AS THE MOST ACCESSIBLE and trusted health care professionals in the United States, pharmacists can be an important resource for sexually transmitted disease (STD) prevention and control. Pharmacists and pharmacies are located in every type of community throughout the nation. The majority of the nation's 175,000 pharmacists practice in community pharmacy settings for extended hours every day. Approximately 23,000 independent and 18,000 chain community pharmacies exist throughout the United States. The profession of pharmacy is positioned well to make a meaningful contribution to STD prevention and control. The accessibility to the public, the large number of pharmacy locations and the trust shared between pharmacists and the public they serve, combine to afford a unique opportunity to reach millions of individuals with STD prevention and control messages and other strategies.
The Profession of Pharmacy
Historically, the professional functions of pharmacists primarily involved preparing the drug product and providing the product to the patient. Pharmacy education and practice has increasingly adopted a patient care orientation, beginning with what is referred to as "clinical pharmacy." This clinical emphasis has given pharmacists the knowledge base to interact with the patient and the prescriber to improve medication use. The term "pharmaceutical care" was coined in 1990 to describe a new approach by pharmacists toward patient care.1 Pharmaceutical care is a patient-centered, outcome-oriented pharmacy practice in which the pharmacist works in concert with the patient and with other healthcare providers to promote health, prevent disease, and assess, monitor, initiate, and modify medication use to assure that drug therapy regimens are safe and effective. The goal of pharmaceutical care is to optimize the patient's health-related quality of life and achieve positive clinical outcomes within realistic budgets.2 A growing number of pharmacists practice what can be considered as population-based pharmaceutical care, whereby subgroups of interest are identified, evidence-based methods are used to identify services to be provided, and delivery strategies rely on information systems and monitoring of outcomes.
As mentioned previously, there are approximately 175,000 licensed pharmacists in active practice. The number of pharmacists per 100,000 people was estimated at 64.4 in 1990. Pharmacy is practiced in a wide range of settings, including community pharmacies, hospitals, nursing homes, the pharmaceutical industry, managed care, and the government (such as in Veterans Affairs, the Department of Defense, Indian Health Service, and in the Public Health Service). The number of independently owned and operated pharmacies has decreased over the past 10 years. Chain pharmacies, food stores, and mass merchandisers with pharmacies have grown in prominence over the same period. However, in many busy community pharmacy practice settings, progress toward the provision of pharmaceutical care has been slow because of several barriers, including limitations in facility design, incomplete patient databases, retraining needs, staffing issues, and a reimbursement structure based upon distribution of products.3
Features of STD Prevention and Control Activities of Pharmacists
According to a 1997 report from the Institute of Medicine, STDs can be prevented by intervening at multiple points with behavioral, biomedical, and structural interventions on individual and community levels.4 As part of a proposed national system for STD prevention, the Institute of Medicine recommended four major strategies for the public and private sector:
- Overcome barriers to adoption of healthy sexual behaviors;
- Develop strong leadership, strengthen investment and improve information systems for STD prevention;
- Design and implement essential STD-related services in innovative ways for adolescents and under-served populations; and
- Ensure access to and quality of essential services for STDs.
The role of pharmacists in the prevention, screening, diagnosis, and treatment of STDs is presented within the context of all four strategies. To the extent possible, this report describes innovative activities involving pharmacists and pharmacies in services related to STDs other than HIV.5-7
Strategies Intended to Overcome Barriers to Adoption of Healthy Sexual Behaviors
Long-term prevention of STDs depends, in part, on the adoption of new social norms of healthy sexual behavior (such as delaying sexual intercourse and using condoms). Among the major barriers to healthy sexual behavior are a lack of awareness among the public and health care providers regarding STDs and the misperception of individual risk and consequences. Mass media messages and other public health programs regarding STDs and healthy sexual behavior are needed. For example:
- The 21st Annual National Condom Week, founded by a pharmacist, is an example of a mass media event designed to inform, alert, and educate the public about the use of condoms as an STD prevention strategy.
- Direct-to-consumer advertising of prescription drugs and over-the-counter products provides opportunities to encourage consumers to seek information from pharmacists.
