Patient-centered community pharmacy-based HIV care model
Dr. Marc Fleming, PhD, MPH, RPh
Associate Professor and Chair, Department of Pharmacotherapy
UNT, System College of Pharmacy
Despite being only 12% of the US population, African-Americans (AA) represent 45% of all persons with HIV. Although evidence that >90% of all persons with HIV can achieve virologic suppression, only 28% of AA are (lowest of all reported races). This disparity is not fully explained by socioeconomic factors. Moreover, within HIV populations AA have both higher rates and poorer control of both diabetes and hypertension (all p<0.001). Recent evidence demonstrates even within HIV populations, AA have significantly (p<0.001) fewer years of productive life than whites. This disparity can be eliminated.
In 2003, community pharmacist-provided comprehensive medication therapy management (CMTM) became a standard of care for all Medicare Part D patients (CFR 423.153(d), www.cms.gov). CMTM is substantially more than patient counseling. In CMTM, pharmacists conduct visits with patients to provide individualized, patient-centered services addressing known domains and levels influencing health disparities in urban AA. Pharmacists, using the patient’s language of choice (limited English) in the community pharmacy (stigma, availability of health services) or via telephone (mobility) educate on diagnoses and medications (health literacy), assess patient understanding (medical decision making) of medical provider’s treatment plan (patient-clinician relationship) while optimizing medications (individual health outcome), adherence (adherence) and provide medication acquisition assistance (insurance coverage). A decade of evidence supports pharmacists delivering CMTM results in improved control of diabetes and hypertension. Populations include complex patients (> 3 medical conditions and > 6 medications and AA. Could CMTM work for AA with HIV?
In 2013, the CDC, in a novel public-private partnership with Walgreens, funded the University of North Texas Health Science Center (UNTHSC, Clay, PI) to conduct a multi-year, nationwide, patient-centered, community pharmacy-based, CMTM demonstration/pilot project in HIV patients (HIV-CMTM). The innovation of HIV-CMTM compared to CMTM was pharmacists obtained subjects’ medical information quarterly. This ongoing project enrolled 796 (49% AA) adults with HIV to receive HIV-CMTM quarterly. Preliminary analyses (of available subjects) suggest improved outcomes in the 201 AA with HIV (85% achieved virologic suppression or (in those entering with virologic suppression) their CD4 count rising above 200 cells/mcL) and diabetes (slight mean A1c decrease with marked variance (SD) improvement implying greater control: 6.91 + 4.78 vs. 6.76 + 2.34). Data permitting analysis of blood pressure control in hypertensives is unavailable. While encouraging, demonstration projects lack scientific rigor or statistical power to prove a cause-effect relationships, halting implementation. We propose to study HIV-CMTM in a prospective, randomized (1:1 HIV-CMTM: standard of care), clinical trial, comparing disease-specific clinical and humanistic outcomes in 200 adult African-Americans with HIV (1:1 men: women) and either diabetes and/or hypertension. The long-term goal is to verify HIV-CMTM as an effective, feasible, sustainable, acceptable, community-based healthcare service that reduces health outcome disparities. Our objective is to demonstrate that HIV-CMTM improves control of HIV, diabetes and/or hypertension (Aim 1), reduces identified causes of health disparities (Aim 2), and determine factors that may affect the acceptance and success of HIV-CMTM (Aim 3) in an AA cohort. The hypothesis of this project is HIV-CMTM improves HIV, diabetes and hypertension control in adult AA with HIV.
SHE Tribe: An intervention to improve health behavior among women in underserved communities
Dr. Emily Spence, Project Lead
The Texas Center for Health Disparities received NIMHD funding to address women’s chronic health conditions through community outreach and research strategies from 2012-2017. A workgroup of community members, former research and program participants, and UNTHSC faculty and staff utilized a Community-Based Participatory Research (CBPR) process to design SHE Tribe (She’s Healthy and Empowered), a social-network based initiative to support healthy behavior adoption among women in underserved communities. This effort was based on our earlier finding that women in underserved neighborhoods were often resistant to participating in a “disease-labeled” intervention (e.g., obesity prevention) and expressed a desire to practice wellness-oriented behaviors that have been adapted for their social and cultural groups. These findings were consistent with the growing body of literature indicating that being “healthy and strong” is perceived as more desirable than engaging in a program where the explicit expectation is to lose weight. As part of the development process, the workgroup sought to develop a sustainable, evidence-based approach that would appeal to underserved communities that are disproportionately impacted by chronic disease.
SUPPORTED BY THE 5U54MD006882-09 NIMHD GRANT