Tip of the Week: PEP, PrEP Services Are at the Intersection of Patient Need and Professional Responsibility

In the United States, more than 1 million individuals are living with HIV and nearly 38,000 new infections occur each year. The prevalence and consequences of HIV will only be mitigated with the scaling up of effective programs and medications to prevent new infections, including pre-exposure prophylaxis (PrEP) for HIV-infected persons and post-exposure prophylaxis (PEP) for individuals at high risk of HIV.

Lopez et al describe the opportunities for pharmacist involvement at these front lines of public health. They describe PrEP as a safe, effective, and strongly recommended; it consists of a single tablet, fixed dose of tenorfovir disoproxil fumerate/emtricitabine (Truvada; Gilead). Notably, it has been estimated that fewer than 10% of individuals who would benefit from PrEP are actually receiving it. Furthermore, uptake is more commonplace in cities like New York and San Francisco and is less common in areas such as the rural south.

Barriers to PrEP uptake include lack of awareness by communities and providers, pre-authorization requirements that are driven by high prices, and low access to general practitioners and sexual health services. Lopez et al state that dissemination of innovations like PrEP require flexibility, re-invention, and local leadership. Community pharmacies are accessible, provide convenient and long store hours, are staffed by pharmacists who know the medications, maintain established relationships within the community, and offer patient care services (ie adherence counseling, vaccinations, oral contraceptives, and point-of-care testing) along with the dispensing of PrEP.

The authors also reviewed successful practices in community pharmacy PrEP programs, such as one in Seattle that utilizes a collaborative drug therapy agreement and another in San Francisco that operates under a collaborative practice agreement (CPA) with the city’s Department of Public Health to provide PrEP and PEP. In both of these models, the pharmacist has prescriptive authority, can obtain initial HIV and other sexually transmitted infection screening tests, has access to laboratory results, performs adherence counseling, and conducts follow-up monitoring.

It is pointed out that disruption of pharmacy workflow could be a concern, although such disruptions are not unique to this service and are likewise similar to adaptions in workflow that have been made to accommodate blood pressure screenings, vaccinations, and other services. This requires consideration of job responsibilities, reconfiguration of employee deployment, and careful consideration of where efficiencies can be gained. It becomes that much more important to train technicians and other staff to incorporate them into the patient care process to the extent possible and to manage paperwork and other related tasks.

There are many unmet societal needs for which pharmacy can take the lead. We are all too familiar with the morbidity and mortality associated with certain diseases like HIV/AIDS. Many patients face undue health burdens that are compounded by lack of access and by lack of knowledge, let alone the difficulty in navigating the health system. Pharmacists will continue to face new challenges and opportunities, but previous models for altering workflow for other services can serve as a roadmap. Managers can determine how greater economies of scale and efficiencies could be gained by incorporating multiple services to include those that present with such great patient need and with such great autonomy for pharmacy professionals.

Additional information aboutValue-Added Services as a Component of Enhancing Pharmacists’ Roles in Public Health can be found in Pharmacy Management: Essentials for All Practice Settings, 5e.

Shane P. Desselle, RPh, PhD, FAPhA, is a professor of social and behavioral pharmacy at the Touro University California College of Pharmacy.

REFERENCE

Lopez MI, Grant RM, Dong BJ. Community pharmacy delivered PrEP to STOP HIV transmission: An opportunity NOT to miss! J Am Pharm Assoc. 2020; 60(4):E18-E24..