- A mass media strategy involving pharmacies is sponsored by the manufacturer of an at-home HIV test service that is commercially available in more than 25,000 pharmacies nationwide. Home Access Health is sponsoring Miss America 1998 Kate Shindle in a year-long effort to educate the public, policymakers, and health care professionals (including pharmacists) about STDs with an emphasis on HIV and AIDS.
It is also important that pharmacists have the requisite knowledge and awareness of sexual health issues and are comfortable discussing them with patients. The curriculum within schools of pharmacy should teach students the information and skills necessary for effective patient care for STDs. Moreover, academic institutions, professional societies, and pharmaceutical manufacturers should collaborate to help pharmacy practitioners with continuing education programs in STDs. Some examples of innovative professional education programs in this regard are as follows:
- Each year the University of Washington offers a popular, clinically-oriented course designed to provide a knowledge base for pharmacy students and other health sciences students to participate effectively in community outreach programs for the prevention of STDs. It is offered cooperatively by the Schools of Pharmacy and Medicine. The majority of students in this course make presentations on STD-related topics in the community.
- Glaxo, Inc. (now Glaxo-Wellcome) offered virtually every practicing pharmacist a home-study continuing pharmacy education guide on HIV/AIDS during the early years of the epidemic. In the early 1990s, Burroughs Wellcome Co. (now Glaxo-Wellcome) joined with nine national health organizations to launch an initiative to encourage the prevention and treatment of STDs. In particular, this initiative emphasized the preparation and distribution of printed information (largely via pharmacies) to help consumers determine their risks of acquiring an STD, check for signs and symptoms, and reduce their chances of becoming infected or infecting others.
Development of Strong Leadership, Strengthening Investment, and Improving Information Systems for STD Prevention
Unfortunately, there has been a lack of visible and strong leadership at the national and state level specifically encouraging pharmacists to get involved in the provision of STD-related services. Recommendations from the Centers for Disease Control and Prevention (CDC) are not generally directed to pharmacists. However, recommendations from the CDC and other groups for the prevention, screening, and treatment of STDs are applicable to pharmacy practice. For example, recommendations exist on several topics relevant to pharmacy practice:
- Proper use of condoms and other barrier methods (CDC and the Food and Drug Administration). Consistent and appropriate use of latex condoms reduces the risk of many STDs. Moreover, use of other barrier methods is associated with a lower risk of certain STDs.
- Counseling to prevent sexually transmitted diseases (CDC, American Medical Association, United States Preventive Services Task Force). According to the United States Preventive Services Task Force Report, clinical counseling in the primary care setting can reduce specific STD risk behaviors.
- Treatment guidelines for STDs (CDC). Where effective drugs are available and used appropriately, there have been significant decreases in the rates of STDs (such as Neisseria gonorrhoeae and Chlamydia trachomatis). Pharmacists must be knowledgeable about how the epidemiology of STDs and newly marketed drugs change recommended therapy.
Although key elements of STD prevention and control are outlined in resources such as those noted above, pharmacists may not fully realize the potential benefits of these efforts. Pharmacists (just like other clinicians) encounter barriers to obtaining clinically important information: they lack the time necessary for keeping up-to-date, their textbooks and journals may be out of date or disorganized, and guidelines from the CDC and other relevant organizations may not even reach practicing pharmacists.
The most publicized public/private health care partnership concerning the pharmacist's role in STD prevention and control was launched in 1992 by the Foundation of Pharmacists & Corporate America for AIDS Education. With initial funding from CDC, pharmaceutical industry supporters and private foundations, FPCA launched the "Facts from Your Pharmacist: Answers About AIDS" Project to demonstrate the effectiveness of a community pharmacy-based HIV/AIDS program. The Foundation of Pharmacists & Corporate America for AIDS Education worked closely with public health agencies, professional pharmacy associations, schools of pharmacy, and other health organizations toward the establishment of a national demonstration project in Alabama to test the effectiveness of a community pharmacy-based HIV/AIDS education prevention and treatment program. Despite the existence of a strong board of directors and initial funding from CDC and other organizations, the Foundation of Pharmacists & Corporate America for AIDS Education and its efforts disappeared a few years ago. Certain elements that were supposed to be components of this failed demonstration effort were developed and are accessible, including the results of a survey of Alabama pharmacists' willingness to assume the distribution of STD information resources, pharmacist continuing education training material, and in-pharmacy educational material in their community.
