Does the choice of pharmacy affect HIV-infected patients' access to patient-centered pharmacy services?

Background: The growth of specialty pharmacy has created a paradigm shift in pharmacy practice from a product-specific to a patient-centered approach. Patient-centered pharmacy services (PCPS) that exceed dispensing services mandated by law, can increase medication adherence, improve health outcomes, and reduce health-care utilization costs of HIV-infected patients. Little is known about the nature and extent of pharmacists' practices related specifically to HIV in community pharmacy settings. We conducted a qualitative interview-based study to compare pharmacists' procedures in providing care to HIV-infected patients in diverse pharmacy settings. Methods: We interviewed 28 licensed pharmacists (13 specialty, 6 semi-specialty, and 9 non-specialty). We asked pharmacists their procedures for providing care to HIV-infected patients with new, refill, and change in prescriptions. We used MAXQDA qualitative software to identify the range of PCPS, and do a comparative analysis of different pharmacy settings. Results: Pharmacist-patient encounters ranged from brief 2-3 minutes at the checkout window to 45-minute private consultations with new patients and 3-hour targeted interventions. Pharmacists providing PCPS (specialty and semi-specialty) reported reinforcing physician adherence messages, providing individualized medication education on side effect management, conducting adherence assessments, intervening to remove adherence barriers, communicating adherence issues to physicians, phone monitoring of new patients and routine monthly reminders to refill prescriptions, participating in HIV-related community events, and providing services (weekly dose packing, medication deliveries) at no cost to patients. In addition, few pharmacists reported collaborating with physicians to conduct medication readiness assessments and therapeutic adherence monitoring, and to identify appropriate antiretroviral regimens. Pharmacists providing PCPS reported having HIV training and experience, close relationships with patients, conducive pharmacy environment for nonjudgmental dialogue, management support (adequate staffing, training), great provider networks that shared information on HIV treatment updates, and collaborating with non-clinical providers (case managers) to resolve patient housing and financial issues. In contrast, non-specialty pharmacies reported having impersonal patient relationships, time and privacy constraints that prevented them from providing PCPS. Pharmacists reported that some insurance programs required HIV-infected patients to fill prescriptions only at mail-order pharmacy. Conclusions: HIV-infected patients not receiving care at specialty and semi-specialty pharmacies lack access to personalized services, close monitoring for medication safety and effectiveness, and access to pharmacists knowledgeable in HIV treatment. Given individual and public health implications of poor adherence, it is important to address the barriers that prevent non-specialty pharmacies from providing PCPS. Future research could evaluate the effectiveness and cost-effectiveness of PCPS in order to justify reimbursement by third-party payers.