Evaluation of Pharmacy-Based HIV Testing in a High-Risk New York City Community

Abstract

Blacks/Hispanics face limited access to HIV testing. We examined in-pharmacy HIV testing among customers in pharmacies participating in a nonprescription syringe program in New York City. Participants were recruited in two pharmacies to complete a survey and receive an optional HIV test. Bivariate and multivariable analyses were performed to examine associations of demographics and risk behaviors with receiving in-pharmacy HIV testing. Most participants were male (55%), black (80%), had used hard drugs (88%), and 39.5% received in-pharmacy HIV testing. Being female (AOR=2.24; 95%CI 1.24–4.05), having multiple sex partners (AOR=1.20; 95% CI 1.06–1.35), having an HIV test more than 12 months ago (AOS=4.06; CI 1.85–8.91), injecting drugs in last 3 months (AOR=2.73; 95% CI 1.31–5.69) and having continuous care (AOR=0.32; 95% CI 0.17–0.58) were associated with receiving in-pharmacy HIV test. These data provide evidence of in-pharmacy HIV testing reaching persons at risk of HIV. HIV testing in pharmacies may complement existing strategies.

Introduction

In 2013, 1.14 million people 13 years and older were estimated to be living with HIV in the United States (US);¹ however, 15.8%, or 1 in 6 of them were unaware of their HIV infection¹ and may be unknowingly transmitting HIV.^2
–4 Current Centers for Disease Control and Prevention (CDC) recommendations for HIV testing advocate routine, voluntary HIV testing of at-risk persons at least annually to identify and diagnose unrecognized infection.⁵ Routine HIV testing is one of the main prevention strategies; testing allows health care providers to identify and link HIV-infected persons to care early and reduce the likelihood of continued transmission.^6
–8

New York City (NYC) has one of the highest rates of new HIV diagnosis in the US, with 1.4% of the population in NYC living with HIV/AIDS.^9,10 In NYC, HIV racial/ethnic disparities persisted in 2012: blacks and Hispanics in NYC accounted for about 80% of the new HIV/AIDS cases.¹⁰ Also, HIV disparities have been observed by geography and poverty level in NYC.¹⁰ In addition, blacks and Hispanics with HIV had poorer survival rates. Studies suggest that impoverished black and Hispanic communities face multiple barriers when accessing care.¹⁰

In 2001, New York State (NYS) legalized nonprescription syringe sales in pharmacies through the Expanded Syringe Access Program (ESAP) with the aim of curbing transmission of HIV and other blood-borne infections among injection drug users (IDUs).^11,12 Thus, ESAP pharmacies are committed to providing prevention services, are public health minded, and have become accustomed to discussing HIV prevention and testing with vulnerable, difficult to access populations such as IDUs.^13,14

Research has shown that pharmacists can successfully provide health counseling and vaccination services to all pharmacy customers,^15
–17 and are supportive of providing expanded pharmacy-based HIV services, such as HIV medication adherence services^18

–21 to all pharmacy customers. In-pharmacy HIV testing may be a feasible strategy to promote routine HIV testing and efficiently reach at-risk populations, consistent with the goals of the United States National HIV/AIDS Strategy.^19
–21 ESAP pharmacies may be ideal venues for HIV testing and prevention services in high risk communities that may have limited access to HIV testing services.^{14

–22} Using the ESAP infrastructure, pharmacies could be excellent venues where HIV prevention could reach vulnerable communities at high risk for HIV who generally have a long history of poor access to healthcare.

We explored the impact of expanding public health prevention services in ESAP pharmacies by offering pharmacy-based HIV testing. In this article, we report the findings of this pharmacy-based HIV testing study implemented in ESAP-registered pharmacies in two high-risk NYC neighborhoods: East Harlem and Central Harlem. Both neighborhoods have high prevalence of HIV infections and are among the highest rates of new HIV diagnoses in NYC.^23,24 They also have a large proportion of black and Hispanic residents, high rates of poverty, limited access to health resources, and several ESAP-registered pharmacy locations.^23
–25 This study assessed the provision of pharmacy-based HIV testing to pharmacy customers in ESAP-registered pharmacies located in high-risk neighborhoods. This evaluation provides the foundation to study a more expansive range of pharmacy-based preventive care services (e.g., cholesterol testing, HIV testing in other types of pharmacies), which may reduce racial/ethnic health disparities by reaching high-risk, marginalized populations who have a history of limited access to healthcare.

