RESEARCH NOTES
Evaluating community pharmacists’ HIV testing knowledge: A crosssectional survey Larry J. Pineda, Renee-Claude Mercier, Thomas Dilworth, Michelle Iandiorio, Shannon Rankin, and Bernadette Jakeman
Abstract Objectives: To assess community pharmacists’ knowledge of human immunodeficiency virus (HIV), antiretroviral therapy, and new in-home oral fluid HIV test. Methods: A cross-sectional questionnaire administered to pharmacists, student pharmacists, and technicians before an education program at the New Mexico Pharmacists Association 2013 Mid-Winter Meeting in Albuquerque, NM. The main outcome measure was community pharmacists’ correct response rate of 75% or more. Results: Overall survey response rate of attendees was 89% (173/194 attendees). Among them 87 participants were community pharmacists; 87% of community pharmacists responded correctly when asked how HIV antiretroviral medications work and 84.3% correctly identified known sources of HIV infection. The 75% predefined adequate knowledge threshold was not met on any HIV screening or in-home HIV test knowledge items. Only 65.1% of community pharmacists correctly identified the minimum number of antiretroviral drugs that should be included in an ideal HIV treatment regimen. The only variable that positively influenced pharmacists’ knowledge was age. An inverse relationship between pharmacist age and HIV knowledge was observed among study participants. Conclusion: Community pharmacists from urban and rural areas in New Mexico possessed adequate basic HIV knowledge, but did not demonstrate adequate HIV screening or in-home HIV test knowledge. Future educational interventions aimed at improving pharmacist knowledge in this area are warranted. J Am Pharm Assoc. 2015;55:424–428. doi: 10.1331/JAPhA.2015.14139
A
ccording to data reported by the Centers for Disease Control and Prevention (CDC), an estimated 1.1 million persons 13 years of age or older are living with human immunodeficiency virus (HIV) infection in the United States.1 Approximately 15.8% are unaware of their infection.1 Undiagnosed persons are thought to be responsible for more than one-half of new HIV cases2, making testing an essential component in preventing the spread of HIV infection. The CDC expanded its recommendations in 2006 for routine screening to include all persons between the ages of 13 and 64.3 This approach aims to increase testing rates in order to try to reach persons that are unaware of their status. Despite these increased efforts, only 54% of U.S. adults report ever having been tested in their lifetime.4 Several barriers exist which deter patients from pursuing HIV screening, including lack of anonymity.4,5 Recently, the Food and Drug Administration approved a new in-home HIV test (OraQuick, OraSure Technologies) that allows for rapid HIV screening. The new test became available in pharmacies, retail stores, and online in 2012. The test uses lateral flow technology to analyze a self-collected oral fluid sample for HIV-1 Larry J. Pineda, PharmD, Visiting Assistant Professor, College of Pharmacy, University of New Mexico, Albuquerque, NM Renee-Claude Mercier, PharmD, BCPS, Associate Professor, College of Pharmacy, University of New Mexico, Albuquerque, NM Thomas Dilworth, PharmD, BCPS, Clinical Pharmacy Supervisor, St. Francis Hospital, Wheaton Franciscan Healthcare, Milwaukee, WI Michelle Iandiorio, MD, Associate Professor, School of Medicine, University of New Mexico, Albuquerque, NM Shannon Rankin, PharmD, BCPS, Pharmacist, Department of Pharmacy, University of New Mexico Hospitals, Albuquerque, NM Bernadette Jakeman, PharmD, BCPS, Assistant Professor, College of Pharmacy, University of New Mexico, Albuquerque, NM Correspondence: Bernadette Jakeman, PharmD, Department of Pharmacy Practice and Administrative Sciences, College of Pharmacy, University of New Mexico, 1 University of New Mexico, MSC09 5360, Albuquerque, NM 87131-0001; [email protected] Disclosure: The authors declare no relevant conflicts of interest or financial relationships. Acknowledgments: Dr. Jennifer Weese for research assistance and questionnaire administration and Dr. Matthew Borrego for assistance with questionnaire study design. Previous presentations: American College of Clinical Pharmacy Annual Meeting, Albuquerque, NM, October 13– 16, 2013. Received June 24, 2014. Accepted for publication February 4, 2015.
