In our assessment of the feasibility and pharmacists’ acceptance of a pilot HCV screening service in community pharmacies, 25 Swiss community pharmacies addressed 435 clients, of which 145 (33%) were interested in having a screening performed.
Having 8 of 145 screenings return positive test results, as reported back to the study group, amounts to a positivity rate, or prevalence, of 5.5%. Given an estimated HCV prevalence of 0.5% for the general Swiss population [11], addressing vulnerable persons in community pharmacies appears to have been purposeful. Our results are comparable to the dry blood spot testing service in community pharmacies on the Isle of Wight, which identified 13 new patients with HCV in 186 performed tests (7.0%) [21]. Radley and colleagues conducted a quantitative service evaluation to assess feasibility and scalability of dried blood spot testing for HCV comparable to ours. Of 143 opioid substitution users that were addressed for testing in pharmacies, 43 (30%) agreed to participate. This is comparable to our questionnaire results, where 30.7% agreed in the overall addressed population and 34.7% agreed in the subset of drug users. Radley and colleagues’ testing, however, returned 12 of 43 (28.0%) positive, which is a higher positivity rate than ours (5.5%) [31]. This difference may be explained by the focus on opioid substitution users, with previous or active drug users being considered at the highest risk for HCV infection [32]. Current models for Switzerland estimate HCV prevalence in people who use drugs between 25 and 40% [18].
Addressing clients in Switzerland due to their vulnerability for HCV including certain behaviours and sexual orientations [13, 17], has the potential to foster preconceptions and dismissive reactions. Three of the five reported barriers for pharmacists likewise concerned HCV being a sensitive topic. Concurrently, 78.6% [11] of the responding pharmacists stated that their clients wanted to use the screening when approached (64.3% rather does apply, 14.3% does fully apply), a possible indicator that the clients, once approached, reacted positively. Addressing vulnerable populations is, finally, just a triage system based on evidence on local infection sources as proposed by the Swiss Federal Office of Public Health. However, addressing these personal vulnerabilities will require strong communication skills from community pharmacists. This is required from a profession, which is described by some to “use technical jargon, display feeble responses to emotional prompts, and control the interaction and content by using close-ended questions” [33].
Two of the main selected facilitators concerned financial items: being able to offer a rapid test free-of-charge to the client and the pharmacy was mentioned by 73.3% [11] of responding pharmacists, and having the service remunerated was stated by 40.0% [6]. This was also reflected in mentioned highlights such as “Free screening.” We argue that this is representative of two difficulties in modern pharmaceutical care: pharmacists struggling with charging clients for services instead of products and pharmacists longing for remuneration for their cognitive services. If national HCV elimination strategies were to include screening interventions by community pharmacies, clear guidelines for billing and remuneration would need to be established. We, additionally, argue that at least parts of the strategy for the SARS-CoV-2 pandemic could be adopted, where Swiss pharmacies were also involved in screening and certain populations either had to pay for the test themselves (e.g., travellers) or the costs were reimbursed by the Swiss government [34].
Our pilot may have also benefitted from community pharmacies being part of the Swiss efforts battling the SARS-CoV-2 pandemic in other ways. Setting up appointments, performing swabs of the oral mucosa, carrying out rapid tests, handling potentially infectious material, and helping clients interpret test results are all skills that were needed and extensively used for SARS-CoV-2 as well. Likewise, community pharmacies were still busy with testing and vaccinating additional clients, which may have negatively affected recruiting and response rates for this pilot.
Apparently, being able to offer yet another new service to their clients was an additional facilitator (66.7%), with stated highlights such as “The possibility given to the pharmacy to possibly find patients with hepatitis C” and “I also found it great to deal with a new service that has nothing to do with Covid19.” These statements are, again, similar to the work by Radley and colleagues, where pharmacist participating in dried blood spot testing commented “’a great opportunity’, ‘an obvious thing to do’ and ‘a no brainer’” [31]. Two additional facilitators in our evaluation concerned training and help: the training was mentioned by 66.7% pharmacists, and the offered documentation around the project by 40.0%. This once again underlines the need for comprehensive training and available documentation for future pharmaceutical HCV services.
Impact
With this assessment of feasibility, we showed that a screening for HCV in Swiss community pharmacies could be implementable, given flexibility in provision and extensive training in communication strategies, as well as financial remuneration. A screening approach through community pharmacies is in line with the Swiss Federal Office of Public Health’s decision to target specific vulnerable populations for HCV testing, follows recent calls by Bechler & Schmassmann [35] and Bihl and colleagues [18] to increase screening for HCV in Switzerland, and is in accordance with the recommendation by the European Centre for Disease Prevention and Control guidance that pharmacies should be part of the screening process [19]. Flexibility is needed to allow for variation in when and by whom precisely the screening is offered and received, adapted to the local population. Clear and empathetic communication styles will be needed to carefully approach persons from vulnerable populations. By providing on-site training and letting the pharmacies define their own communication strategies for selected populations, our pilot allowed for this flexibility and simultaneously called for participating pharmacies to take a critical look at their individualized approach.
Limitations
Our feasibility assessment has several limitations. Importantly, there was significant dropout in performing the service and questionnaire filling. Out of the originally involved 36 pharmacies, 25 actively participated. Of these, only 15 handed in their aggregated counts of reasons for addressing and recruiting their clients. Likewise, only 15 pharmacists answered our questionnaire on acceptability, feasibility, and appropriateness of the new service. This dropout becomes apparent when comparing the number of reported screenings: Of 145 screenings reported for pay-outs, of which eight were positive, only 79 were mentioned in the separate questionnaire. Furthermore, the number of positive rapid tests were not assessed within the questionnaires, which would have allowed for stratification by vulnerable population. As individual client data were not assessed, the proportion of clients successfully linked to additional care for diagnosis and treatment was not known. This missingness may introduce distortions in our analysis and interpretation, especially the comparisons to national HCV prevalence estimates. Pilot results consisting of only 15 responding pharmacies also have limited generalisability. It is possible that especially committed pharmacies that feel particularly comfortable with their clients have participated, which introduces a selection bias. Additionally, we queried on pre-specified barriers and facilitators to reduce questionnaire filling time during the SARS-CoV-2 pandemic. This approach may have introduced anchoring bias by influencing subsequent free text answers. The additional free text answers, however, also included independent statements, showcasing that not all respondents were influenced. Finally, being a feasibility assessment, an active comparator was not part of the investigation, which negates any comparisons to other health care service providers. Direct comparisons were, however, part of the studies in Scotland [22].
Conclusion
This assessment showed the general feasibility of an HCV screening service with rapid saliva antibody tests in Swiss community pharmacies. Important facilitators and barriers were identified, which included the sensitivity of approaching pharmacy clients according to their vulnerability towards an infectious disease. Given appropriate communication trainings and remuneration, Swiss community pharmacies may be an important partner for achieving the HCV goals set by the WHO.