Pharmacists Can Help Mitigate Pre-Exposure Prophylaxis Drug Concerns With Education, Adherence Assistance

When taken as prescribed, pre-exposure prophylaxis (PrEP) medications have been proven to be effective at preventing HIV. Proper use of PrEP reduces the risk of contracting HIV from sex by 99% and from injection drug use by at least 74%, according to the US Centers for Disease Control and Prevention (CDC).

In the years since the FDA approved the first PrEP drug under the brand name Truvada in 2012 and the CDC released guidelines recommending its use among certain high-risk groups in 2014, incidence of HIV has decreased. From 2016 to 2019, HIV incidence declined by 8% in the United States. New diagnoses in 2020 dropped by 17% versus the prior year, though much of this sharp decline is attributed to the impacts of the pandemic.

While PrEP has been a game-changer in preventing HIV in individuals at high risk, its growing use has sparked controversy about whether PrEP leads to riskier behavior. Various studies have found that PrEP use does, in fact, increase certain high-risk behaviors among particular segments of the population.

For example, a 2019 study published by the National Center for Biotechnology Information estimated that an increase in PrEP use was associated with a decrease in the prevalence of consistent condom use from 18.5% to 9.4% among men who have sex with men, and an increase in the percentage of individuals with multiple condomless anal intercourse partners. The study authors concluded that although risks for HIV infection may be decreasing due in part to an increase in PrEP use, the population faces increased risks for other sexually transmitted infections (STIs).

A study published on Springer in December 2022 of a hospital-based PrEP program in Barcelona, Spain, analyzed the behavior of 295 high-risk individuals, including 94% men, 5% transgender women, and 10% sex workers, with a mean age of 34 years. During follow-up, condom use for anal intercourse decreased from 41% to 13%.

One HIV infection was detected, while other risk behaviors and STIs remained stable. PrEP adherence was correct in 80% of users, the study found. The authors concluded that PrEP implementation in the hospital program was adequate, because it allowed overall user risk behaviors and STIs to remain stable in a population at high risk for HIV, with only 1 positive HIV diagnosis during the follow-up. The goals going forward should be to target specific strategies to improve adherence and retention in care, according to the study authors.

Education and counseling about proper adherence to PrEP and continued education about the risks associated with certain behaviors are integral to improving the health of the populations that are at high-risk for HIV. During their initial visit with their health care provider, patients should receive counseling about PrEP, including how it works, the importance of adherence, potential adverse effects (AEs), and safe sex and sterile injection practices. Patients must also have a negative HIV test and undergo certain other medical tests before receiving a PrEP prescription.

Pharmacists play an important role in providing education and assistance with adherence. Pharmacists need to educate themselves about advancements in PrEP medications and changes in the marketplace so that they can provide the most up-to-date guidance to customers regarding proper usage, AEs, insurance coverage, and alternative medications.

Pharmacists can also assist patients in enrolling in medication assistance programs, such as “Ready, Set, PrEP,” which offers coverage for PrEP medication for individuals who do not have prescription drug coverage.

Pharmacists can further assist with proper adherence by using technology to track when patients are running low on their medications and in need of refills, and to communicate with patients and physicians when refills are needed. Patients may wait until the day they run out of pills to contact the physician for a refill and if the physician is not available, they may miss a dose or multiple doses.

A good pharmacist manages and coordinates the timing of refills to prevent these interruptions. Compliance packaging also assists with adherence, as does reconciling all a patient’s medications to a set schedule so they get all their medications at the same time every month.

Retention in the PrEP regimen is key. Pharmacists can help ensure patients continue to take their medication by following up and communicating through telepharmacy to determine if there are untenable AEs or other challenges that make them stop taking their medication, and, when applicable, communicating with prescribing physicians and insurance companies to problem-solve for the benefit of the patient.

About the Author

Hossam Maksoud, PharmD, is president, founder and chairman of Community Care Rx, a unique long-term care pharmacy with offices in Hempstead, N.Y. and Totowa, N.J., which provides comprehensive pharmacy services to various types of organizations.