Engaging young adult clients of community pharmacies for HIV screening in Coastal Kenya: a cross-sectional study

Pharmacy-based sexually transmitted infection service implementation considerations: A scoping review

BACKGROUND

Rates of sexually transmitted infections (STIs) are rising despite significant management efforts in traditional healthcare settings. The growing number of individuals affected by STIs demonstrates a gap in care. Pharmacy-based STI clinical services are a potential solution to improve care.

OBJECTIVE

To identify and summarize research about the implementation of pharmacy-based STI services, focusing on program characteristics, barriers, facilitators, and pharmacist and patient experiences.

METHODS

A search of PubMed, Embase, and Cochrane Database of Systematic Reviews was conducted for papers evaluating STI expanded-scope clinical services performed by regulated pharmacists in an outpatient/community pharmacy setting. Study setting, design, data collection method, outcomes, target infection, services offered, patient population, and barriers and facilitators are reported.

RESULTS

Twelve studies, 11 cross-sectional and 1 randomized control trial, were identified in this review. All studies focused on chlamydia, and two included gonorrhea and trichomoniasis or syphilis. Eleven services investigated STI screening, with four also offering treatment, and two offering partner treatment. Overall, patients reported positive experiences, found the services accessible, and trusted pharmacists. Pharmacists recognized the importance of STI services, were keen, and felt comfortable performing clinical tasks. Patients described convenience as a key facilitator, and concerns about privacy, particularly at the pharmacy counter, and the stigma and fear of judgement associated with STIs as primary barriers. For facilitators, pharmacists reported increased job satisfaction and a sense of relieving the burden on traditional STI services; for barriers, pharmacists highlighted patient recruitment, communication challenges, and lack of remuneration.

CONCLUSION

Research on pharmacy-based STI services includes predominately small-scale, cross-sectional studies, and focuses on chlamydia screening. Both patients and pharmacists perceive these services to be acceptable and feasible, though strategies addressing patient privacy and recruitment, pharmacist competency, training, and remuneration must be considered to support the success of pharmacy-based STI services.

Public Health Interventions Delivered by Pharmacy Professionals in Low- and Middle-Income Countries in Africa: A Systematic Scoping Review

Pharmacists and their teams play an important role in providing public health services, however little is known about their level of contribution and the strength of evidence in Africa's Low- and Middle-Income Countries (LMICs). The purpose of this scoping review was to explore and map the available evidence on pharmacy professional-delivered public health interventions in Africa's LMICs. Six electronic databases (Medline, Embase, International Pharmaceutical Abstract, PsycInfo, Maternity and Infant Care, and Cochrane database), relevant grey literature sources, key journals focused on African health issues, and libraries of relevant organizations were searched between January 2010 and December 2020. Studies were included if they reported public health interventions delivered by pharmacy professionals (pharmacists or pharmacy technicians) or their teams. The quality of the individual studies was assessed using an adapted grading system. Thirty-nine studies were included in this review. Pharmacy professionals delivered a wide range of public health interventions, with the most common themes being noncommunicable diseases, infectious diseases, sexual and reproductive health, antimicrobial resistance, and other health conditions, e.g., dental health, unused drugs or waste, minor ailments. The majority of the studies were classified as low-quality evidence. They were predominantly feasibility and acceptability studies conducted in a narrow study area, in a small number of LMICs in Africa, resulting in little evidence of service effectiveness, issues of broad generalizability of the findings, and sustainability. The major constraints to service provision were identified as a lack of training, public recognition, and supporting policies. Pharmacy professionals and their teams across LMICs in Africa have attempted to expand their practice in public health. However, the pace of the expansion has been slow and lacks strong evidence for its generalizability and sustainability. Future research is needed to improve the quality of evidence, which will subsequently serve as a foundation for policy reform, allowing pharmacy professionals to make significant contributions to the public health initiatives in the region.

