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Fred Cruz, R.Ph.
Honolulu, Hawaii
 


Fred Cruz
  Hawaiian HIV specialty pharmacist Fred Cruz is far more than just a healthcare professional in an exotic location; he personally calls each of his clients every month to ensure that their health, and their treatment, is doing as well as possible.
Hawaiian HIV Pharmacist Improves Clients' Lives One at a Time Hawaii may be an island chain far removed from the continental United States, but HIV is as much a reality there as it is in the rest of the country. Texas native Fred Cruz has been living in Honolulu for the past 13 years, and during much of that time has developed a reputation for his standout work as a pharmacist specializing in HIV.

As a pharmacist for 26 years, the last nine of which have been spent specializing in HIV, Fred has built far more than just an understanding of medications. He has committed himself to giving compassionate assistance to any client who needs help adhering to their treatment and prescription programs, and personally speaks with each of his clients -- who live throughout Hawaii's islands, as well as in American Samoa and Guam -- every month to ensure they aren't having any problems with their medication regimen.

In addition to helping his HIV-positive clients stay on treatment, Fred is also actively involved in efforts to make sure low-income HIV-positive people get access to the treatment and care they need. He seeks out cost savings for state funds in order to maximize the number of people who can enroll in Hawaii's budget-strapped AIDS Drug Assistance Program. He also serves as the vice president on the board of the AIDS Community Care Team, a group responsible for the allocation and management of Hawaii's Ryan White CARE Act Title II funds, which help AIDS organizations provide services to people living with HIV.

PRACTICE

Can you tell me a little about your pharmacy?

We are different because we aren't a walk-in pharmacy. Pro Care is a branch of CVS pharmacies that specialize in long-term treatment. We are a closed-door pharmacy; all clients are referred to us, word-of-mouth through patients or from physicians. We serve all seven islands, Guam and American Samoa. I know when all my clients' refills are due. I will call them on a monthly basis and ask them if they are ready for their medications. I get to know my clients over the phone and we ship medications out to the clients. The Big Island is very large, but everyone knows everyone else. Our method of delivery keeps our clients anonymous to the general public, because they don't have to go to a specific location where everyone knows why they are going there. And some patients live farther out and so the meds can come to their door. We specialize in HIV and other long-term conditions where people will be on meds for the rest of their lives. I specialize in HIV, but we aren't exclusively an HIV pharmacy.

"I have learned to be grateful for the magic in each day, and to cherish my time with loved ones."

What is your client demographic?

Our clients are mostly men, but the number of female clients is increasing. I also have pediatric clients, nine children -- a five-month-old baby to a 16-year-old.

How is your relationship with your clients unique from other types of pharmacies?

The way it works at the beginning is that I call them and introduce to them how it all works. It is hard at first, I can tell they are really skeptical, but by the third month, when they are talking to me about their sex lives, I know that I've gained their trust. I've been calling many of them for years and I don't even have to introduce myself anymore, they recognize my voice. It is unique, because we will talk on the phone for years sometimes, but never meet. I will meet many of my clients for the first time when I do presentations. I go to the different islands, for example, I went to Kauai in October and was on a round table discussion. Some of the other people involved were my clients, and even though I had known them for years, it was the first time I had met them.

Do your services for your clients extend beyond their HIV medication needs?

We encourage our clients to utilize us and have us dispense all of their medications. This includes anything they are taking for an opportunistic infection to their mental health medications, since many clients experience depression as a side effect of some of the HIV medications. Any drug interactions are easier for me to see if I have all the information and I can contact their doctor and let them know of anything that I notice. I routinely monitor my clients for side effects. For instance, if they experience nausea or vomiting, I will ask them if they want me to ask their doctor to prescribe something for their symptoms. I know all of the HIV doctors on every island throughout the state. The doctor will use my services as a reminder to the patient that they need to come in and get a check up. A doctor may call up and allow only a month for a refill, instead of multiple months, so the patient will know they have to schedule an appointment to refill again.

