How Are Nonphysician Providers Changing the HIV Prevention Landscape?

Christina M. Madison, PharmD, FCCP, BCACP, AAHIVP

Associate Professor of Pharmacy Practice
Roseman University of Health Sciences
Henderson, Nevada

Christina M. Madison, PharmD, FCCP, BCACP, AAHIVP, has disclosed that she has served on speaker bureaus for Janssen Therapeutics.

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Released: June 4, 2019

HIV prevention by ARVs can be divided into 2 main components. The first includes pre-exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) for at-risk uninfected individuals. The second is treatment as prevention (TasP), which refers to treating individuals with HIV infection to maintain undetectable viral loads, thereby essentially eliminating the risk of transmission. PrEP, when taken consistently, can be more than 90% effective at reducing the risk of HIV acquisition, making it a vital component of prevention that can help drastically reduce the number of new HIV infections. Although there were approximately 77,000 PrEP users in 2016, various barriers are still preventing a large majority of the 1.2 million individuals considered to be at high risk for HIV infection from accessing PrEP care. For example, lack of provider education remains a substantial barrier to PrEP uptake, with 1 in 3 primary care physicians and nurses reporting no knowledge of PrEP. Understanding an individual’s risk and the possible barriers to care can help providers make the best HIV prevention recommendations for their patients.

Nurse Practitioners and Physicians Assistants Are Jumping Into PrEP Provision
In March 2019, the CDC reported an increase in PrEP providers based on data from the IQVIA pharmacy database. From 2014 through 2017, the number of emtricitabine/tenofovir DF PrEP prescribers increased 5.4-fold from 6368 to 34,337. Whereas the percentage of PrEP prescribers who are physicians declined from 80.6% in 2014 to 73.0% in 2017, the percentage of PrEP prescribers who are nurse practitioners increased from 10.4% to 16.1% The percentage of physician assistant prescribers also increased from 7.0% to 8.3%. The average number of PrEP patients per nurse practitioner increased by the greatest margin (2.9 to 6.5), followed by physician assistants (3.3 to 5.6), and physicians (2.2 to 3.5). Improving access to care for those who are most at risk of acquiring or having HIV infection can help us get closer to reaching the UNAIDS 90-90-90 HIV goals (diagnose 90% of all HIV-positive persons, provide ART for 90% of those diagnosed, achieve viral suppression for 90% of those treated) by increasing the percentage of individuals who are aware of their status and increasing PrEP and HIV treatment uptake.

Harnessing the Potential of Pharmacy-Based PrEP Services
In addition to increased PrEP provision by nurse practitioners and physician assistants, we have also seen an increase in pharmacy-based PrEP across the United States. Among a small but growing number of pharmacy sites that have begun to provide expanded PrEP care, available services range from HIV testing only to full PrEP provision including laboratory testing, prescribing, dispensing, and follow-up monitoring. In all cases, there is a team approach that includes either nurse practitioner or physician assistant providers or a collaborative practice agreement with a physician. In 2015, there were a total of 67,753 community pharmacies in the United States, underscoring the enormous potential for increased capacity to expand PrEP access for those who may have difficulty going to a primary care office or accessing care through the traditional healthcare system.

A recent study consisting of qualitative interviews with black men who have sex with men (MSM) receiving PrEP for at least 1 month demonstrated high acceptability for receiving PrEP through a pharmacy. The responses indicated that PrEP recipients perceived greater convenience, increased accessibility, and less stigma with pharmacy-based PrEP compared with a traditional clinical setting. As one of the most accessible healthcare providers, the pharmacist can act not only as a provider, but also as an advocate for HIV prevention and harm reduction strategies. Individuals seeking PrEP could be counseled on HIV risk factors and other harm reduction strategies, such as consistent and correct condom use, in addition to discussing eligibility for PrEP care. The pharmacy can also provide patient education resources, assist with medication patient assistance programs for those who lack insurance or who are underinsured, and provide medication counseling and adherence support for therapy when PrEP care is initiated. This is an exciting time to be working in HIV prevention and care as we continue to improve resources available to decrease new HIV acquisitions. Nonphysician providers offer a growing alternative to the traditional care model and are allowing more eligible individuals to access and receive PrEP services.

Your Thoughts?
Do you think that PrEP from nonphysician providers is a good option to expand access to care? What are some of the benefits and obstacles that you can see to utilizing nonphysician providers for PrEP provision? Please join the conversation and share your experiences in the comments box below.

Provided by the Annenberg Center for Health Sciences at Eisenhower

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