424 JAPhA | 5 5:4 | JUL /AUG 2 0 1 5
ja p h a.org
Journal of the American Pharmacists Association
RESEARCH NOTES
and HIV-2 antibodies in approximately 20 minutes.6 The results are displayed much like an in-home pregnancy test, where two lines indicate a positive result and one line represents a negative result.6 While this test can provide privacy and confidentiality for patients, there is still a need for counseling on appropriate use before the test as well as follow-up care after the test. There is a concern for misinterpretation of a ‘negative’ test result. On average, the ‘window period’ between the time an individual is exposed to HIV and the time until HIV antibodies levels are detectable may be as long as 3 months.7 To address issues related to this test, user-friendly packaging and instructions were included with the test, and a 24-hour toll-free customer service line and customer service website were made available to patients.6 However, these resources do not address issues of low literacy levels or limited internet/ telephone access for some patients, providing pharmacists with the opportunity to actively engage in improving public health by providing patient counseling related to testing procedure, interpretation of results, and resources for care. To effectively provide this public service, pharmacists must be knowledgeable about the test and HIV. However, several studies have revealed that community pharmacists have low baseline HIV knowledge.8–10
Key Points Background: ❚❚ Community pharmacists are presented with a great opportunity to actively engage in improving public health by providing guidance and counseling related to the recently approved rapid oral human immunodeficiency virus (HIV) screening test. ❚❚ Previous studies have revealed that community pharmacists have low baseline HIV knowledge, and HIV screening knowledge has not been described. Findings: ❚❚
❚❚
This cross-sectional survey reveals that community pharmacists’ baseline knowledge of HIV screening, in-home oral test, and basic HIV and antiretroviral therapy needs improvement. The predetermined adequate knowledge threshold of 75% was not met on any HIV screening or in-home HIV test knowledge items. An inverse relationship between pharmacist age and HIV knowledge was observed among community pharmacists.
Journal of the American Pharmacists Association
Objectives The objectives of this study were to (1) assess the basic HIV screening and in-home HIV test knowledge of community pharmacists, and (2) determine if knowledge in these areas was affected by pharmacist characteristics.
Methods This was a cross-sectional study using a questionnaire administered to attendees of the New Mexico Pharmacists Association (NMPhA) 2013 Mid-Winter Meeting in Albuquerque, NM. The study was approved by the University of New Mexico Institutional Review Board and permission was granted by NMPhA to administer the questionnaire before an HIV and screening continuing pharmacy education (CPE) program. The purpose of our study was to assess baseline knowledge only; therefore, no post-CPE questionnaire was administered for comparison. Based on historical attendance, a turnout of 120 to 180 pharmacists was expected. The target population for our study was community pharmacists since they are at the forefront of patient counseling in the outpatient setting. All attendees were encouraged to participate; however, only responses from community pharmacists defined as pharmacists practicing in community, retail, or clinic were included in the primary analysis. Instructions were provided to participants within the slide presentation before survey administration. Only participants who completed at least 20% of the survey items were included. No form of compensation was offered for participation. Responses from this convenience sample were captured using audience response system technology. Each questionnaire item was displayed sequentially in a slide presentation and read aloud for the participants. The majority of the questionnaire was adapted from previously validated surveys.8–10 Seven of the 18 items were developed by the study investigators to evaluate knowledge of the new in-home HIV test. To discourage guessing or nonresponses, an answer choice of ‘I don’t know’ was included for most knowledge items. The survey instrument was reviewed for validity and accuracy by HIV-experienced clinical pharmacists and physicians, and was pilot-tested with a small sample of six pharmacists and four student pharmacists to verify clarity and length. The complete questionnaire is provided in Appendix 1 (available online in the Supplemental Content section of this article on JAPhA.org). As CPE programs traditionally require more than 75% correct response rate for completion, we used this as our ‘adequate’ knowledge threshold for each item. Responses of ‘I don’t know’ were categorized as ‘incorrect’ for analysis. Nonresponses were excluded from data analysis. Demographic, knowledge, and perception data for the target population as a whole were reported as frequencies and percentages. j apha.org
JU L/A U G 2015 | 55:4 |
JAPhA 425
RESEARCH NOTES
A multiple linear regression analysis was performed to identify pharmacist-level factors that contributed to variability in community pharmacist HIV knowledge. The dependent variable was HIV knowledge, which was operationalized as a composite score of correct HIV knowledge question responses (range 0–10; 10 being the maximum score). The independent variables were pharmacist age, pharmacy location, whether or not their pharmacy stocked antiretroviral therapy (ART), and the number of ART prescriptions dispensed per month.