The effectiveness, feasibility and acceptability of HIV service delivery at private pharmacies in sub-Saharan Africa: a scoping review

INTRODUCTION

Private pharmacies are an understudied setting for differentiated delivery of HIV services that may address barriers to clinic-delivered services, such as stigma and long wait times. To understand the potential for pharmacy-delivered HIV services in sub-Saharan Africa, we conducted a scoping review of the published and grey literature.

METHODS

Using a modified Cochrane approach, we searched electronic databases through March 2022 and HIV conference abstracts in the past 5 years for studies that: (1) focused on the delivery of HIV testing, antiretroviral therapy (ART) and/or pre-exposure prophylaxis (PrEP) at private pharmacies in sub-Saharan Africa; (2) reported on effectiveness outcomes (e.g. HIV incidence) or implementation outcomes, specifically feasibility and/or acceptability; and (3) were published in English. Two authors identified studies and extracted data on study setting, population, design, outcomes and findings by HIV service type.

RESULTS AND DISCUSSION

Our search identified 1646 studies. After screening and review, we included 28 studies: seven on HIV testing, nine on ART delivery and 12 on PrEP delivery. Most studies (n = 16) were conducted in East Africa, primarily in Kenya. Only two studies evaluated effectiveness outcomes; the majority (n = 26) reported on feasibility and/or acceptability outcomes. The limited effectiveness data (n = 2 randomized trials) suggest that pharmacy-delivered HIV services can increase demand and result in comparable clinical outcomes (e.g. viral load suppression) to standard-of-care clinic-based models. Studies assessing implementation outcomes found actual and hypothetical models of pharmacy-delivered HIV services to be largely feasible (e.g. high initiation and continuation) and acceptable (e.g. preferable to facility-based models and high willingness to pay/provide) among stakeholders, providers and clients. Potential barriers to implementation included a lack of pharmacy provider training on HIV service delivery, costs to clients and providers, and perceived low quality of care.

CONCLUSIONS

The current evidence suggests that pharmacy-delivered HIV services may be feasible to implement and acceptable to clients and providers in parts of sub-Saharan Africa. However, limited evidence outside East Africa exists, as does limited evidence on the effectiveness of and costs associated with pharmacy-delivered HIV services. More research of this nature is needed to inform the scale-up of this new differentiated service delivery model throughout the region.

Design of a care pathway for pharmacy-based PrEP delivery in Kenya: results from a collaborative stakeholder consultation

INTRODUCTION

In Kenya, pre-exposure prophylaxis (PrEP) for HIV prevention is almost exclusively delivered at HIV clinics. Developing novel PrEP delivery models is important for increasing the reach of PrEP. Delivery of PrEP through pharmacies is one approach utilized in the US to improve accessibility. Retail pharmacies are commonly used as a first-line access point for medical care in Kenya, but have not been utilized for PrEP delivery. We conducted a collaborative consultative meeting of stakeholders to develop a care pathway for pharmacy-based PrEP delivery in Kenya.

METHODS

In January 2020, we held a one-day meeting in Nairobi with 36 stakeholders from PrEP regulatory, professional, healthcare service delivery, civil society, and research organizations. Attendees reviewed a theory of change model, results from formative qualitative research with pharmacy providers and clients, and anticipated core components of pharmacy-based PrEP delivery: counseling, HIV testing, prescribing, and dispensing. Stakeholders participated in small and large group discussions to identify potential challenges and solutions. We synthesized the key findings from these discussions.

RESULTS

Stakeholders were enthusiastic about a model for pharmacy-based PrEP delivery. Potential challenges identified included insufficient pharmacy provider knowledge and skills, regulatory hurdles to providing affordable HIV testing at pharmacies, and undefined pathways for PrEP procurement. Potential solutions identified included having pharmacy providers complete the Kenya Ministry of Health-approved PrEP training, use of a PrEP prescribing checklist with remote clinician oversight and provider-assisted HIV self-testing, and having the government provide PrEP and HIV self-testing kits to pharmacies during a pilot test. A care pathway was developed over the course of the meeting.

