receipt of pharmacist counseling in the past 6 months. Recall bias may have underestimated the true proportion of participants who received counseling. Another explanation is that pharmacists may be missing valuable opportunities to detect and intervene on patient adherence and medication problems. The low proportion of participants reporting counseling in our study could be reflective of the WIHS population. Female gender has been associated with underutilization of HIV health care services and this may also be true of HIV pharmacy services.16
HIV-positive patients may be less likely to seek pharmacist counseling due to concerns about privacy around HIV medications; however, the proportions of HIV-positive and HIV-negative participants reporting pharmacist counseling in our study were similar.19
Given that pharmacists are a vast potential resource for adherence support, it is important to understand the reasons why participants may not communicate with their pharmacists. These reasons cannot be fully elucidated by our retrospective, survey-based study design and should be further explored in qualitative studies with both patients and pharmacists.
HIV-infected women who did report pharmacist counseling in the past 6 months also reported higher antiretroviral therapy adherence and increased CD4+
cell counts compared with those who had not. These observed associations were small, but positive. Though the point estimates did not achieve statistical significance, our findings are consistent with other studies which found that HIV pharmacists in ambulatory care and inpatient settings had a positive impact on CD4+
cell counts and improving antiretroviral adherence, in addition to achieving undetectable HIV viral loads, adjusting for drug interactions, and lowering numbers of office visits.20
Despite their efforts to improve the health of patients with chronic diseases, the work of community pharmacists in HIV may be underappreciated, and is less frequently described in the literature. Three papers described a pilot program of 10 California community pharmacies that received funding to provide medication therapy management services for HIV-positive patients.13
Services offered in these 10 pharmacies varied greatly; they included adherence enhancements such as refill reminders, reminder packaging, and specialized antiretroviral medication counseling.13
At 3 years, HIV-positive patients filling their antiretroviral therapy at the pilot pharmacies (n = 2234) demonstrated higher refill adherence (medication possession ratios 69.4% versus 47.3%, P
< 0.001), and a higher odds of having optimal adherence (OR 2.74, 95% CI 2.44–3.10, after controlling for age, gender, and ethnicity) compared with traditional pharmacies.33
These pilot programs represent the ideal end of the spectrum of HIV community pharmacy care. Many other community pharmacists might hope to provide this type of high level care for their HIV-positive patients, but may be unable to do so for lack of funding, time, support, or expertise.35
Our study reveals minimal engagement in the potentially beneficial relationship between HIV-positive women and their community pharmacists. This information in itself is valuable, but also speaks to the continued research that needs to be done to understand HIV patient-pharmacist relationships better, the impact of community pharmacy care, and how to optimize elements of HIV pharmacy care to have maximal clinical and adherence impact. It can be challenging to operationalize research on pharmacists’ day-to-day practice, yet conducting these types of studies is important to substantiate the benefits of pharmacist counseling on outcomes for HIV and other chronic diseases. With further studies quantifying the health benefits added by the intense participation of community pharmacists on the HIV health care team, funding and support may be made more readily available, and HIV pharmacist services may be made more accessible to all patients.24
There are various limitations associated with our study. Our study required participants to self-identify whether or not they had received pharmacist counseling. This could have been subject to recall bias or lack of identification of counseling within an encounter, underestimating the overall penetration of pharmacist counseling. Study participants were already highly adherent to their antiretroviral therapy regimens, leaving minimal room for improvement for any intervention. Participants utilized different pharmacies that may represent very diverse models of HIV pharmacy care. A standardized pharmacist counseling intervention developed in collaboration with local HIV clinics may have a clearer impact on clinical and adherence outcomes for HIV-positive persons. Lastly, confounding by indication could have masked some positive effects of counseling. Patients who appeared to be struggling with adherence (and subsequently having lower CD4+ cell counts and increased viral loads) could have been more likely to receive counseling from their pharmacists. If poor adherence prompted pharmacist counseling, this could cause counseling to appear to perform poorly, even if it truly is effective in improving adherence.