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1.  Reporting of critical information in studies of pharmacists in HIV care 
To evaluate manuscripts documenting HIV pharmacist interventions and assess adequacy of reporting as defined by CONSORT and STROBE criteria.
PubMed, EMBASE, Cochrane Library, Web of Science, BIOSIS Previews, and PsycINFO databases were searched from inception-6/1/2011. Studies were included if pharmacists performed an intervention to improve HIV patient care, and the study evaluated the intervention’s impact. Qualitative studies, non-English language reports, abstracts, and studies where the pharmacist did not intervene were excluded. Manuscripts were independently evaluated by two reviewers for the presence, absence, or lack of applicability of STROBE (observational studies) or CONSORT (randomized studies) criteria, for presence or absence of description of pharmacist’s duties, CD4+ cell count, HIV viral load, and adherence measurement. Reviewers met to discuss the rationale behind their evaluation; a third arbiter was consulted when reviewers could not agree on a particular criterion.
Key findings
Twenty-two manuscripts met inclusion criteria. Observational studies of HIV pharmacists (n=19) included 56% of applicable STROBE criteria. Randomized studies of HIV pharmacists (n=3) adhered more closely to CONSORT reporting guidelines (average 80% of applicable criteria). Manuscripts published after 2004 more consistently evaluated pharmacist impact on HIV outcomes such as CD4+ and viral load.
Thorough reporting increases the reader’s ability to critically evaluate manuscripts of HIV pharmacist services. Increasing pharmacist awareness of manuscript guidelines such as CONSORT and STROBE may improve clarity of reporting in studies of HIV pharmacist interventions and clinical programs.
PMCID: PMC4112174  PMID: 24467531
clinical pharmacy; anti-infectives; research method; observation; RCT
2.  Improved antiretroviral refill adherence in HIV-focused community pharmacies 
To determine differences in patient characteristics, antiretroviral therapy (ART) regimen characteristics, and regimen refill adherence for HIV-focused pharmacy (HIV-P) versus traditional pharmacy (TP) users.
Retrospective cohort study
California Walgreens pharmacies, May 2007 – August 2009
HIV-positive (HIV+) patients with greater than 30 days of antiretroviral prescription claims.
Main outcome measures
Modified medication possession ratio (mMPR) to calculate regimen refill adherence, and dichotomous measure of optimal adherence ≥ 95%.
4254 HIV-P and 11679 TP users were included. Compared to TP users, HIV-P users traveled farther to pharmacies (5.03 vs. 1.26 miles), filled more chronic disease medications (35% vs. 30%), and received more fixed-dose combination tablets (92% vs. 83%); all p < 0.01. Median mMPR was higher for HIV-P users (90% vs. 77%, p < 0.0001). After adjustment for age, gender, insurance, medication use, and distance from pharmacy, use of HIV-P (OR= 2.18, 95% CI 1.88–2.52) and use of fixed-dose combination antiretroviral tablets (OR=2.43, 95% CI 1.83–3.22) were factors most strongly associated with having ≥ 95% regimen refill adherence.
For HIV+ patients struggling with antiretroviral adherence, clinicians could consider minimizing pill burden with combination tablets and referral to an HIV-focused pharmacy.
PMCID: PMC4607273  PMID: 23023860
antiretroviral; adherence; community pharmacy; HIV; medication therapy management
3.  Community Pharmacy Use Patterns of Women with HIV and Women At Risk for HIV in the San Francisco Bay Area 
Community pharmacies play a key role in the care of patients when dispensing antiretroviral therapy. The primary objective of this study was to describe patterns of community pharmacy use of women enrolled in the San Francisco site of the Women’s Interagency HIV Study (WIHS). The secondary objective was to determine whether the number of pharmacies a patient uses is associated with specific patient characteristics or virologic outcomes in HIV positive women.
The primary objective was to determine factors which were associated with using multiple dispensing pharmacies to obtain medications in a population of HIV+ and at-risk women. The secondary objective was to determine whether use of multiple pharmacies was associated with immunologic or virologic changes for the subset of HIV+ women.
A survey on community pharmacy use was distributed to San Francisco WIHS participants from 2004–2007. Poisson, linear, and logistic regression methods were used to determine associations between specific patient characteristics and use of multiple dispensing pharmacies and associations between multiple pharmacy use and CD4+ cell count or viral load changes.