Methods

Study design

Data for the present analysis were drawn from the Pharmacies as Resources Making Links to HIV testing (PHARM-HIV) study, a cross-sectional study among customers in ESAP pharmacies in Harlem, NYC. The study was conducted from June 2010 to August 2011. The overall goal of the study was to assess the feasibility of expanding pharmacy services to include the provision of HIV testing referrals and services.

Pharmacy enrollment

The study was conducted in East and Central Harlem. The neighborhoods were selected based on our previous work in high HIV risk communities.²⁶ Pharmacy eligibility criteria included: (1) having an up-to-date ESAP registration; (2) selling syringes without additional requirements (i.e., asking for identification); (3) having at least one regular ESAP customer per month; and (4) having at least one new ESAP customer per month become a regular customer. Although we recruited all pharmacy customers, IDU or not, this criteria ensured that the ESAP pharmacy was truly committed to the ESAP program and to HIV prevention, and allowed the study to reach and recruit IDUs.

We present results from the two pharmacies that offered in-pharmacy HIV testing services. The study was approved by the institutional review boards of Columbia University Medical Center, the New York Academy of Medicine, and the Centers for Disease Control and Prevention.

Participant enrollment

During pharmacy sales, pharmacy staff discretely informed customers that the pharmacy was participating in a study of pharmacy-based HIV testing. Customers were informed that undergoing an HIV test was not required to take part in the study. Customers who expressed interest were scheduled for an appointment. Two research staff maintained on-site pharmacy hours 3 days per week, and customers were typically scheduled for an appointment within 1–5 days of making contact with the pharmacy staff member. Customers were also informed about the study through pamphlets and word of mouth. Customers age ≥18 years were eligible to participate.

After providing informed consent, study participants completed a 20-min audio computer-assisted self-interview (ACASI) about demographics, risk behaviors, and their attitudes regarding expanding HIV services in pharmacies, and were then offered rapid HIV testing. Survey administration and HIV testing and counseling were performed in a private area created by installing partitions in a section of the pharmacy away from customer traffic. To further enhance privacy, interviews were completed on computers with privacy screens and headsets. Study participants were given $15 for their time and effort.

In-pharmacy HIV testing

HIV testing was performed using the OraQuick™ ADVANCE^® HIV-1/2 Antibody Test on oral fluid. If a participant tested preliminarily positive, or had an indeterminate test, blood was collected by phlebotomy and sent to a laboratory for confirmatory HIV testing by Western blot. Participants with positive test results were given an appointment within 1 week to follow-up on confirmatory test results and to be linked to care.

Measures

The dependent variable was defined as in-pharmacy HIV testing (yes, no). Independent variables assessed as correlates of in-pharmacy HIV testing included sociodemographic characteristics, sexual and drug risk behaviors, HIV testing behaviors, and health care access and utilization.

Sociodemographic factors assessed included age (continuous), race/ethnicity (black, Latino, white/other), sex (male, female), location of birth (continental United States, Puerto Rico/outside of continental United States), marital status (yes, no), education (lower than high school, high school/GED graduate or more), income (up to or equal to $5000/year, over $5000/year), income from paid work in the past 3 months (yes, no), illicit income (income from selling drugs, robbing, stealing, or conning), exchanging sex for money in the past 3 months (yes, no), and homelessness in the past 3 months (yes, no).

Sexual behaviors included number of sex partners in the past 3 months (continuous), and condom use (100% condom use, less than perfect condom use) in the last 30 days.

Drug risk behaviors included ever using hard drugs (crack, cocaine, non-injection heroin), current hard drugs use (yes, no), and injecting drugs in the last 3 months (yes, no). Moreover, we assessed injection frequency (less than daily, daily), injected in the past month (yes, no), and receptive syringe sharing (yes, no) among those that injected in the last 3 months.

HIV testing behaviors assessed included lifetime history of HIV testing (yes, no) and last tested for HIV (12 months ago or less, more than 12 months ago).

