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• Improving access to PrEP using a pharmacist-centric model
  Elizabeth E McParland
  Published on: 15 June 2022

• Published on: 15 June 2022

  Improving access to PrEP using a pharmacist-centric model

  • Elizabeth E McParland, Student George Washington University- Milken Institute School of Public Health

  The Virginia Mason Medical Center’s Department of Primary Care partnered with their Proudly VM LGBTQIA+ interest group to increase the number of patients receiving new PrEP prescriptions in Seattle. VM’s initiative targeted PCPs instead of pharmacist as the main touch point for PrEP prescribing citing scope of practice concerns (Lumsden et al., 2022). The Lumsden article demonstrated that the program helped to increase new PrEP prescriptions but there were limitations. Research indicates that Pharmacist may be better positioned than PCPs to not only increase new PrEP prescriptions, but also increase PrEP adherence.

  Nationally, the scope of care for pharmacist has been expanded through collaborative practice agreements (CPA). CPAs allow pharmacist to fulfil additional responsibilities under the supervision of a physician. Washington is 1 of 48 states that have legalized CPAs, which despite Lumsden’s findings would allow VM to empower pharmacist to be more involved in the recruitment and retention of PrEP patients (Lopez et al., 2020).

  Over 90% of Americans live within 5 miles of a pharmacy; making pharmacies one of the most accessible healthcare entry points (Tung et al., 2018). Moreover, populations that have high risk for HIV, such as POC LGBTQ+ individuals and intravenous drug users, tend to live in disadvantaged neighborhoods that have fewer physicians (Crawford et al., 2020). This population is likely to rely on resources that are easy to access within...

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  The Virginia Mason Medical Center’s Department of Primary Care partnered with their Proudly VM LGBTQIA+ interest group to increase the number of patients receiving new PrEP prescriptions in Seattle. VM’s initiative targeted PCPs instead of pharmacist as the main touch point for PrEP prescribing citing scope of practice concerns (Lumsden et al., 2022). The Lumsden article demonstrated that the program helped to increase new PrEP prescriptions but there were limitations. Research indicates that Pharmacist may be better positioned than PCPs to not only increase new PrEP prescriptions, but also increase PrEP adherence.

  Nationally, the scope of care for pharmacist has been expanded through collaborative practice agreements (CPA). CPAs allow pharmacist to fulfil additional responsibilities under the supervision of a physician. Washington is 1 of 48 states that have legalized CPAs, which despite Lumsden’s findings would allow VM to empower pharmacist to be more involved in the recruitment and retention of PrEP patients (Lopez et al., 2020).

  Over 90% of Americans live within 5 miles of a pharmacy; making pharmacies one of the most accessible healthcare entry points (Tung et al., 2018). Moreover, populations that have high risk for HIV, such as POC LGBTQ+ individuals and intravenous drug users, tend to live in disadvantaged neighborhoods that have fewer physicians (Crawford et al., 2020). This population is likely to rely on resources that are easy to access within their community like local pharmacies (Okoro & Hillman, 2018). Additionally, the LGBTQ community has reported mistrust of physicians and concerns of discrimination in physician offices as deterrents to PrEP uptake (Zhao et al., 2021).

  There is an opportunity to allow pharmacist to lead PrEP initiatives. Pharmacists are in the unique position to engage with patients from first consideration of PrEP through dispensing and continued medication management (Meyerson et al., 2019). Pharmacists are well situated in the community to recruit new PrEP patients through one-on-one, pharmacist-patient interactions and population-based initiatives. Pharmacists are geographically accessible and have regular interactions with patients in a site of care that has less associated stigma. They are often involved in community outreach programs like needle exchanges and Narcan distribution events which have a target population that overlap with those at risk for HIV (Meyerson et al., 2019). Pharmacists also have the knowledge required help patients navigate insurance and PrEP cost assistance programs, removing additional financial barriers to care (Tung et al., 2018).