There was a trend towards an association between HIV status and use of multiple pharmacies (IRR=1.23; 95% CI 1.00–1.51, p =0.05). In multivariable analyses of HIV positive women, use of additional pharmacies (over the primary pharmacy) during the study period was not associated with statistically significant changes in CD4+ count or viral load.
HIV positive participants may tend to use multiple pharmacies more frequently than their HIV negative counterparts, though this practice does not appear to be associated with poorer immunologic or virologic outcomes. Future studies should be conducted to determine whether different patient patterns of community pharmacy use affect HIV treatment outcomes.
PMCID: PMC4607290  PMID: 26478916
HIV; community pharmacy; women
The use of single-tablet ART regimens and its implications on adherence among HIV-infected women have not been well-described.
Participants were enrolled in the Women’s Interagency HIV Study (WIHS), a longitudinal study of HIV infection in U.S. women. We examined semiannual trends in single-tablet regimen use and ART adherence, defined as self-reported 95% adherence in the past 6 months, during 2006–2013. In a nested cohort study, we assessed the comparative effectiveness of a single-tablet versus a multiple-tablet regimen with respect to adherence, virologic suppression, quality of life, and AIDS-defining events, using propensity score matching to account for demographic, behavioral, and clinical confounders. We also examined these outcomes in a subset of women switching from a multiple- to single-tablet regimen, using a case-crossover design.
15,523 person-visits, representing 1,727 women (53% black, 29% Hispanic, 25% IDU, median age 47), were included. Use of single-tablet regimens among ART users increased from 7% in 2006 to 27% in 2013; adherence increased from 78% to 85% during the same period (both p<0.001). Single-tablet regimen use was significantly associated with increased adherence (adjusted RR 1.05, 95% CI 1.03–1.08) and virologic suppression (RR 1.06, 95% CI 1.01–1.11), while associations with improved quality of life and fewer AIDS-defining events did not achieve statistical significance. Similar findings were observed among the subset of switchers.
Single-tablet regimen use was associated with increased adherence and virologic suppression. Despite this, 15% of women prescribed ART were still not optimally adherent; additional interventions are needed to maximize therapeutic benefits.
PMCID: PMC3999284  PMID: 24326606
adherence; antiretroviral therapy; HIV; time factors; United States; viral load; women
5.  Do HIV-Positive Women Receive Depression Treatment that Meets Best Practice Guidelines? 
AIDS and behavior  2014;18(6):1094-1102.
This study addressed whether psychopharmacologic and psychotherapeutic treatment of depressed HIV+ women met standards defined in the best practice literature, and tested hypothesized predictors of standard-concordant care. 1,352 HIV-positive women in the multi-center Women’s Interagency HIV Study were queried about depressive symptoms and mental health service utilization using standards published by the American Psychiatric Association and the Agency for Healthcare Quality and Research to define adequate depression treatment. We identified those who: 1) reported clinically significant depressive symptoms (CSDS) using Centers for Epidemiological Studies – Depression Scale (CES-D) scores of ≥ 16; or 2) had lifetime diagnoses of major depressive disorder (MDD) assessed by World Mental Health Composite International Diagnostic Interviews plus concurrent elevated depressive symptoms in the past 12 months. Adequate treatment prevalence was 46.2% (n=84) for MDD and 37.9% (n=211) for CSDS. Multivariable logistic regression analysis found that adequate treatment was more likely among women who saw the same primary care provider consistently, who had poorer role functioning, who paid out-of-pocket for healthcare, and who were not African American or Hispanic/Latina. This suggests that adequate depression treatment may be increased by promoting healthcare provider continuity, outreaching individuals with lower levels of role impairment, and addressing the specific needs and concerns of African American and Hispanic/Latina women.
PMCID: PMC4020946  PMID: 24402689
Women and HIV; Depression Treatment; Psychopharmacology; Psychotherapy
6.  A qualitative study examining HIV Antiretroviral Adherence Counseling and Support in Community Pharmacies 
To use qualitative research methods to obtain an in-depth understanding of how antiretroviral therapy (ART) adherence support and counseling is provided in HIV-focused community pharmacies. To determine relevant facilitators and barriers around adherence support from both patient’s and pharmacist’s perspectives.
Qualitative research study of patients who patronize and pharmacists employed at HIV-focused pharmacies in the San Francisco Bay Area. Participants were recruited using flyers at HIV clinics, community-based organizations, and using newsletter blurbs. Transcripts were analyzed using grounded theory methods to determine emergent themes in the data.
