Department of Clinical Pharmacy
University of California, San Francisco
San Francisco, California
Jennifer Cocohoba, PharmD, has no real or apparent conflicts of interest to report.
Pre-exposure prophylaxis for HIV (PrEP) has the potential to prevent new HIV infections worldwide. The number of persons receiving PrEP in the United States has grown rapidly, increasing by approximately 30% from 2016 to 2017. Despite these encouraging figures, PrEP is still underutilized. In a 2016 assessment in the United States, only 7% of the approximately 1.1 million persons eligible for PrEP by virtue of being at high risk for HIV infection actually received PrEP. In addition, concerning disparities in PrEP uptake have been identified. Black and Hispanic persons made up a significant proportion of those eligible for PrEP, yet represented a small proportion of actual PrEP users. Only 2.1% of eligible women were receiving PrEP.
Pharmacy-Based PrEP: Can We Build It?
At this point in the evolution of PrEP, we need to explore alternate models of delivery to help address low uptake and disparities. Herein lies the promise of pharmacy-based provision of PrEP. In this model, a community pharmacist conducts a risk assessment, orders and/or performs lab draws, evaluates lab results, and prescribes PrEP to a patient at risk of contracting HIV. Can we build it? Theoretically, yes, we can. However, there are many moving parts that need to be in place for a successful program to be implemented. For example, community pharmacies may need to rethink use of physical space to improve privacy, allow for confidential risk assessments and discussions, and potentially allocate rooms for phlebotomy or other point-of-care screenings, such as HIV testing. In addition, the pharmacists must have the confidence and skills to provide a new clinical service. Survey studies have begun to explore pharmacist knowledge and perceptions of PrEP in several states, including Indiana, Nebraska, Iowa, Minnesota, Utah, and Florida. Although these studies demonstrated overall limited familiarity or experience with PrEP, many pharmacists were nonetheless willing to learn how to provide it. A variety of structural factors can contribute to the success of community pharmacy–run PrEP programs. These include partnerships with physicians willing to participate in collaborative practice agreements, federal recognition of the pharmacist as a healthcare provider, and financial models that support the pharmacist providing PrEP care. Sometimes the community pharmacy can feel like an island: It remains challenging to securely and efficiently share electronic medical, laboratory, and pharmacy records and find optimal ways to communicate between systems to effectively integrate the community pharmacist into the healthcare team.
If You Build It, Will They Come?
This is the question on everyone’s mind. There certainly would be ample opportunity. Data suggest that approximately 9 out of every 10 Americans live within 2 miles of a community pharmacy. Several other novel, pharmacy-based models of care, including immunizations, the Asheville diabetes project, and the Barbershop hypertension project, have been remarkably successful. These promising examples have led some public health officials to move forward with implementing similar programs for PrEP. For example, pending California legislation could allow community pharmacists to provide both PrEP and postexposure prophylaxis to patients. A community pharmacy in Washington state also recently published successful results with implementation of the One-Step PrEP Program, through which 695 persons initiated PrEP during a 3-year period. This pharmacy-based program demonstrated a low rate of lost to follow-up and financial sustainability by allowing pharmacists to bill insurance plans for their PrEP services. The success of One-Step PrEP demonstrates that if pharmacies offer PrEP, patients will come. If more such models are implemented across the United States, we will continue to increase our understanding of what the impact might be and how the pharmacy profession can continue to serve as an active force in the fight to eliminate HIV.
Do you think that implementation of pharmacy-based PrEP would be possible in your practice? What do you see as the major challenges? Please share your thoughts in the comments box.