A lot of times a client will tell the doctor what they think the doctor wants to hear. They are more comfortable telling me what is really going on. If the doctor asks a client if they are taking their medications, they think the doctor wants to hear them say yes. But I notice that I haven't heard back from them for two months, which might be because they decide to go on a drug holiday. I always ask permission from the client before I ask or tell their doctor anything that they have told me. Many times, the case is that the clients are afraid to tell the doctor the truth, but because we have established trust, they will tell me. So I can act as a mediator. I sometimes find myself telling a doctor what is really going on. I try to always keep the individual needs out front for the doctors. Sometimes a doctor will tell me that we have to change a medication plan because a client isn't responding to their current routine and I may have knowledge that the client's life has been under a lot of stress lately, so I will tell the doctor that this client needs their plan to be SIMPLE because they are having trouble taking a more complicated regimen.

What made you interested in HIV pharmacy?

I have been working with HIV for the past eight years. I was drawn towards a specialty in HIV because I felt it was a very dynamic and ever changing specialty, having a pharmacist who is keeping current with all the research and their findings is the paramount need for HIV clients. This is because they need to be able to understand the various therapies available to them and what their benefits and effects might be to make better-informed decisions.

I became interested in HIV care on a more personal level when I had a lot of friends who were diagnosed positive and I wanted to know what was going on with them. It is constantly changing, which is what makes the field more challenging. I have to keep up with all the new changes. Clients will call me up and ask me if I have read this or that. If I don't know, I won't act like I have, I'll admit it and ask where they got the information so that I can learn all I can about new research on the disease. I read a lot of the magazines, the Internet is probably my biggest source of information. The Body Pro is great, it has a lot of information. I read both kinds of resources, what the clients are going to read and where the professionals go.

When did you decide on pharmacy school?

I decided at about six years old that I wanted to be a pharmacist. I remember visiting the pharmacy with my mother and always being captivated by the whole experience and even being more intrigued when my mother told me the pharmacist knew what each of the pills in all the different bottles was for and how they helped people. I just thought it was so fascinating that this man knew about all those bottles. I knew that someday I wanted to know what they all meant as well.

Does your most successful work come as a result of working in a team environment?

Each member of my team has a personal commitment to their job. We each take great pride in doing our share in order to get the job done efficiently and accurately. I feel like this applies to both types of teams that I work with. At the pharmacy, I fulfill my primary job making contact with the clients, answering their questions, processing their prescriptions, counseling them and finding out if there is anything they need from the doctor. Then the rest of the team works together and the technicians actually fill the prescriptions. Someone else then checks the prescriptions and someone else packages them. There is a whole different team I work with including the client, who lets the doctor, the pharmacist, the caseworker know what their needs are. We all work together to fulfill those needs for the client.

The client's caseworker is responsible for applying for the insurance, but I will serve as an advocate for the patient if an insurance company denies a patient a drug. I have two things on my desk right now requesting drug assistance. The majority of our clients are on Medicaid, but we have some clients that are on third party insurance. HDAP (Hawaii Drug Assistance Program) Ryan White Funds from the federal government provide the funds for medications for clients who do not have access or cannot get drug coverage. I will advocate for the client and let the insurance company know what the common uses are for the drug; sometimes I will even fax them proof. For example, when Fuzeon, the only injectable HIV med, which must be injected twice a day, came out. At first, Medicaid didn't require prior authorization, and when they decided that it needed authorization, I had to get a few clients grandfathered in to having the drug approved for them after explaining to the supervisor the gravity of the situation these patients were facing.

How do you encourage your clients to adhere to their medication regime?

Clients are going to do what they think is right. One client told me that every day he takes his meds he is reminded about his illness. I helped him by telling him of another client who sees her medication as being a light that helps keep her alive. There are two ways to look at everything. She sees each little pill as being a light for her body, which helps to keep her alive. I try to get to know my clients. I'm not there just to ask, "Are you ready for refill? Okay, I'll talk to you in a month." When they start to engage in conversation with me I start to really get to know them as individuals. I had commented to the woman that I just used as an example that she has a very positive attitude about her illness. I think her sharing her story with me made my relationship with her more comfortable and also helped my relationship with the other client, because he was able to hear about someone in the same situation having a positive outlook. The most important aspect to my job is getting clients to trust me, and getting them to understand that I am here to help them. It is rare that anyone will get to know their pharmacist. The fact that I get to know my clients is one of the most rewarding aspects of this job.

