ASSESSMENT OF THE ROLE OF COMMUNITY PHARMACISTS IN MANAGEMENT OF HIV-POSITIVE INDIVIDUALS IN THE SOUTHERN REGION OF NIGERIA

Background: The long- recognized challenges to HIV care remained relevant as newer challenges emerge. Pharmacists’ role has evolved and expanded to help patients and other healthcare providers to achieve the core goals of HIV management. 
Objectives: this study assessed the role/services community pharmacists play/offer in the management of HIV patients in Rivers State, Southern region of Nigeria, and evaluated the perception of community pharmacists towards management of HIV infected patients. 
Method: A cross-sectional study was carried out among three hundred and seventy- four community pharmacist- owned pharmacies spread across Rivers State. Data were collected using pre-tested structured questionnaire. The structure comprises (1) demographic information (2) services offered to HIV infected patients (3) perception towards community pharmacists’ involvement in management of HIV. Data were analyzed with SPSS version 16 and statistical significance taken at p<0.05. 
Results: Out of 374 (100%) community pharmacist-owned pharmacies only 30 (8%) were involved in the management of HIV patients. 22(73.3%) were male and 8(26.7%) were female. While 23(76.7%) had B.Pharm degree; 2(6.7%) had Pharm D. 18(70%) had 11 – 20yrs practice experience as 7(23%) had over 20 yrs experience. 23(76.6%) had special HIV training program while 3(10%) self-acquired information on HIV. The Likert scale to measure perception is biased towards agreement, Likert scale 3.89, that community pharmacists are knowledgeable and well positioned to play role in the management of HIV infected patients. 
Conclusion: Very few 30(8%) of registered community pharmacists are involved in the management of HIV patients. Although the services offered cut across the guidelines for management of HIV infected patients, there is still need for improvement and regular update on HIV training for community pharmacists. These steps would help to involve more community pharmacists, decongest hospitals and reduce workload on hospital pharmacists. 
                    
Peer Review History: 
Received 23 January 2021; Revised 5 February; Accepted 26 February, Available online 15 March 2021 
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Received file:                Reviewer's Comments: 
Average Peer review marks at initial stage: 5.0/10 
Average Peer review marks at publication stage: 7.0/10 
Reviewer(s) detail: 
Prof. Dr. Hassan A.H. Al-Shamahy,  
Sana'a University, Yemen, shmahe@yemen.net.ye 
Dr. Bilge Ahsen KARA,  
Ankara Gazi Mustafa Kemal Hospital, Turkey, ahsndkyc@gmail.com 
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INTRODUCTION
While the long-recognized challenges to successful HIV care remained relevant (such as lack of early diagnosis, insufficient linkage and retention of care, poor adherence to antiretrovirals, stigma and perception, as well as disparities in accessing care for disadvantaged populations or socially marginalized, newer challenges to successful HIV care and prevention emerge, such as HIV in the elderly population, the application of new preventive methods such as pre-exposure prophylaxis, the optimal timing to start antiretroviral therapy (ART), and management of special groups of infected patients 1,2,3 . As the HIV epidemic evolves and new challenges to successful care and prevention emerge, healthcare providers, including pharmacists, are expanding their roles to ensure optimal patient care 4, 5 . Pharmacists have long been recognized as essential members of the HIV patient care team, and their involvement in managing HIV infected patients has been associated with improved outcomes. Pharmacists' activities such as helping the team in selecting individualized HIV treatment regimens, providing patient counseling, monitoring for treatment responses and adverse effects, evaluating regimens for potential drug-drug interactions, and identifying opportunities for regimen simplification, are associated with better viral load reduction and CD+ T-lymphocytes responses, improved ART adherence, simpler regimens, and reductions in medication errors 6,7,8,9,10 . To address these emerging challenges, pharmacists will need to apply their traditional expertise within an interdisciplinary healthcare framework in multiple practice settings (i.e. inpatient, community, and ambulatory care) as well as identify and establish new roles in evolving area of HIV care, including HIV testing and diagnosis, medication therapy management, transition of care, patient retention, acute HIV treatment, pre-exposure prophylaxis (PrEP) and initiation of ART in key populations such as those with acute opportunistic infections, hepatitis co-infections, and solid organ transplantation. In developing these roles, it's essential for pharmacists to remain highly engaged in the rapidly changing field of HIV using reliable resources such as https://aidsinfo.nih.gov; the US Department of Health and Human Services (US DHHS), HIV management guidelines, as well as other resources. Previous studies 11,12 support the potential role that pharmacists can play in improving HIV selfmanagement. In a meta analysis of 14 randomizedcontrolled trials investigating the effect of pharmacists' intervention in patients with HIV across a number of countries, significant and clinically relevant improvements in glycemic control were observed 13 . Pharmacists' interventions included nonpharmacological HIV education as well as pharmaco-logical interventions such as medication use counseling, (i.e. medication type and dosages). Traditionally, community pharmacists' services are accessed till extended working hours. This is particularly valuable in parts of the world where multidisciplinary HIV care team are not yet well established. HIV education and support professionals such as HIV nurses and educators are scare in sub Saharan African region. In recent years, pharmacists' roles have expanded from simply packaging and dispensing medications to working with other healthcare professionals and the public. The role of pharmacists in HIV management, including patient identification, assessment, education, referral, and monitoring, has been well established elsewhere in the world 14 . Given the ongoing evolution of HIV medicine, pharmacists must continue to evolve their roles as part of the healthcare team to identify and meet the future needs of HIV infected patients. This goal can be achieved through continuous assessment of the role of HIV pharmacists, the development and maintenance of HIV specialty pharmacist -training programs, and expert certification, and the continued collaboration with other healthcare providers, patients, activist groups, and professional HIV medicine and pharmacy organizations. Consequently, this study aimed to assess the role played/services provided by community pharmacists in management of patients with HIV and also evaluated their perception to managing HIV patients in Southern region of Nigeria.

