Pharmacy Integration in HIV Prevention Services
In this podcast, Natalie D. Crawford, PhD, discusses the results of her team's recent study examining the potential benefits of pharmacy integration in increasing access and use of preexposure prophylaxis (PrEP) for HIV prevention among areas with low PrEP uptake and populations at increased risk of HIV infection.
- Harrington KRV, Chandra C, Alohan DI, et al. Examination of HIV preexposure prophylaxis need, availability, and potential pharmacy integration in the southeastern US. JAMA Netw Open. 2023; 6(7):e2326028. doi:10.1001/jamanetworkopen.2023.26028.
Hello everyone and welcome to another installment of Podcasts360, your go-to resource for medical education and clinical updates. I'm your moderator, Leigh Precopio, with Consultant360, a multidisciplinary medical information network.
According to the CDC, approximately 30% of individuals at risk for HIV infection within the United States are prescribed pre-exposure prophylaxis (PrEP). Nationwide initiatives aimed at increasing PrEP use among at-risk populations have resulted in a steady and encouraging increase, but additional efforts are needed to reach the national goal of 50% of individuals who could benefit from PrEP to be using it by 2025.
One potential strategy that researchers are exploring is the use of pharmacies to increase access to PrEP, a common barrier to PrEP utilization. To explore the role that pharmacists may have in HIV prevention services, researchers conducted a cross-sectional study examining current PrEP-prescribing locations and pharmacy locations across the Southeastern United States.
To learn more about this study, Consultant360 reached out to the lead study author, Natalie D. Crawford, PhD, who is an Associate Professor in Behavioral, Social, and Health Education Sciences in the Rollins School of Public Health at Emory University.
LP: Thank you for joining me today. What prompted this study?
Natalie D. Crawford, PhD: So one of the main barriers that people report to obtaining HIV prevention services is access. And so we really wanted to visualize what does access look like for people in the areas most affected by HIV. And what we saw was staggering. The areas with the highest HIV prevalence and incidence have the fewest PrEP clinics, but there are ample PrEP clinics in the areas with the least amount of HIV. So there was a clear mismatch and where we need these critical services and where they are available.
But we didn't really want that to be the end of the story because we know there are so many rich resources that we could harness so we wanted to also visualize what might this access look like if we could expand HIV prevention services such as HIV testing and pharmacists prescribing for pre-exposure prophylaxis. And the picture became much more of a success story when we imagined this new story. And so if we were to integrate pharmacies as places to obtain HIV prevention services, we could increase access by 80 fold and that's just in the southeast. So we felt like that's a story worth telling. We really wanted a positive story and a solutions-oriented story to be what we tacked on to what we already know about poor access for HIV prevention.
LP: Can you discuss the current role of pharmacists and HIV prevention and the use of PrEP?
NDC: Sure. So right now we have so many pharmacists who care about HIV prevention and are doing everything that they can to advise their clients. But most pharmacists are limited in what they can do. Only about 17 states have some legislation that allows pharmacists to provide PrEP in some way, but this is very state dependent and the on the ground application of this really varies widely in how uptake of the implementation of these policies has happened. So in order to truly expand HIV prevention in pharmacies we really need national legislation that allows for pharmacists to be reimbursed for their time related to HIV prevention and specifically PrEP screening and dispensing. So this is a major barrier to fully integrating HIV prevention services into the pharmacist workflow, particularly in the areas with the highest need.
LP: Your study found that if pharmacies began widely PrEP there would be an 80.9 overall fold increase in PrEP providers. Was your team anticipating this increase or did these results surprise you?
NDC: We were certainly shocked by the magnitude, but in reality these were the stories that our qualitative data have been telling us for years. And so people have been sharing stories of their challenges getting on PrEP because clinics were too far away and they had to make real life choices on do I use my last quarter tank of gas to go grocery shopping and pay for childcare or whatever their basic needs are, or do I drive across town in traffic and potentially have to take off work to get an appointment to screen for PrEP and get a PrEP prescription, right? So as researchers, we've heard these stories but our individual level interventions have fallen short of addressing these upstream and structural challenges that everyday people have. And so this is what we really want to tackle is how do we make these services accessible for just everyday people, people that are really grappling with real life challenges with their income and income insecurity and housing insecurity. And so obviously the magnitude was a bit of a surprise, but we knew that this was a story we were hearing from people in qualitative interviews all the time.
