Pharmacist-provided HIV point-of-care testing
Newfoundland and Labrador and Alberta, Canada
A point-of-care (POC) HIV testing pilot program took place in two Canadian provinces, Newfoundland and Labrador and Alberta, to increase access to HIV testing and provide linkage to care. The program used pharmacists in four community pharmacies to provide HIV POC testing, including pre- and post-test counselling. Three-quarters of the people who were tested were at moderate to high risk for HIV and 27% were first-time testers. Pharmacies were found to be an acceptable venue for HIV POC testing by both pharmacists and clients; pharmacists felt prepared to provide testing and confident in doing so, and clients indicated that they felt comfortable receiving testing from pharmacists. Almost all clients (99%) who participated in a study of the pilot program indicated that HIV POC testing should be routinely offered in pharmacies.
Advisory committees were created in Alberta and Newfoundland to assist with the design of the pilot program. Committees consisted of a variety of stakeholders including public health officials, policy-makers, pharmacists, healthcare workers with experience providing care for people with HIV and individuals with lived experience.
The program provided free HIV POC testing using pharmacists in four community-based pharmacies in both urban and rural locations in Alberta and Newfoundland. The program was promoted through newspapers, social media (e.g., Grindr) and posters displayed in communities, as well as through organizations that serve populations that may be at risk for HIV. Clients could request an HIV POC test at one of the four sites by making an appointment or by visiting during scheduled drop-in testing hours.
At least one pharmacist at each pharmacy received training to participate in the program, which included training on consent and pre- and post-test counselling, as well as on how to administer the HIV POC test and interpret results. Pharmacists were provided with information on where to link clients if the HIV POC test was reactive, including support services in their area.
Participating pharmacies had a private room where clients and pharmacists met for testing and pre- and post-test counselling. The INSTI HIV-1/HIV-2 rapid antibody test (which requires a finger-prick blood sample) was used. Results were available within one minute; they were interpreted by the pharmacists and then shared with the client. Pharmacists completed pre- and post-test counselling, which included providing information on testing for other sexually transmitted and blood-borne infections.
If the test was reactive, the pharmacist provided the clients with a requisition for blood work to complete confirmatory tests, in addition to providing counselling and referral to additional supports. Confirmatory test results were sent to a designated physician or nurse practitioner, according to the linkage plan established in each province.
A study of the pilot program (i.e., the APPROACH study) looked at the feasibility and acceptability of a pharmacist-provided HIV POC testing program and used a mixed-methods design. The study took place between February and September 2017. Clients were asked to complete two questionnaires (i.e., one before and one after testing) and were also invited to take part in a telephone semi-structured interview about their testing experience. Pharmacists’ perspectives were obtained through focus groups where they were asked to share information about the training and supports provided, as well as their thoughts on the scalability and sustainability of the program.
A total of 123 tests were conducted (10% in rural communities), with one reactive test. The person with the reactive test was linked to confirmatory testing and then successfully linked with the provincial HIV program within 72 hours of the HIV POC test. Additionally:
- Pharmacists spent an average of 30 minutes completing the testing process, including pre- and post-test counselling.
- 27% of clients indicated that this was their first HIV test. Of these, 69% were at moderate to high risk of undiagnosed HIV infection.
- 75% of participants were at moderate to very high risk of HIV infection1 (47% self-identified as men who have sex with men, 7% had previously exchanged sex for money or drugs and 5% had a history of intravenous drug use).
Results from client questionnaires indicated that:
- clients felt comfortable getting tested at the pharmacy and had a high degree of confidence in the pharmacist’s ability to complete the test
- clients pursued pharmacy testing because of their ability to receive an immediate result and because testing took place in a private room
- 99% of clients indicated that HIV testing should be routinely offered through pharmacies
- 78% of clients indicated that they would pay for an HIV POC test at a pharmacy
Results from focus groups with pharmacists indicated that pharmacists felt that:
- the training provided prepared them well for the program
- a key element of the program was a clear linkage to care plan established by the advisory committee
- it would be important to have multiple pharmacists trained to perform the testing to increase accessibility
- lack of remuneration was a major challenge to the scale-up and sustainability of the program
- HIV POC testing was part of their professional role and identity
What does this mean for service providers?
Service providers should consider ways to move HIV POC testing into community locations where it might be possible for service providers to reach more people for testing and eliminate barriers experienced by potential testers (e.g., concerns over privacy and discretion). Pharmacies provide a way to normalize the testing experience in an environment that is familiar to people. Pharmacists who participated in this study indicated that providing HIV POC testing aligns with what they see as their professional role and identity.
Service providers looking to create a similar program should consider the workflow changes in the pharmacy required to implement it (e.g., support staff, documentation of results and follow- up plans). Consideration will also need to be given to the remuneration of pharmacists for providing the testing service, as well as the need to have adequate staffing so that a trained pharmacist can be available and provide greater flexibility for clients in terms of drop-in hours. Service providers should also ensure that an adequate linkage to care plan is in place for clients who have a reactive POC test. The quality assurance of the testing process and the standards of practice related to pharmacists’ ability to perform HIV POC testing in each province/territory should also be considered when developing a program.
Task-shifting in HIV testing services
Rapid point-of-care HIV testing: a review of the evidence
Kelly DV, Kielly J, Hughes C et al. Expanding access to HIV testing through Canadian community pharmacies: findings from the APPROACH study. BMC Public Health. 2020;20:639.
- HIV risk was based on the Denver HIV Risk Score using information gathered from the first participant questionnaire. A score of 30 points or higher indicated an increased risk of undiagnosed HIV and that someone should be offered routine HIV testing.