Results The survey response rate of attendees was 89% (173/194). One attendee’s responses were excluded from data analysis because of device malfunction. Four participants were removed from analysis because they had less than 20% response rate to the questionnaire. A total of 87 participants were identified as community pharmacists. Approximately one-half of the community pharmacist group was younger than 50 years of age (51.2%). There was an even distribution of community pharmacists who practiced in rural versus urban areas (46.9% and 53.1%, respectively). Additionally, 69.8% of community pharmacists reported that their establishment stocked HIV medications. The majority of community pharmacists either agreed (35.6%) or strongly agreed (52.9%) that providing information about HIV is part of a pharmacist’s professional responsibility. Correct response rates to the knowledge items of the questionnaire are found in Table 1. Community pharmacists performed well on two of three basic HIV and highly active ART knowledge items, but only 65.1% correctly recognized the minimum number of ART drugs that should be included in an ideal HIV treatment regimen. The adequate knowledge threshold of more than 75% was not met on any HIV screening or in-home HIV test knowledge items. Furthermore, a large number of attendees responded “I don’t know” to questions about HIV detection and interpretation of the in-home HIV test. Pharmacist age, location, whether or not their pharmacy stocked ART, and number of ART prescriptions dispensed per month were used in a multiple linear regression analysis to predict community pharmacist HIV knowledge. The multiple linear regression analysis of the model was significant (P
Evaluating community pharmacists’ HIV testing knowledge: A crosssectional survey Larry J. Pineda, Renee-Claude Mercier, Thomas Dilworth, Michelle Iandiorio, Shannon Rankin, and Bernadette Jakeman
Abstract Objectives: To assess community pharmacists’ knowledge of human immunodeficiency virus (HIV), antiretroviral therapy, and new in-home oral fluid HIV test. Methods: A cross-sectional questionnaire administered to pharmacists, student pharmacists, and technicians before an education program at the New Mexico Pharmacists Association 2013 Mid-Winter Meeting in Albuquerque, NM. The main outcome measure was community pharmacists’ correct response rate of 75% or more. Results: Overall survey response rate of attendees was 89% (173/194 attendees). Among them 87 participants were community pharmacists; 87% of community pharmacists responded correctly when asked how HIV antiretroviral medications work and 84.3% correctly identified known sources of HIV infection. The 75% predefined adequate knowledge threshold was not met on any HIV screening or in-home HIV test knowledge items. Only 65.1% of community pharmacists correctly identified the minimum number of antiretroviral drugs that should be included in an ideal HIV treatment regimen. The only variable that positively influenced pharmacists’ knowledge was age. An inverse relationship between pharmacist age and HIV knowledge was observed among study participants. Conclusion: Community pharmacists from urban and rural areas in New Mexico possessed adequate basic HIV knowledge, but did not demonstrate adequate HIV screening or in-home HIV test knowledge. Future educational interventions aimed at improving pharmacist knowledge in this area are warranted. J Am Pharm Assoc. 2015;55:424–428. doi: 10.1331/JAPhA.2015.14139
A
ccording to data reported by the Centers for Disease Control and Prevention (CDC), an estimated 1.1 million persons 13 years of age or older are living with human immunodeficiency virus (HIV) infection in the United States.1 Approximately 15.8% are unaware of their infection.1 Undiagnosed persons are thought to be responsible for more than one-half of new HIV cases2, making testing an essential component in preventing the spread of HIV infection. The CDC expanded its recommendations in 2006 for routine screening to include all persons between the ages of 13 and 64.3 This approach aims to increase testing rates in order to try to reach persons that are unaware of their status. Despite these increased