The health care access variables included were continuity of care, defined as seeing the same doctor, nurse, or physician's assistant more than 90% of all clinical visits (yes, no), and having health insurance (yes, no).

Statistical analysis

We undertook a descriptive analysis to characterize the analytic sample as well as each of the independent variables. Then we examined the bivariable associations between the independent variables and whether customers underwent in-pharmacy HIV testing. We used chi-square test of independence and Fisher's exact test for the categorical variables and independent samples t-test for the continuous variables. Given the non-normal distribution of the number of sex partners, we examined the bivariable association between this variable and the main outcome using Wilcoxon-Mann-Whitney test. Binary logistic regression models were examined to determine the extent to which the independent variables explained the likelihood of undergoing in-pharmacy HIV testing. Independent variables with a significance level ≤0.10 in the bivariate analyses were included in the regression analysis. We used a stepwise approach for variable selection in the regression analysis. Finally, customers characteristics were considered significant in the regression analysis at a significance level <0.05. All analyses were conducted in STATA 12.1.²⁷

Results

A total of 332 participants were enrolled to participate in the study at the two pharmacies that offered in-pharmacy HIV testing services. Ninety-six of those reported being HIV positive; those participants were excluded from this analysis. Two participants that reported being transgender or transsexual also were excluded from the analysis. Moreover, another participant was excluded due to missed data on the main outcome, in-pharmacy HIV testing. Thus, the analytic sample for the ensuing analysis consisted of 233 customers in ESAP pharmacies.

Sociodemographic characteristics

Table 1 summarizes the sociodemographic characteristics of the analytic sample and the distribution of the independent variables. The sample consisted of predominantly racial/ethnic minorities. Most participants were male, US born, not married, and reported an educational attainment of high school/GED or higher. The vast majority of participants reported an income over $5000; however, most did not receive income from paid work or from illicit activities in the last 3 months. About 20% of the sample was homeless.

Table 1.

Sociodemographic Characteristics, Sexual and Drug Risk Behaviors, HIV Testing Behaviors, and Health Care Access and Utilization, New York City, 2010–2011

	Analytic sample (n=233) No. %
Sociodemographic characteristics
Age, mean years (SD)	51.0 (8.7)
Race/ethnicity
Hispanic	30 (13.1)
Black	183 (79.9)
White/other	16 (7.0)
Sex
Male	128 (54.9)
Female	105 (45.1)
Location of birth
Continental United States	221 (94.9)
Puerto Rico/outside continental United States	12 (5.1)
Married
No	201 (86.3)
Yes	32 (13.7)
High school/GED graduate
No	76 (32.6)
Yes	157 (67.4)
Income, legal and/or off-books
Up to $5,000	71 (30.6)
Over $5,000	161 (69.4)
Income from paid work in the last 3 months
No	165 (70.8)
Yes	68 (29.2)
Illicit income in the last 3 months^a
No	209 (90.1)
Yes	23 (9.9)
Homelessness the last 3 months
No	185 (79.4)
Yes	48 (20.6)
Exchanging sex for money in the last 3 months
No	217 (93.1)
Yes	16 (6.9)
Sexual and drug risk behaviors
Number of sex partners in the last 3 months, median (SD)	1 (3.8)
Condom use^b
100% condom use	80 (44.7)
Less than perfect condom use	99 (55.3)
Ever use hard drugs or club drugs^c
No	27 (11.6)
Yes	206 (88.4)
Current hard drug or club drug user
No	103 (44.2)
Yes	130 (55.8)
Injected drugs in the last 3 months
No	190 (81.6)
Yes	43 (18.4)
HIV testing behaviors
Ever tested for HIV
No	11 (4.7)
Yes	222 (95.3)
Last time tested negative for HIV^d
Less than 12 months ago	178 (81.6)
Twelve months ago or more	40 (18.4)
Health care access and utilization
Continuous care^e
No	53 (22.9)
Yes	178 (77.1)
Health insurance in the last 3 months
No	16 (6.9)
Yes	217 (93.1)

Illicit income was defined in the survey as income from illegal activities (e.g., selling rugs, robbing, stealing, or conning). ^bOnly among those having anal or vaginal intercourse.