19 eligible patients with a self-reported diagnosis of HIV, taking their current ART regimen for at least 3 months, and who obtained their ART from a community pharmacy in the San Francisco Bay Area were included. 9 pharmacists employed at 13 different pharmacy locations frequented by participants were interviewed. Emergent themes included descriptions of pharmacy adherence counseling and support, roles and responsibilities regarding medication adherence, barriers to providing adherence support, and feeling connected as a facilitator to adherence support relationships.
Pharmacists provide diverse types of ART adherence support and are uniquely positioned to help clients manage their medications. Additional training on developing relationships with patients and advertising regarding their adherence services may further the role of community pharmacists in supporting antiretroviral adherence.
PMCID: PMC3988691  PMID: 23806059
AIDS/HIV; community pharmacy; antiretroviral therapy; adherence
7.  Impact of HIV-Specialized Pharmacies on Adherence and Persistence with Antiretroviral Therapy 
AIDS Patient Care and STDs  2012;26(9):526-531.
Patient adherence (the degree to which patients follow their therapeutic regimen as prescribed within a set period of time) and persistence (the time to treatment discontinuation, with a permissible gap) with drug therapy are essential components of HIV/AIDS treatment. Select community pharmacies offer specialized services for HIV/AIDS patients to help combat some of the barriers to adherence and persistence. We assessed adherence and persistence with antiretroviral therapy (ART) for patients using HIV-specialized pharmacies in nine cities from seven states compared to traditional community pharmacy users over a 1-year period. Data were limited to one pharmacy chain. Propensity scoring was used to obtain 1:1 matches for “Specialized” and “Traditional” pharmacy users based on age, gender, number of prescription-inferred chronic conditions (obtained by mapping a patient's prescriptions to the Medi-Span Drug Indications Database), and presence of prescription anxiety and/or depression medication, resulting in 7064 patients in each group. Proportion of days covered (PDC) was used to measure adherence. Specialized pharmacy users had a significantly greater mean (74.1% versus 69.2%, p<0.0001) and median (90.3% versus 86.3%, p<0.0001) PDC. A greater percentage of patients in the Specialized group were able to obtain a PDC of 95% or better (39.3% versus 35.5%). Patients in the Specialized group were significantly more persistent (p=0.0117). Community pharmacies specialized in HIV services may be effective avenues for helping patients achieve greater adherence and persistence with ART. Given the value of specialized community pharmacies, payers should consider implementing policies to encourage the use of such pharmacies for filling ART.
PMCID: PMC4088351  PMID: 22860900
8.  Influence of gender on receipt of guideline-based antiretroviral therapy in the era of HAART 
AIDS Care  2011;24(1):20-29.
United States HIV treatment guidelines delineate preferred antiretroviral regimens (ART) and discourage use of subpotent, toxic, or adversely interacting combinations. It is unclear how often patients receive guideline concordant ART and what factors are correlated with receiving guideline-inconsistent ART. The objective of this study was to assess ART reported by participants of the Women's Interagency HIV Study (WIHS) and the Multicenter AIDS Cohort Study (MACS) to determine whether gender is associated with receipt of guideline-inconsistent ART. ART reported by WIHS and MACS participants from 1/1/2001 – 12/31/2007 was assessed for concordance with HIV guidelines. Logistic regression with generalized estimating equations estimated the crude and adjusted odds ratios and 95% confidence intervals associated with guideline-inconsistent regimens. Of 2937 participants, 463 subjects (WIHS n=263; MACS n=200) reported guideline-inconsistent ART during the study period. Age greater than 50 years (aOR = 2.22, 95% CI 1.14, 4.33) and HIV-1 RNA (aOR=1.17, 95% CI 1.08, 1.25) but not participant gender (aOR= 1.21, 95% CI 0.88, 1.65) were associated with guideline-inconsistent ART. The prevalence of guideline inconsistent ART peaked in 2004, however there was not a statistically significant increase or decrease over time. Guideline inconsistent ART was not related to gender, but was often used by older patients, and patients with higher viral loads. Monitoring ART quality based on concordance with expert guidelines could improve treatment outcomes in a substantial number of patients.