efforts, only 54% of U.S. adults report ever having been tested in their lifetime.4 Several barriers exist which deter patients from pursuing HIV screening, including lack of anonymity.4,5 Recently, the Food and Drug Administration approved a new in-home HIV test (OraQuick, OraSure Technologies) that allows for rapid HIV screening. The new test became available in pharmacies, retail stores, and online in 2012. The test uses lateral flow technology to analyze a self-collected oral fluid sample for HIV-1 Larry J. Pineda, PharmD, Visiting Assistant Professor, College of Pharmacy, University of New Mexico, Albuquerque, NM Renee-Claude Mercier, PharmD, BCPS, Associate Professor, College of Pharmacy, University of New Mexico, Albuquerque, NM Thomas Dilworth, PharmD, BCPS, Clinical Pharmacy Supervisor, St. Francis Hospital, Wheaton Franciscan Healthcare, Milwaukee, WI Michelle Iandiorio, MD, Associate Professor, School of Medicine, University of New Mexico, Albuquerque, NM Shannon Rankin, PharmD, BCPS, Pharmacist, Department of Pharmacy, University of New Mexico Hospitals, Albuquerque, NM Bernadette Jakeman, PharmD, BCPS, Assistant Professor, College of Pharmacy, University of New Mexico, Albuquerque, NM Correspondence: Bernadette Jakeman, PharmD, Department of Pharmacy Practice and Administrative Sciences, College of Pharmacy, University of New Mexico, 1 University of New Mexico, MSC09 5360, Albuquerque, NM 87131-0001; [email protected] Disclosure: The authors declare no relevant conflicts of interest or financial relationships. Acknowledgments: Dr. Jennifer Weese for research assistance and questionnaire administration and Dr. Matthew Borrego for assistance with questionnaire study design. Previous presentations: American College of Clinical Pharmacy Annual Meeting, Albuquerque, NM, October 13– 16, 2013. Received June 24, 2014. Accepted for publication February 4, 2015.
424 JAPhA | 5 5:4 | JUL /AUG 2 0 1 5
ja p h a.org
Journal of the American Pharmacists Association
RESEARCH NOTES
and HIV-2 antibodies in approximately 20 minutes.6 The results are displayed much like an in-home pregnancy test, where two lines indicate a positive result and one line represents a negative result.6 While this test can provide privacy and confidentiality for patients, there is still a need for counseling on appropriate use before the test as well as follow-up care after the test. There is a concern for misinterpretation of a ‘negative’ test result. On average, the ‘window period’ between the time an individual is exposed to HIV and the time until HIV antibodies levels are detectable may be as long as 3 months.7 To address issues related to this test, user-friendly packaging and instructions were included with the test, and a 24-hour toll-free customer service line and customer service website were made available to patients.6 However, these resources do not address issues of low literacy levels or limited internet/ telephone access for some patients, providing pharmacists with the opportunity to actively engage in improving public health by providing patient counseling related to testing procedure, interpretation of results, and resources for care. To effectively provide this public service, pharmacists must be knowledgeable about the test and HIV. However, several studies have revealed that community pharmacists have low baseline HIV knowledge.8–10
Key Points Background: ❚❚ Community pharmacists are presented with a great opportunity to actively engage in improving public health by providing guidance and counseling related to the recently approved rapid oral human immunodeficiency virus (HIV) screening test. ❚❚ Previous studies have revealed that community pharmacists have low baseline HIV knowledge, and HIV screening knowledge has not been described. Findings: ❚❚
❚❚
This cross-sectional survey reveals that community pharmacists’ baseline knowledge of HIV screening, in-home oral test, and basic HIV and antiretroviral therapy needs improvement. The predetermined adequate knowledge threshold of 75% was not met on any HIV screening or in-home HIV test knowledge items. An inverse relationship between pharmacist age and HIV knowledge was observed among community pharmacists.
