Enhancing PrEP Utilization Among Transgender Women: A Crucial Role for Pharmacists

Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention strategy, yet its uptake among transgender women remains disappointingly low.¹ According to data from the National HIV Behavioral Surveillance, only about 32% of transgender women without HIV used PrEP, and among these individuals, discontinuation rates were high.¹ Pharmacists, who are among the most accessible and trusted health care providers, are uniquely positioned to address this PrEP utilization gap.

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Transgender women face unique challenges that hinder PrEP uptake, including lack of awareness and misinformation. Many transgender women are unaware of PrEP or harbor misconceptions about its compatibility with hormone therapy.^1,2 Stigma and discrimination along with negative experiences in health care settings also can deter transgender women from seeking health care, including PrEP.³ Mental health issues, substance use, and housing instability further complicate PrEP access for transgender women.⁴

Pharmacists can mitigate these barriers through several key interventions. Pharmacists can provide accurate information about PrEP, dispelling myths and emphasizing its safety alongside hormone therapy. Pharmacist-provided patient education and counseling should be culturally sensitive and affirming of transgender identities.² Pharmacists should also foster an inclusive and nonjudgmental atmosphere and facilitate access by streamlining the PrEP initiation process. This can be provided by the pharmacist through point-of-care testing for HIV, prescribing PrEP as allowed by state-specific protocols, and providing adherence counseling.⁵

In a review, Zamantakis et al explored various factors that impact PrEP uptake and adherence in transgender communities, including cost and access. While emphasizing the importance of access to trans-affirming providers—including pharmacists—in improving PrEP utilization, this review also identifies a need for studies attending to the unique barriers, facilitators, and needs of transgender women.⁶

To maximize the impact pharmacists can have in increasing PrEP utilization among transgender women, several policy changes are necessary. States need to expand pharmacist prescribing authority, which would allow pharmacists to provide PrEP and reduce barriers to access.⁵ For this to occur, investments need to be made in training programs to equip pharmacists with the knowledge and skills to provide culturally competent health care to transgender women.⁷ Clinical pharmacy services also need to be integrated into existing transgender health programs, which can enhance accessibility and uptake of PrEP among transgender women.⁴

In many states, pharmacists currently have the authority to initiate and manage PrEP for HIV prevention under specific protocols.⁸ NASTAD outlines the authority of pharmacists to initiate PrEP and postexposure prophylaxis across various states. In these states, pharmacists can dispense PrEP medications under standing orders, which are preapproved protocols that allow pharmacists to provide PrEP without a prescription from a physician. These protocols also allow pharmacists to provide patient assessments, education and counseling, medication management, as well as follow-up and monitoring.⁸ Clinical pharmacist practitioners in North Carolina work under collaborative practice agreements with physicians, creating a team-based approach to transgender health care, including PrEP.

Pharmacists play a pivotal role in improving PrEP utilization among transgender women. They are well equipped to offer patient education, foster inclusive environments, and ensure access to PrEP. By doing so, pharmacists can significantly help reduce HIV incidence in this vulnerable population. To maximize their impact, state-level policy changes that expand the clinical scope of pharmacists are essential.

REFERENCES

1. Morris E, Teplinskaya A, Olansky E, Rinderle JK, Chapin-Bardales J; National HIV Behavioral Surveillance Among Transgender Women Study Group. Characteristics associated with pre-exposure prophylaxis discussion and use among transgender women without HIV infection - national HIV behavioral surveillance among transgender women, seven urban areas, United States, 2019-2020. MMWR Suppl. 2024;73(suppl 1): 9-20. doi:10.15585/mmwr.su7301a2

2. Jaiswal J, LoSchiavo C, Meanley S, et al. Correlates of PrEP uptake among young sexual minority men and transgender women in New York City: the need to reframe “risk” messaging and normalize preventative health. AIDS Behav. 2021;25(10):3057-3073. doi:10.1007/s10461-021-03254-4

3. Bass SB, Kelly PJ, Brajuha J, et al. Exploring barriers and facilitators to PrEP use among transgender women in two urban areas: implications for messaging and communication. BMC Public Health. 2022;22(1):17. doi:10.1186/s12889-021-12425-w

4. Kuhns LM, Perloff J, Johnson AK, et al. A cross-sectional analysis of psychosocial and structural barriers and facilitators associated with PrEP use among a sample of transgender women in Chicago, IL. AIDS Res Ther. 2023;20(1):24. doi:10.1186/s12981-023-00516-0

5. Zhao A, Dangerfield DT 2nd, Nunn A, et al. Pharmacy-based interventions to increase use of HIV pre-exposure prophylaxis in the United States: a scoping review. AIDS Behav. 2022;26(5):1377-1392. doi:10.1007/s10461-021-03494-4

6. Zamantakis A, Li DH, Benbow N, Smith JD, Mustanski B. Determinants of pre-exposure prophylaxis (PrEP) implementation in transgender populations: a qualitative scoping review. AIDS Behav. 2023;27(5):1600-1618. doi:10.1007/s10461-022-03943-8

7. Klein A, Golub SA. Increasing access to pre-exposure prophylaxis among transgender women and transfeminine nonbinary individuals. AIDS Patient Care STDS. 2019;33(6):262-269. doi:10.1089/apc.2019.0049

8. Pharmacist authority to initiate PrEP and PEP and participate in collaborative practice agreements. NASTAD. August 2023. Accessed September 25, 2024. https://nastad.org/sites/default/files/2023-08/PDF-Pharmacist-Authority-Initiate-PrEP-PEP.pdf