Why do you think people with HIV nominated you as their favorite pharmacist?

I believe I received the nomination because of the effort and pride I put into being able to serve each client, knowing it is something that is very personal and critical to their daily well being.

Is there anything special you try to do for people living with HIV when they come to pick up their medications?

I don't get the opportunity to serve my clients face to face, so I make an extra effort to get to know each client as an individual and how their medications are working for them through monthly telephone conversations. During these calls I often ask if there might be any additional assistance I could help arrange when it is needed.

If I were to follow you for a week what would I observe you doing?

If you were to observe me for a week, you would primarily see me on the phone conversing with my clients. You would hear me asking about their needs, checking on their adherence through conversation, as well as checking the computer to see if they are on schedule. I work with the clients' doctors who are experiencing adverse effects from medications. I discuss with them what may help the clients tolerate the medications better or I might recommend alternative therapies. I will often be advocating for my clients with their insurance companies who deny their treatments or continued therapy by providing them with literature substantiating my clients' needs.

Most weeks you would also find me attending an evening meeting with one of the various HIV/AIDS agencies located in Honolulu, or find me attending monthly in-service training sessions for professional providers of HIV, sponsored by pharmaceutical companies.

I am also vice-president of AIDS Community Care Team, an organization which is contracted by the State Department of Health to oversee the distribution of Ryan White Funds for the state.

What is the best thing about your job? Why?

Having the opportunity to speak with my clients at least once a month is the best part of my job. This enables me to get to know my clients individually, and by doing this, I am often able to detect when they may be in need of additional support. It could be a medication change, financial or emotional support that is needed. Helping a client locate the proper assistance when it is needed is often a service that will be beneficial to them throughout their life.

I have found that assisting my clients find the needed support helps them keep down stress levels and anxiety, which often disturbs their medication adherence, which in turn causes additional problems. Knowing that I am able to help catch a problem and resolve it before it becomes overwhelming for my client is very rewarding for me personally.

What is the worst thing about your job?

Not being able to meet my clients in person because they live on a different island. I find meeting my clients face-to-face often helps build our relationship and their trust in me. Having their trust earns me the ability to get my clients to share with me when they are having medication issues, which they might not be comfortable discussing this with their physicians directly. Without it, I am not able to act as a liaison for my clients between them and their physicians.

What is the biggest challenge you face as a pharmacist? Would other pharmacists give a similar answer?

My biggest challenge is accepting when one of my clients passes away. I feel any pharmacist who is able to get to know their clients individually like I am would likely give the same answer.

What do you think is the biggest risk factor for HIV?

Complacency. People surviving with HIV for years at undetectable levels and not coming down with AIDS as quickly seems to be leading people to think that they no longer have to practice safe sex. The more advanced medication regimens, which are becoming more easy to adhere to often allows people to believe that it is not a big deal if they become infected.

What do you think are the biggest problems people with HIV face today?

One of the biggest problems that my clients face, especially in the beginning, is accepting the fact they are positive, learning to take the steps needed to ensure they receive adequate care and support for their illness. Once they have started taking these steps, they usually fare better than my clients who try to handle everything that comes along with becoming infected with HIV alone.

What is the most important thing you have learned from people living with HIV?

I have learned to be grateful for the magic in each day, and to cherish my time with loved ones.

How do you maintain a positive outlook and avoid burning out?

I avoid burnout by remembering the hugs and thank yous I have received from the many clients I have been able to assist. It is better for me once I have met the client, because we both know whom we are speaking to after that. I do have a few very difficult clients. One time, just meeting a client changed his attitude toward me completely, and our relationship has continued to grow after our meeting.

If you weren't a pharmacist, what would your profession be?

Nursing, because I think it would be very rewarding. I would want to be an emergency room nurse, or in a surgical field, because I think those areas would be more high-adrenaline then regular bedside nursing.

AWARD

Would you like to dedicate this award to anyone?

