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Pre-exposure prophylaxis (PrEP) for HIV prevention is gaining traction as an important tool in the fight against HIV. While PrEP uptake rates vary widely across regions, HIV incidents have been declining in cities with high PrEP uptake, such as San Francisco, while increasing in areas where PrEP use is low, such as rural areas in the South.(1) PrEP, as well as PEP (post-exposure prophylaxis) offer an effective means of protection for individuals testing negative for HIV. When taken daily, it reduces the risk of HIV acquisition through sex by about 99 percent. However, only an estimated 10-20 percent of individuals in the U.S. who have an indication for PrEP have received a prescription.(2) PrEP/PEP availability in the community pharmacy setting has a unique opportunity to increase uptake of these preventative medications and improve adherence among vulnerable populations.

Communities that would benefit most from PrEP and PEP face multiple barriers to its uptake, including lack of education and awareness by both providers and individuals, high costs of drugs, increased health care costs and low access to health care providers and sexual health services.(3) As medication experts, pharmacists play an important role in public health and can be advocates for safe and appropriate PrEP use. Pharmacies are ideal sites for offering PrEP given their accessibility. With more than 60,000 community pharmacies in the United States, the pharmacist is one of the most accessible and trusted providers who can aid in PrEP and PEP uptake in communities that may not be engaged in care.(4)

Physicians typically see their patients a few times per year; pharmacists see patients monthly, oftentimes several times per month. This makes pharmacists much more accessible as health providers, as patients only need to walk through the door and ask to speak to a pharmacist in most pharmacies. Higher pharmacist-patient interaction frequency and easier access means more opportunity for pharmacists to discuss sexual health, risk factors, offer testing and initiate PrEP.(5)

Two published models of community pharmacists initiating PrEP and PEP under collaborative practice in Seattle and San Francisco demonstrate the feasibility of such programs; Kelley-Ross Clinic in Seattle and Mission Wellness in San Francisco. Washington State has passed legislation that requires insurance providers to cover point-of-care testing supplied by pharmacists, while San Francisco is operating on a grant in cooperation with SF General Hospital.(5, 9) The Seattle site operates under a collaborative drug therapy agreement with a private physician and has served more than 700 patients to date.(5) The San Francisco site provides PrEP and PEP under a Certified Public Accountant (CPA) with the San Francisco Department of Public Health (SFDPH) and is reaching populations that have historically low rates of PrEP uptake.(8) This site overcame several barriers to provide onsite testing, including creating an agreement with the SFDPH to oversee their phlebotomist.

In 2017, New York State passed Assembly Bill A20724 (AB A10724,) permitting pharmacists to initiate 7 days of PEP. A similar bill was passed in 2019 in California, Senate Bill 159 (SB 159), which will soon allow pharmacists to initiate up to 60 days of PrEP and a course of PEP.(6, 9) Both bills require pharmacists to transfer care to a medical provider, providing important linkage to care services along the HIV care continuum. These bills expand pharmacists’ scope of practice and potentially can increase PrEP and PEP uptake, thereby decreasing HIV infections.

While these models are in their beginning stages, they are very encouraging examples of areas where pharmacists have the potential to address challenges in providing support for PrEP delivery, either directly as providers or under collaborative practice agreements. Attempts to expand PrEP provision through pharmacies will need to consider several factors, such as pharmacist buy-in and education, reimbursement policies, and pharmacy infrastructure (i.e. access to lab testing). Community pharmacists have demonstrated success in providing preventive care in accessible and cost-effective ways. By working with local agencies and governments, community pharmacists can implement PrEP in a pharmacy and work toward the U.S. goal to end the HIV epidemic.

Matt Martin is the grassroots advocacy manager of the NC AIDS Action Network. Andrea Rodriguez is a fellow with NC AIDS Action Network and has her MPH from the University of California, Berkeley.

References

  1. Lopez, M. I., & Dong, B. J. (2020), “Implementing PrEP in the pharmacy.” Pharmacy Today, 26(4), 39-53.
  2. CDC. HIV surveillance data tables (early release). Core indicators for monitoring the ending: The HIV epidemic data tables. Data reported through December 2019. https://www.cdc.gov/hiv/library/reports/ehe-core-indicators/index.html. Published March 2020.
  3. Calabrese S.K.,Magnus M., Mayer K.H. et al. “Putting PrEP into practice: Lessons learned from early-adopting U.S. providers’ firsthand experiences providing HIV pre-exposure prophylaxis and associated care.” PLoS One. 2016; 11: e0157324
  4. Qato, D. M., Zenk, S., Wilder, J., Harrington, R., Gaskin, D., & Alexander, G. C. (2017). “The availability of pharmacies in the United States: 2007–2015.” PloS One, 12(8), e0183172.
  5. Lopez M.I., Cohen S.E., Cocohoba J.M. et al. “Implementation of PrEP at a community pharmacy through a collaborative practice agreement with San Francisco Department of Public Health.” J Am Pharm Assoc. 2019; 60: 138-144
  6. New York Board of Pharmacy. “The licensed pharmacist role in initiating HIV post-exposure prophylaxis.” www.health.ny.gov/aids/general/pep/docs/pharmacists_role. Accessed on November 25, 2020.
  7. San Francisco Department of Public Health. “HIV epidemiology annual report 2018.” https://www.sfdph.org/dph/files/reports/RptsHIVAIDS/HIV-Epidemiology-Annual-Report-2018.pdd. Accessed November 27, 2020.
  8. Tung E.L., Thomas A. Eichner A., Shalit P. “Implementation of a community pharmacy-based pre-exposure prophylaxis service; a novel model for pre-exposure prophylaxis care.” Sex Health. 2018; 15: 556-561
  9. Zraick, K., & Garcia, S. E. (2019). “California Makes HIV-Prevention Drugs Available Without a Prescription.” The New York Times.
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