CONCLUSIONS

PrEP delivery stakeholders in Kenya were strongly supportive of developing and testing a model for pharmacy-based PrEP delivery to increase PrEP access. We collaboratively developed a care pathway for pilot testing that has the potential to expand PrEP delivery options in Kenya and other similar settings.

Screening for HIV and linkage to care in adolescents: insights from a systematic review of recent interventions in high- versus low- and middle-income settings

Introduction

Compared to adults, adolescents and young adults have a higher incidence of HIV infection, yet lower rates of HIV testing. Few evidence-based interventions effectively diagnose new HIV infections among adolescents while successfully providing linkage to care.

Methods

We conducted a systematic review of recent interventions to increase HIV testing among adolescents and young adults using data retrieved from PubMed and Google Scholar, and using abstracts presented at the International AIDS Society conferences and Conference on Retroviruses and Opportunistic Infections published between January 1, 2015, and April 28, 2018.

Results

We identified 36 interventions (N=14 in high- income countries and N=22 in low- and middle-income countries) that were published in the literature (N=28) or presented at conferences (N=8). Interventions were categorized as behavioral/educational, alternate venue/self-testing, youth-friendly services, technology/mobile health, incentives, or peer-based/community-based interventions. The studies consisted of randomized controlled trials (RCTs), prospective and retrospective observational studies, and quasi-experimental/pre-post evaluations with variable sample sizes. Study designs, populations, and settings varied. All categories showed some degree of acceptability, yet not all interventions were effective in increasing HIV testing. Effectiveness was seen in more than one RCT involving technology/mobile health (2/3 RCTs) and alternative venue/self-testing (3/3 RCTs) interventions, and only in one RCT each for behavioral interventions, community interventions, and incentives. There were no effective RCTs for adolescent-friendly services. Data were limited on the number of new infections identified and on the methods to increase linkage to care after diagnosis.

Conclusion

Future studies should include combinations of proven methods for engaging adolescents in HIV testing, while ensuring effective methods of linkage to care.

Uptake and Acceptability of Oral HIV Self-Testing among Community Pharmacy Clients in Kenya: A Feasibility Study

BACKGROUND

While HIV testing and counselling is a key entry point for treatment as prevention, over half of HIV-infected adults in Kenya are unaware they are infected. Offering HIV self-testing (HST) at community pharmacies may enhance detection of undiagnosed infections. We assessed the feasibility of pharmacy-based HST in Coastal Kenya.

METHODS

Staff at five pharmacies, supported by on-site research assistants, recruited adult clients (≥18 years) seeking services indicative of HIV risk. Participants were offered oral HST kits (OraQuick®) at US$1 per test. Within one week of buying a test, participants were contacted for post-test data collection and counselling. The primary outcome was test uptake, defined as the proportion of invited clients who bought tests. Views of participating pharmacy staff were solicited in feedback sessions during and after the study.

RESULTS

Between November 2015 and April 2016, 463 clients were invited to participate; 174 (38%) were enrolled; and 161 (35% [95% Confidence Interval (CI) 31-39%]) bought a test. Uptake was higher among clients seeking HIV testing compared to those seeking other services (84% vs. 11%, adjusted risk ratio 6.9 [95% CI 4.9-9.8]). Only 4% of non-testers (11/302) stated inability to pay as the reason they did not take up the test. All but one tester reported the process was easy (29%) or very easy (70%). Demand for HST kits persisted after the study and participating service providers expressed interest in continuing to offer the service.

CONCLUSIONS

Pharmacy HST is feasible in Kenya and may be in high demand. The uptake pattern observed suggests that a client-initiated approach is more feasible compared to pharmacy-initiated testing. Price is unlikely to be a barrier if set at about US$1 per test. Further implementation research is required to assess uptake, yield, and linkage to care on a larger scale.