As pharmacists continue to expand their practice toward patient- and population-centered health activities, it is important for professional associations and other agencies and organizations to provide more leadership for STD-related services provided by pharmacists. Moreover, it is important for federal agencies and private foundations to support research to advance the scientific basis for the expansion of pharmaceutical care services into STD prevention and control. The Agency for Health Care Policy and Research's Pharmaceutical Outcomes Research Initiative is an example of a program which successfully involved the private and public sector in developing and supporting a cohesive research agenda pertaining to the effectiveness of pharmaceuticals and pharmaceutical care.
Pharmacists can also assist in improving surveillance for STDs by monitoring the epidemiology of STDs and the management and effectiveness of programs. For example, automated pharmacy records have the potential to provide data to determine trends in the use of therapies for STDs and their sequelae. Assuming that privacy concerns can be addressed, data from pharmacies should be examined to determine its utility in improving community-based STD surveillance systems. On an individual patient level, pharmacists can use patient medication profiles to assist in counseling women to use methods for STD prevention when using oral contraceptives, for example. Also, pharmacist counseling can help reduce the occurrence of misdiagnoses when women self-treat with over-the-counter medications. According to a recent survey, 70% of women self-treat vaginal infections with over-the-counter medications before seeking medical attention.
Design and Implementation of Essential STD-related Services for Adolescents and the Under-served
The location of pharmacies in under-served areas and the anonymity they afford to adolescents makes them useful for providing essential STD prevention and control services. Also, pharmacists have recently begun providing immunization services in the context of CDC-recommended immunization schedules. The administration of hepatitis B vaccinations by pharmacists is one approach in providing STD prevention services to adolescents.
Access to and Quality of Essential Services for STDs
Listed below are some examples of pharmacist-based services related to STD prevention and control.
- With the passage of the Omnibus Budget Reconciliation Act of 1990 (OBRA-90), pharmacists' patient counseling is mandatory for Medicaid patients.
- Needle exchange programs have been established at the state and local level to prevent the transmission of HIV and hepatitis B. Pharmacists have participated in some syringe exchange programs.
- Pharmacy-based syndromic protocols for STD counseling and treatment have been developed by Program for Appropriate Technology in Health (PATH) and are being tested in developing countries.
- Washington State pharmacists are the first in the country to dispense birth control pills under protocol without a doctor's prescription for emergency contraception use. The project, funded by the David and Lucile Packard Foundation, is a collaboration among PATH, the Washington State Pharmacists Association, the University of Washington Department of Pharmacy, the Washington State Board of Pharmacy, and Elgin DDB. The program includes pharmacist-provided services directed at STD prevention.
The profession of pharmacy is recognizing that its future rests on managing the rational and appropriate use of medications as well as upon other patient-focused and population-based services.8 The access that communities have to pharmacists and the high esteem in which pharmacists are held are important reasons to incorporate STD prevention and control into pharmacy's infrastructure and professional capabilities. Barriers that need to be addressed include the need for improved training and education of pharmacists in STD prevention and control, consideration of a reimbursement system that is not entirely based upon distribution of products, and the need to expand the scientific basis for these roles through applied research. The numerous innovative activities involving pharmacists and pharmacies in STD-related services suggest an expanded role for pharmacy.
1. American Pharmaceutical Association. Principles of Practice for Pharmaceutical Care, Washington, DC, 1995.
2. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990; 47:533-543.
3. Pew Health Professions Commission. Health Professions Education for the Future: Schools in Service to the Nation. San Francisco, CA, 1993.
4. Institute of Medicine. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Institute of Medicine: Washington, DC, 1997.
5. Binkley D, Waller L, Potts L, et al. Pharmacists as HIV/AIDS information resources: survey of Alabama pharmacists. AIDS Educ Prev 1995; 7:455-466.
6. Cockerill RW, Meyers T, Worthington C, et al. Pharmacies and their role in the prevention of HIV/AIDS. J Soc Admin Pharm
7. Pick S, Reyes J, Alvarez M, et al. AIDS prevention training for pharmacy workers in Mexico City. AIDS Care 1996; 8:55-69.
8. Pew Health Professions Commission. Critical Challenges: Revitalizing the Health Professions for the Twenty-First Century. San Francisco, CA, 1996.