Hard or club drugs were defined as illicit, recreational substances such as crack, cocaine, and non-injection heroin. ^dAmong those ever tested for HIV. ^eContinuous care was defined as seeing the same doctor, nurse, or physicians' assistant during more than 90% of all clinical visits.

SD, standard deviation.

Sexual and drug risk behaviors

Among participants that reported having anal or vaginal intercourse in the previous 30 days, 55.3% reported less than perfect condom use. Most participants reported having 1 partner in the last 3 months and 10.3% reported sexual behaviors with a person of the same sex in the last 30 days.

While 18.5% of the participants were active IDUs, 88.4% of the sample had a history of hard drug use and 55.8% reported currently using hard drugs without injecting them.

HIV testing behaviors

The majority of participants reported being tested for HIV at least once in their lifetime. Most of those had an HIV test within the previous year.

Health care access and utilization

Most participants had health insurance. In addition, 77.06% reported seeing the same health care provider more than 90% of the times when they go for medical care

Correlates of in-pharmacy HIV testing

Almost 40% of the sample underwent in-pharmacy HIV testing. Table 2 summarizes the bivariate associations between the independent variables and whether participants underwent in-pharmacy HIV testing.

Table 2.

Sociodemographic Characteristics, Sexual and Drug Risk Behaviors, and Health Care Access and Utilization of In-Pharmacy HIV Testing, New York City, 2010–2011

	Declined HIV testing N=141 No. (%)	Accepted HIV testing N=92 No. (%)	p Value
Sociodemographic characteristics
Age, mean years (SD)	51.7 (8.1)	49.9 (9.6)	0.11
Race/ethnicity
Hispanic	15 (50.0)	15 (50.0)	0.25
Black	116 (63.4)	67 (36.6)
Other	8 (50.0)	8 (50.0)
Sex
Male	86 (67.2)	42 (32.8)	0.02
Female	55 (52.4)	50 (47.6)
Location of birth
Continental United States	132 (59.7)	89 (40.3)	0.37
Puerto Rico/outside of continental United States	9 (75.0)	3 (25.0)
Married
No	17 (53.1)	15 (47.0)	0.36
Yes	124 (61.7)	77 (38.3)
High school/GED graduate
No	38 (50.0)	38 (50.0)	0.02
Yes	103 (65.6)	54 (34.4)
Income, legal and/or off-books
Up to $5000	46 (64.8)	25 (35.2)	0.41
Over $5000	95 (59.0)	66 (41.0)
Income from paid work in the last 3 months
No	106 (64.2)	59 (35.8)	0.07
Yes	35 (51.5)	33 (48.5)
Illicit income in the last 3 months^a
No	130 (62.2)	79 (37.8)	0.18
Yes	11 (47.8)	12 (52.2)
Homelessness in the last 3 months
No	116 (62.7)	69 (37.3)	0.18
Yes	25 (52.1)	23 (47.9)
Exchanging sex for money in the last 3 months
No	134 (61.8)	83 (38.3)	0.16
Yes	7 (43.8)	9 (56.3)
Sexual and drug risk behaviors
Number of sex partners in the last 3 months, median (SD)	1 (4.3)	1 (3.0)	0.19
Condom use^b
100% condom use	50 (62.5)	30 (37.5)	0.595
Less than perfect condom use	58 (58.6)	41 (41.4)
Ever use hard drugs or club drugs^c
No	17 (63)	10 (37.0)	0.78
Yes	124 (60.2)	82 (39.8)
Current hard drug or club drug user
No	69 (67)	34 (33.0)	0.07
Yes	72 (55.4)	58 (44.6)
Injected drugs in the last 3 months
No	122 (64.2)	68 (35.8)	0.02
Yes	19 (44.2)	24 (55.8)
HIV testing behaviors
Ever tested for HIV
No	5 (45.5)	6 (54.6)	0.29
Yes	136 (61.3)	86 (38.8)
Last time tested negative for HIV
Less than 12 months ago	118 (66.3)	60 (33.7)	<0.001
Twelve months ago or more	14 (35.0)	26 (65.0)
Health care access and utilization
Continuous care^d
No	23 (43.4)	30 (56.6)	0.004
Yes	116 (65.2)	62 (34.8)
Health insurance in the last 3 months
No	7 (43.8)	9 (56.3)	0.16
Yes	134 (61.8)	83 (38.3)

Illicit income was defined in the survey as income from illegal activities (e.g., selling drugs, robbing, stealing, or conning). ^bOnly among those having anal or vaginal intercourse. ^cHard or club drugs were defined as illicit, recreational substances such as crack, cocaine, and non-injection heroin. ^dContinuous care was defined as seeing the same doctor, nurse, or physicians' assistant during more than 90% of all clinical visits.