LP: Your study mentioned that individuals may have critical barriers to access other than a lack of an available PrEP prescribing clinician. Could you discuss this further?
NDC: Absolutely. One of the major barriers that we see is stigma. Period point blank, right? And that means a lot. So stigma means that people aren't all completely comfortable talking about their sexual history. They aren't comfortable completely sharing and divulging their substance use behaviors. But even when they do do that and when they get to a place where there's someone who they can receive a PrEP prescription for, they can get screened. There is stigma related to just being on PrEP, right? Their people want some privacy around being on PrEP. Being on PrEP may mean something to, if someone else learns about it, it may mean that you're a person who engages in deviant behavior. And so there's just a lot of stigma around everything associated with HIV prevention and particularly PrEP. And that is really a critical barrier to progress even once we expand this access that I think we're going to have to contend with. Another barrier of course is access in a different way, is financial access. So there are programs that help subsidize PrEP costs. As well as some insurance companies fully cover PrEP. But then we have the issue with paying for labs to remain on PrEP, which some insurance companies fall short of and some people cannot pay for out of pocket. And so that's also a challenge and one that I think we can work around, but also another challenge that is a barrier for folks.
LP: So in addition to the use of pharmacies for expanding access to PrEP, are there any other underutilized strategies that may help expand PrEP access for those high priority areas in the Ending the HIV Epidemic in the US initiative?
NDC: Again, stigma. Stigma reduction needs to be at the top of the list for strategies that we promote. We know we can reduce stigma by decentralizing HIV prevention services, yet we continue to treat HIV like it's different from every other chronic disease. We discuss sexual behavior and substance use as if swaths of the population have not engaged in these behaviors. Literally all of our existence is dependent on someone having sex, right? And so everyone does it, but yet there's so much stigma attached to sexual behavior. There's a lot of stigma attached to even engaging in sexual behavior that is pleasurable. And those are problems because if we don't make people comfortable and we aren't realistic about these behaviors happening, we isolate people. So people don't want to talk to us and they certainly don't want to hear us preaching to them about what they need to do to protect themselves.
And so we really need to shift our thinking around this and figure out how to meet people where they are. We need to shift our behavior so that we are welcoming and understanding and realistic, just flat out realistic that people are having sex. People are always going to have sex until the end of time. People use drugs. I mean, our existence is also predicated on a lot of substance use, whether it's legal or illegal, but those are things that happen. And in order for us to make strides we really need to figure out how to redress our issues with stigma in the way that we treat HIV.
LP: What are the next steps in expanding HIV prevention and care services to pharmacies in other high priority areas and nationwide?
NDC: So my hope is that we will do the right thing on a national level and obtain legislation that really allows us to expand HIV prevention services in pharmacies. That would be the ultimate goal and wishlist. In the absence of that though, there are still work that can be done on a state level. State policies can be enacted to allow on a state by state basis for pharmacies to provide additional HIV prevention services in the southeast. We currently have, I think Virginia, that is the only state that is doing some PrEP-specific legislation. North Carolina is doing stuff around PEP (post-exposure prophylaxis), but we really need all the states in the southeast. And I believe the entire nation, but particularly in the southeast where HIV is really; we're driving HIV numbers in the southeast. And so every legislator in the southeast should care about this because we are at epidemic levels and we should all care when we have an epidemic on our turf.
And so state policies, the other thing that we can continue to do and which is where I feel really useful is we can continue to develop research and evidence-based strategies that would allow us to continue to try to integrate some HIV prevention services in the absence of policy. And so we are currently testing models for self screening, HIV testing, self HIV testing in pharmacies because there isn't legislation that allows pharmacists to do that, but so that someone would have someone that could counsel them in person if they couldn't make it all the way to a place to get HIV testing. And so there are a number of innovative strategies that we can test in the absence of policy. And so my hope is that we just continue on a multi-pronged approach that tries to continue to chip away at this problem and improve access for people.
LP: Is there anything else that you would like to add today?
NDC: Today on a positive note, I just always like to end things with, this is a big problem but there's a lot of hope. And there is a lot of potential for us to change this and to help people. And my hope is that we all rally together and we do what is best for our community and making everyone have access to just basic resources, right? Critical resources. So that's the only thing I would like to add.
LP: Thank you so much for taking the time to speak with me today.
NDC: Thank you for having me. I really appreciate you taking the time.