  Pharmacist-led service teams have already had great success with HIV related care. A 2021 literature review by Zhao et al., reviewed pharmacy-based interventions and found a positive association between pharmacist-centered HIV care with improvements of anti-retroviral adherence, care retention, and viral load suppression. Two specific pharmacy activities that contribute to these results are regular refill reminders and adherence counseling; both activities can be leveraged in VMs program improve PrEP uptake and adherence (Zhao et al., 2021).

  Less than 2.5 miles away from VM Medical Center, during roughly the same time period the Kelley-Ross Pharmacy Group developed a pharmacist-managed PrEP clinic. The clinic operated under a CPA and allowed pharmacists to take the lead in the PrEP continuum of care. This model was successful and reported high PrEP initiation and adherence rates; 695 new patients started PrEP and 74% of patients began PrEP the same day as their initial visit. 90% of the patients were considered adherent to their PrEP regiment (Tung et al., 2018).

  The VM’s PrEP program can be improved by shifting to a pharmacy-centric model by leveraging a CPA. Pharmacies are more accessible than PCP offices and pharmacists have a skill set that is better suited to handle the unique challenges associated with PrEP care.

  Works Cited
  Crawford, N. D., Josma, D., Morris, J., Hopkins, R., & Young, H. N. (2020). Pharmacy-based pre-exposure prophylaxis support among pharmacists and men who have sex with men. Journal of the American Pharmacists Association, 60(4), 602–608. https://doi.org/10.1016/j.japh.2019.12.003
  Lopez, M. I., Cocohoba, J., Cohen, S. E., Trainor, N., Levy, M. M., & Dong, B. J. (2020). Implementation of pre-exposure prophylaxis at a community pharmacy through a collaborative practice agreement with San Francisco Department of Public Health. Journal of the American Pharmacists Association, 60(1), 138–144. https://doi.org/10.1016/j.japh.2019.06.021
  Lumsden, J., Dave, A. J., Johnson, C., & Blackmore, C. (2022). Improving access to pre-exposure prophylaxis for HIV prescribing in a primary care setting. BMJ Open Quality, 11(2), e001749. https://doi.org/10.1136/bmjoq-2021-001749
  Meyerson, B. E., Dinh, P. C., Agley, J. D., Hill, B. J., Motley, D. N., Carter, G. A., Jayawardene, W., & Ryder, P. T. (2019). Predicting Pharmacist Dispensing Practices and Comfort Related to Pre-exposure Prophylaxis for HIV Prevention (PrEP). AIDS and Behavior, 23(7), 1925–1938. https://doi.org/10.1007/s10461-018-02383-7
  Myers, J. E., Farhat, D., Guzman, A., & Arya, V. (2019). Pharmacists in HIV Prevention: An Untapped Potential. American Journal of Public Health, 109(6), 859–861. https://doi.org/10.2105/ajph.2019.305057
  Okoro, O., & Hillman, L. (2018). HIV pre-exposure prophylaxis: Exploring the potential for expanding the role of pharmacists in public health. Journal of the American Pharmacists Association, 58(4), 412–420.e3. https://doi.org/10.1016/j.japh.2018.04.007
  Tung, E. L., Thomas, A., Eichner, A., & Shalit, P. (2018). Implementation of a community pharmacy-based pre-exposure prophylaxis service: a novel model for pre-exposure prophylaxis care. Sexual Health, 15(6), 556. https://doi.org/10.1071/sh18084
  Zhao, A., Dangerfield, D. T., Nunn, A., Patel, R., Farley, J. E., Ugoji, C. C., & Dean, L. T. (2021). Pharmacy-Based Interventions to Increase Use of HIV Pre-exposure Prophylaxis in the United States: A Scoping Review. AIDS and Behavior, 26(5), 1377–1392. https://doi.org/10.1007/s10461-021-03494-4

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  Conflict of Interest:
  None declared.

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