SD, standard deviation.

Participants who underwent in-pharmacy HIV testing were more likely to be female and have a less than high school education. Those that received income from paid work in the last 3 months were also more likely to undergo in-pharmacy HIV testing. Participants who injected drugs in the last 3 months, those who were currently using hard and/or club drugs, and those who lack continuous medical care were more likely to undergo in-pharmacy HIV testing. In addition, participants who last tested for HIV 12 months ago or more were more likely to undergo in-pharmacy HIV testing.

In regard to those participants that injected drugs in the last 3 months, 55.8% underwent in-pharmacy HIV testing. From those who underwent in-pharmacy HIV testing and injected drugs in the last 3 months, 79.2% injected in the last 30 days and 33.3% were daily injectors. Moreover, three participants were injectors and never tested before for HIV, all of them underwent in-pharmacy HIV testing in the study.

Binary logistic regression models of in-pharmacy HIV testing

Table 3 depicts the results of the logistic regression model exploring the extent to which the independent variables explained the likelihood of accepting in-pharmacy HIV testing. Controlling for other variables, female participants, participants with a higher number of sex partners, and those who injected drugs were more likely to undergo in-pharmacy HIV testing. In addition, those who last tested for HIV 12 months ago or more were more that 4 times more likely to undergo in-pharmacy HIV testing. Those having continuity of care were less likely to undergo in-pharmacy HIV testing. The final model approached significance (LR χ² (6)=43.6, p<0.001).

Table 3.

Multivariable Associations on In-Pharmacy HIV Testing, New York City, 2010–2011

	COR (95% CI)	AOR (95% CI)
Sex
Female	1.9 (1.1, 3.2)^*	2.4 (1.3, 4.5)^*
High school/GED graduate
Yes	0.5 (0.3, 0.9)^*	0.6 (0.3, 1.1)
Number of sex partners in the last 3 month	1.0 (0.9, 1.1)	1.21(1.1, 1.4)^*
Injected in the last 3 months
Yes	2.3 (1.2, 4.4)^*	2.6 (1.2, 5.7)^*
Last time tested negative for HIV
Twelve months ago or more	3.7 (1.8, 7.5)^*	4.1 (1.9, 8.9)^*
Continuous care^a
Yes	0.4 (0.2, 0.8)^*	0.3 (0.2, 0.6)^*

Continuous care was defined as seeing the same doctor, nurse, or physicians' assistant during more than 90% of all clinical visits.

AOR, Adjusted Odd Ratio; CI, Confidence Interval; COR, Crude Odd Ratio.

p<0.05.

Discussion

In-pharmacy HIV testing was feasible in two pharmacies located in communities with drug activity and high prevalence of HIV. More than a third (39.6%) of the total HIV-negative sample received in-pharmacy HIV testing. The ability to provide in-pharmacy HIV testing in this study may be linked to the high support of in-pharmacy HIV testing among pharmacy staff.^{14

–21,28} Previous research has indicated that pharmacists and other pharmacy personnel routinely engaged in conversations with syringe customers about health counseling and the importance of HIV testing,^16,19 suggesting that pharmacy staff may be comfortable talking with pharmacy customers about HIV and health-related topics. Thus, pharmacies are valuable partners in health promotion efforts.