Study area
The study was carried out in Port Harcourt, Rivers State. Port Harcourt is located in the South East of Nigeria, in the Niger delta region within the South-South geo-political Zone of Nigeria. Rivers State has been reported to have the highest HIV prevalence of all the 36 states in Nigeria. Within Port Harcourt there are two local government areas: Obio-Akpor and Port Harcourt City (Phalga). Three hundred and seventyfour (374) registered community pharmacies are spread across the two local government areas as at the time of the study. Sample size All the registered pharmacists practicing within the community pharmacy in the State were the target population. At the time of this study, all the community pharmacists were targeted for the study. Preliminary investigation showed that of the 374 registered community pharmacies in Rivers State (record from Rivers State Ministry of Health), only 30 registered and licensed pharmacist manage HIV infected patients in their pharmacy. This figure was also confirmed with a list obtained from the Association of Community Pharmacists of Nigeria (ACPN) Rivers Sate branch. Thus, a total of 30 community pharmacists were recruited into this study.

Study design/data collection
The study was a cross-sectional study using structured questionnaire to collect relevant data from the community pharmacists within the study area. The questionnaire was structured into three parts: demographic data; services offered by the pharmacist; and perception questions relating to the services. Demographic data section included: gender; year of practice; as well as educational qualification. The second part assessed services offered by the community pharmacist in the pharmacy, including medication refill, monitoring of patient's blood pressure and blood glucose level, education of patients on HIV disease, referral to laboratory for relevant tests, counseling on adherence to therapy, interpretation of test results, monitoring for adverse drug reaction, identification and referral for patients' failing therapy, referral for drug resistance testing, and assessment of potential drug interaction. The third part assessed community pharmacists' perception towards management of HIV patients in terms of knowledge base, position, and added value to both patient and the pharmacist. The Likert scale was used to analyze the perception of respondents towards HIV management. A total of 30 questionnaire were distributed and all retrieved Data analysis The data obtained were analyzed using statistical package for social sciences (SPSS) version 16, for both descriptive and inferential statistics. The statistical significance difference was taken at p<0.05. Chi square was used for comparative analysis.    Table 4, while Table 5 illustrated with Likert scale, values and group frequency on the subunit of the perception scale. The four perception questions represented with A, B, C, and D as shown in Table 4 indicates diverse scores on a Likert scale as shown in Table 5. It was observed that none of the respondents strongly disagreed with the general statement on perception of community pharmacists' knowledge and positioning to manage HIV infected patients. The general trend on the Likert scale is biased towards 4 (agree). The tail end of the Likert scale i.e. 1 (strongly disagree) and 2 (disagree) had the least scores generally.
H=Sum of frequency of community pharmacists' response on each four sub unit score, ranging from strongly disagree to strongly agree, of the Likert scale. I=The total sum of frequency of community pharmacists responding to a particular sub scale.       Figure 1. The result showed that all the respondents both male and female refill medications for the patients. But more female offered other services, such as documentation of patients' medication history, referral to tests, education on HIV prevention, and counseling on medication adherence, than the male. The result of effect of years of experience on the services offered to HIV infected patients by community pharmacists is given in Figure 2. Analysis of the results as shown in Table 6 and Table 7 indicate that there is no significant difference (p> 0.05) in the services offered by the various categories of community pharmacists with different years of practice experiences, as well as in gender difference. The overall services scores were classified as: (1)     The core goals of management remain maximal suppression of viral replication and promotion of immune reconstitution through combination antiretroviral therapy. Secondary goals of therapy include promoting long term adherence, avoidance of drug interaction, minimizing toxic effects of drugs, simplifying treatment regimens, decreasing drug costs, managing co-morbid conditions, and preventing transmission of HIV by achieving undetectable viral load 15,16 . Consequently, the pharmacist's role has evolved and expanded to help patients and other health care providers to achieve these goals. Pharmacists are recognized as established and integral members of HIV health care teams across Canada and United States 17 . Pharmacists' involvement in the care of HIV infected patients has been associated with improved patient outcomes, including enhanced adherence 6 , reduced pill burden, and dosing frequency, greater increases in CD4+ cell counts, higher rates of viral suppression 7,8 , and decreases in medication errors 9,10 . The current guideline points out pharmacists' role in many aspects of caring for patients with HIV/AIDS, including selecting and reviewing therapy, tailoring treatment for specific populations, counseling patients, monitoring response to therapy guiding transition of care, and undertaking scholarly and professional activities. In this study, all the respondents were involved in the refill of antiretroviral medications for the patients. Most, 28(93%), exhibited good knowledge on decision

AUTHOR'S CONTRIBUTION
This research work is part of the project done for a Pharm D program. The authors collected the data, revised and edited. The corresponding author designed and supervised work.