Journal of the American Pharmacists Association
Objectives The objectives of this study were to (1) assess the basic HIV screening and in-home HIV test knowledge of community pharmacists, and (2) determine if knowledge in these areas was affected by pharmacist characteristics.
Methods This was a cross-sectional study using a questionnaire administered to attendees of the New Mexico Pharmacists Association (NMPhA) 2013 Mid-Winter Meeting in Albuquerque, NM. The study was approved by the University of New Mexico Institutional Review Board and permission was granted by NMPhA to administer the questionnaire before an HIV and screening continuing pharmacy education (CPE) program. The purpose of our study was to assess baseline knowledge only; therefore, no post-CPE questionnaire was administered for comparison. Based on historical attendance, a turnout of 120 to 180 pharmacists was expected. The target population for our study was community pharmacists since they are at the forefront of patient counseling in the outpatient setting. All attendees were encouraged to participate; however, only responses from community pharmacists defined as pharmacists practicing in community, retail, or clinic were included in the primary analysis. Instructions were provided to participants within the slide presentation before survey administration. Only participants who completed at least 20% of the survey items were included. No form of compensation was offered for participation. Responses from this convenience sample were captured using audience response system technology. Each questionnaire item was displayed sequentially in a slide presentation and read aloud for the participants. The majority of the questionnaire was adapted from previously validated surveys.8–10 Seven of the 18 items were developed by the study investigators to evaluate knowledge of the new in-home HIV test. To discourage guessing or nonresponses, an answer choice of ‘I don’t know’ was included for most knowledge items. The survey instrument was reviewed for validity and accuracy by HIV-experienced clinical pharmacists and physicians, and was pilot-tested with a small sample of six pharmacists and four student pharmacists to verify clarity and length. The complete questionnaire is provided in Appendix 1 (available online in the Supplemental Content section of this article on JAPhA.org). As CPE programs traditionally require more than 75% correct response rate for completion, we used this as our ‘adequate’ knowledge threshold for each item. Responses of ‘I don’t know’ were categorized as ‘incorrect’ for analysis. Nonresponses were excluded from data analysis. Demographic, knowledge, and perception data for the target population as a whole were reported as frequencies and percentages. j apha.org
JU L/A U G 2015 | 55:4 |
JAPhA 425
RESEARCH NOTES
A multiple linear regression analysis was performed to identify pharmacist-level factors that contributed to variability in community pharmacist HIV knowledge. The dependent variable was HIV knowledge, which was operationalized as a composite score of correct HIV knowledge question responses (range 0–10; 10 being the maximum score). The independent variables were pharmacist age, pharmacy location, whether or not their pharmacy stocked antiretroviral therapy (ART), and the number of ART prescriptions dispensed per month.
Results The survey response rate of attendees was 89% (173/194). One attendee’s responses were excluded from data analysis because of device malfunction. Four participants were removed from analysis because they had less than 20% response rate to the questionnaire. A total of 87 participants were identified as community pharmacists. Approximately one-half of the community pharmacist group was younger than 50 years of age (51.2%). There was an even distribution of community pharmacists who practiced in rural versus urban areas (46.9% and 53.1%, respectively). Additionally, 69.8% of community pharmacists reported that their establishment stocked HIV medications. The majority of community pharmacists either agreed (35.6%) or strongly agreed (52.9%) that providing information about HIV is part of a pharmacist’s professional responsibility. Correct response rates to the knowledge items of the questionnaire are found in Table 1. Community pharmacists performed well on two of three basic HIV and highly active ART knowledge items, but only 65.1% correctly recognized the minimum number of ART drugs that should be included in an ideal HIV treatment regimen. The adequate knowledge threshold of more than 75% was not met on any HIV screening or in-home HIV test knowledge items. Furthermore, a large number of attendees responded “I don’t know” to questions about HIV detection and interpretation of the in-home HIV test. Pharmacist age, location, whether or not their pharmacy stocked ART, and number of ART prescriptions dispensed per month were used in a multiple linear regression analysis to predict community pharmacist HIV knowledge. The multiple linear regression analysis of the model was significant (P