PMCID: PMC3222784  PMID: 21732716
antiretroviral; gender; guideline; concordance; treatment disparities
9.  Pharmacist counseling in a cohort of women with HIV and women at risk for HIV 
Background and methods
Achieving high adherence to antiretroviral therapy for human immunodeficiency virus (HIV) is challenging due to various system-related, medication-related, and patient-related factors. Community pharmacists can help patients resolve many medication-related issues that lead to poor adherence. The purpose of this cross-sectional survey nested within the Women’s Interagency HIV Study was to describe characteristics of women who had received pharmacist medication counseling within the previous 6 months. The secondary objective was to determine whether HIV-positive women who received pharmacist counseling had better treatment outcomes, including self-reported adherence, CD4+ cell counts, and HIV-1 viral loads.
Of the 783 eligible participants in the Women’s Interagency HIV Study who completed the survey, only 30% of participants reported receiving pharmacist counseling within the last 6 months. Factors independently associated with counseling included increased age (odds ratio [OR] 1.28; 95% confidence interval [CI] 1.07–1.55), depression (OR 1.75; 95% CI 1.25–2.45), and use of multiple pharmacies (OR 1.65; 95% CI 1.15–2.37). Patients with higher educational attainment were less likely to report pharmacist counseling (OR 0.68; 95% CI 0.48–0.98), while HIV status did not play a statistically significant role. HIV-positive participants who received pharmacist counseling were more likely to have optimal adherence (OR 1.23; 95% CI 0.70–2.18) and increased CD4+ cell counts (+43 cells/mm3, 95% CI 17.7–104.3) compared with those who had not received counseling, though these estimates did not achieve statistical significance.
Pharmacist medication counseling rates are suboptimal in HIV-positive and at-risk women. Pharmacist counseling is an underutilized resource which may contribute to improved adherence and CD4+ counts, though prospective studies should be conducted to explore this effect further.
PMCID: PMC3393123  PMID: 22791983
human immunodeficiency virus; acquired immunodeficiency syndrome; antiretroviral therapy; community pharmacy; pharmacy practice; women’s health
10.  The impact of HIV clinical pharmacists on HIV treatment outcomes: a systematic review 
Due to the rapid proliferation of human immunodeficiency virus (HIV) treatment options, there is a need for health care providers with knowledge of antiretroviral therapy intricacies. In a HIV multidisciplinary care team, the HIV pharmacist is well-equipped to provide this expertise. We conducted a systematic review to assess the impact of HIV pharmacists on HIV clinical outcomes.
We searched six electronic databases from January 1, 1980 to June 1, 2011 and included all quantitative studies that examined pharmacist’s roles in the clinical care of HIV-positive adults. Primary outcomes were antiretroviral adherence, viral load, and CD4+ cell count and secondary outcomes included health care utilization parameters, antiretroviral modifications, and other descriptive variables.
Thirty-two publications were included. Despite methodological limitation, the involvement of HIV pharmacists was associated with statistically significant adherence improvements and positive impact on viral suppression in the majority of studies.
This systematic review provides evidence of the beneficial impact of HIV pharmacists on HIV treatment outcomes and offers suggestions for future research.
PMCID: PMC3333818  PMID: 22536064
pharmacist; HIV/AIDS; clinical; adherence; impact
11.  The Impact of the AIDS Drug Assistance Program (ADAP) on Use of Highly Active Antiretroviral and Antihypertensive Therapy among HIV-Infected Women 
To evaluate the association between enrollment into an AIDS Drug Assistance Program (ADAP) and use of highly active antiretroviral therapy (HAART) and antihypertensive therapy.
Cross-sectional analyses of data were performed on HAART-eligible women enrolled in the California (n=439), Illinois (n=168), and New York (n=487) Women’s Interagency HIV Study (WIHS) sites. A subset of HIV-infected women with hypertension (n=395) was also analyzed. Unadjusted and adjusted backward stepwise elimination logistic regression measured the association between demographic, behavioral, and health service factors and non-use of HAART or antihypertensive medication.
In adjusted analysis of HAART non-use, women without ADAP were significantly more likely not to use HAART (odds ratio [OR] = 2.4, 95% confidence interval [CI] = 1.5–3.7) than women with ADAP. In adjusted analysis of antihypertensive medication non-use, women without ADAP had an increased but not significant odds of antihypertensive medication non-use (OR = 2.4, 95% CI = 0.93–6.0) than women with ADAP.
Government-funded programs for prescription drug coverage, such as ADAP, may play an important role in how HIV-positive women to access and use essential medications for chronic diseases.
PMCID: PMC3042745  PMID: 21239994
AIDS; antiretroviral therapy; hypertension; women; healthcare disparity; prescription insurance

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