Expanding Pharmacist-Prescribed HIV PrEP

June 21, 2023 | Rachel Scheckman

When taken as prescribed, Preexposure Prophylaxis (PrEP) reduces the risk of HIV transmission among people who are at risk of exposure to HIV. It can be taken as a daily pill or regular injection. Access to PrEP can be challenging—especially for Black and Hispanic people and people living in the southern United States. Stigma associated with HIV/AIDS, lack of provider education, lack of access to healthcare providers, and drug pricing can all act as barriers to accessing PrEP.

PrEP is a powerful tool to reduce new infections; expanding access to PrEP is a priority within the federal Ending the HIV Epidemic in the U.S. initiative and National HIV/AIDS Strategy. One way to increase access to PrEP is by allowing pharmacists to prescribe and dispense it. Nine out of ten people in the United States live within five miles of a community pharmacy. Patients visit their pharmacist significantly more often than primary care provider, making pharmacists a highly visible access point for PrEP.

Pharmacists’ patient care is defined through their scope of practice, which can be based in legislation or regulated by a state’s board of pharmacy (or other appropriate state agency). Scope of practice can be expanded through several different mechanisms, including legislation or collaborative practice agreements (CPAs)—formal agreements allowing licensed pharmacists to perform specific patient care functions under the supervision and authority of another licensed healthcare provider.

As of May 2023, at least ten states (AR, CA, CO, IL, ME, NM, NV, OR, UT, and VA) have enacted legislation to allow pharmacists to prescribe a 30- to 90-day supply of PrEP. To accomplish this goal, these states have done one or more of the following:

• Modified scope of practice laws to expand prescriptive authority statewide.
• Adopted statewide standing orders that allow pharmacists to prescribe.
• Enabled the medical director of a local health department to grant standing orders to allow prescribing by pharmacists in their jurisdiction.

At least six more states (MA, MD, MN, MO, NJ, and RI) have proposed bills in the 2023 legislative session that would expand pharmacists’ ability to prescribe PrEP. These are the major points of consideration.

Pharmacist Training

State legislation may define the components of pharmacists’ training, or it may leave the specifics to a licensing authority. At least eight states (AR, CA, CO, IL, ME, NV, OR, VA) specify formal training for pharmacists to be authorized to prescribe PrEP and PEP. The statute-based standard is 1.5 hours of PrEP- and PEP-specific education followed by an assessment, and continuing education credits often serve as incentive. Training may be held by higher education institutions, the state board of pharmacy, or another entity. The AIDS Education & Training Center Program also offers further information for pharmacists and pharmacies initiating services.

Prescription Duration Limits

CDC guidelines specify that patients taking oral PrEP should be tested to confirm they are HIV-negative when beginning PrEP and get tested at least every three months to ensure HIV-negative status and check for any medication side effects. Nevada, Oregon, and Virginia allow pharmacists to prescribe a 90-day supply and refills if the pharmacist receives confirmation that a patient has followed through on testing beyond the initial HIV screen. This method allows the client to continue care with the same practitioner. Arkansas, California, and Maine cap the number of 30- to 60-day prescriptions by a pharmacist at two per year, which is intended to prompt clients to connect with a primary care practitioner. Illinois and Utah have not yet published duration limits, which are to be determined by licensing authorities.

PrEP Counseling

At least nine states (AR, CA, CO, IL, ME, NV, OR, UT, and VA) required pharmacists to counsel patients. The content of counseling sessions varies but generally includes obtaining a sexual history, information on how to take PrEP, the possible side effects, and referrals to a doctor or clinic for continued care. If the patient tests positive for HIV or STIs or has any other contraindications, they are immediately referred to a healthcare provider or clinic.

Testing Requirements

At least nine states (AR, CA, CO, IL, ME, NV, OR, UT, and VA) require a negative HIV test result from the patient. Pharmacists can perform a point-of-care finger stick test, order their own tests, or accept results of an antigen/antibody test from another provider that is less than seven days old. Testing is followed by consultation and screening for risk factors and signs and symptoms of acute HIV infection.

In states that allow a pharmacist to prescribe a full 90-day supply of PrEP, the patient must be tested for HIV, Hepatitis B, renal function, and sexually transmitted infections and take a pregnancy test when applicable. Both Colorado and Oregon have stipulations in their provider protocols that allow for the patient to receive a 30-day supply after a negative HIV test while waiting to receive other test results.

Conclusion

Since 2019, ten states have passed legislation that allows pharmacists to prescribe PrEP in their jurisdictions. Pharmacist-prescribed PrEP is a powerful tool to end the HIV epidemic in the United States; jurisdictions have several options to design policies to meet the needs of their communities.

Appendix A  Appendix B