We found that women were more likely to undergo in-pharmacy HIV testing than men. Previous studies support that women are more likely to test for reasons related to family and significant others, and because they receive greater social support.^29
–31 We also found that persons who tested in the pharmacy were more likely to be sexually active with multiple partners, had not tested recently for HIV (<12 months prior to study), and had injected drugs in the prior 3 months. These findings suggest that persons at higher risk for HIV infection may utilize in-pharmacy HIV testing services, underscoring the importance of access to confidential and convenient HIV testing in these settings.³² Furthermore, when a person believes he or she may have been exposed to HIV through risk behaviors, pharmacies may provide quick access to HIV testing and facilitated referral for urgent HIV prevention methods such as non-occupational post-exposure prophylaxis (nPEP).³³

Lack of continuity of care was independently predictive of receiving in-pharmacy HIV testing among our sample. Persons who visit the same provider may have a more trusting relationship with their provider, the provider may feel more comfortable discussing risk factors and recommending HIV testing, and patients in turn may feel that they can go to their provider for HIV testing and to discuss risks at any time.³⁴ Studies have demonstrated that having both insurance and a usual source of care is associated with the receipt of preventive services, and with HIV testing.^35

–38 A provider's recommendation to test for HIV is one of the most important factors in receiving an HIV test.³² However, for myriad of reasons, including discomfort discussing sexual health, providers may be missing opportunities to offer HIV testing.^37,38

The percentage of persons who underwent in-pharmacy testing in our study (39.6%) was within the range reported by HIV testing programs in emergency departments of 25–87%.^39,40 When testing is provided free by health departments, CBOs in affiliated community clinics, and in non-clinical settings, HIV testing rates vary from 24% to 60% depending on the venue,^41

–45 comparable to our results. Most of these non-clinic-based programs targeted individuals at risk for HIV, potentially reaching a population with less access to healthcare than that reached by clinic-based programs. Pharmacy-based testing provides an alternative to testing in healthcare settings by offering targeted, rapid HIV testing for people at high risk of HIV infection

This study demonstrated that in-pharmacy HIV testing was utilized by pharmacy customers in two NYC communities with high prevalence of HIV infection. Pharmacies may be an accessible health resource for HIV testing for hard-to-reach populations facing multiple personal and structural barriers to establishing continuous healthcare access. The need for creative HIV prevention strategies in high-risk communities, and the feasibility and cost-effectiveness of pharmacies contributing to such strategies, should be explored. HIV testing and early HIV diagnosis may help facilitate earlier access to HIV treatment that would prolong life, preserve health, prevent ongoing HIV transmission, and help decrease HIV-related racial/ethnic health disparities. Next steps should include research that identifies individual and structural barriers and facilitators of in-pharmacy HIV testing that can directly inform HIV testing programs for all customers at pharmacies.

Limitations

Our findings must be viewed within the context of the limitations of our study. The data were drawn from a convenience sample; therefore, the findings are not representative of all ESAP registered pharmacy customers in NYS and are not generalizable to other ESAP customers. Selection bias was possible, as study participation may have been more common among persons who had positive attitudes and opinions regarding expanded pharmacy services, including HIV testing. Having the proper infrastructure to guarantee privacy and confidentiality may limit the number of pharmacies that could provide in-pharmacy HIV testing.

In our study, we initially assessed the availability of potential private space in our study pharmacies. Survey administration and HIV testing and counseling were performed in the pharmacy private area, which was a section of the pharmacy away from customer traffic. This privacy area was enhanced by installing partitions, and interviews were completed on computers with screens with privacy devices and headsets. We have conducted other studies where in-pharmacy HIV testing has been done;⁴⁶ we have dealt with privacy and confidentiality issues in a similar manner.

With limitations acknowledged, this study has some important strengths. This study presents evidence for a potential venue for HIV testing that could provide access for hard-to-reach populations that have limited access to HIV testing. Also, the approach we used was feasible to pharmacists.¹³ Given that pharmacies are located virtually everywhere in NYC, have flexible hours of operation, and have access to new point-of-care and home-based HIV testing technologies, the provision of HIV testing in pharmacies could provide a quick, easy, and accessible point of access for IDUs, as well as other populations.

Footnotes

Acknowledgments

The authors thank study participants and the PHARM-HIV research staff.

Funding: Centers for Disease Control and Prevention, Minority HIV/AIDS Research Initiative (MARI)– (3U01PS000698), 2007–12.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Author Disclosure Statement

We disclose that there are no potential conflicts of interest or financial interests.

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