Most definitely, I would dedicate it to all of my clients, past and present. If it weren't for them I would not enjoy going to work on a daily basis. I would like to thank the patient that nominated me, because the act is very encouraging. Hopefully, they will let me know who they are so that I can thank them personally.

PERSONAL

Where do you live?

I grew up in El Paso, and went to school in Houston, and I've lived out here in Hawaii for 13 years. I live in Hawaii Kai, a marina community in Honolulu. Hawaii is a great place because the people are incredibly friendly. It is a mixture of all cultures, because there is a lot of Asian influence. The food is fantastic. You couldn't ask for better weather, especially if you are an outdoor person. Right now is whale season. My partner and I go out every weekend to watch the whales and take photos. Sometimes we take for granted how beautiful it is here, I drive along the beach for my commute. I've seen it for so long, with such regularity, but when I go back to the mainland, I always can't wait to get back. Sometimes when people move to the islands they get something we call "Rock Fever," they feel trapped out here, but I have never felt that way.

All the islands have different aspects to appreciate. We can go the Big Island, which is the island with the largest land mass, and see the active volcano that just flows out into the ocean -- you can get some really great pictures there. The islands are all divided by the volcanoes that created them and there is different weather on the different sides. All the islands on the northern side are much more rainy, greener, than the leeward side, which is on the south, where it will be sunny. Oahu is the most populated island, two million people, including the tourists, and that comes with certain benefits. For instance, on Oahu, there are three major tunnels to get through the island's volcano, you will start on one side where it is rainy and exit on the other side where it will be sunny. On the other islands, with lower populations and less major roads, you have to drive around the volcano.

Have you found yourself immersed in the culture of Hawaii?

I took up hula dancing, and I did it for about two years. There are different types of hula dancing: Ancient hula (costumes include a grass skirt) and Modern hula, (the costume is flowered dresses for the women and flowered shirts for the men).

It is very time consuming, we were practicing four or five times a week before a competition. I was performing with a hula troupe, and we competed in two competitions where we did quite well. We also performed at the Sheraton hotel on Saturdays. It was really beautiful when we were performing at sunset with our back to the ocean. There would always be a band playing Hawaiian music, which uses a lot of ukulele, and a slack key guitar (12-string guitar). You can hear hula in Hawaiian or English. It is sort of like sign language in dance, but it is quite challenging, because everyone is dancing the language in unison, so if you screw up, someone will be able to notice.

Who have been the most influential people in your life, professionally and personally?

My parents have been most influential, because of their encouragement, support and teachings, through which I learned to be a caring person. Using what they taught me, helped me pursue and follow through with my career goals, even when it became difficult to continue with my education because of financial obligations that required me to work full-time while also attending college.

When you are able to get some spare time, what are your hobbies?

Currently, it is humpback whale season here in Hawaii and I enjoy watching for them. Outside of whale season, I spend more time working out at the gym, road bicycling, hiking, kayaking and snorkeling. In the evenings, I enjoy reading.

Do you have a partner? Pets?

I have a great partner, Zeuz. No pets, but I would love to have a dog someday.

If you could live anywhere (besides where you live now) where would you locate yourself?

San Francisco, I love the character of the city and all the diversity it has to offer.

What was the best vacation you've ever had?

My favorite vacation so far has been the summer my mother and father took the family by car from El Paso, Texas, all the way down to Acapulco, Mexico. You get a real taste of the country during a road trip. But that vacation was when I was young. In Hawaii, it is hard to take a road trip. We are going to New York City and the East Coast soon, my partner is a police officer, so he is going to do a big 250-mile bike ride, they are representing all the officers that have died in the last year on the line. The first time I went to New York was in 1964 with my parents and we went to the World's Fair.

What are you currently reading? Is there a book you would say has had a big impact on you?

Currently I am reading The Last Juror by John Grisham. The book that has had the biggest impact on me has been Honor Thy Children by Molly Fumia.

Is there an album you listen to most?

I enjoy all kinds of music, my least favorites are country and rap. Currently the album that keeps finding it's way into my CD player is Heaven by Los Lonely Boys.

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