The Pharmacist's Expanding Role in HIV Pre-Exposure Prophylaxis

Assessment of the implementation of pharmacist prescribing: Challenges and pathways for ambulatory practice

BACKGROUND

Prescribing by pharmacists is an increasingly common practice worldwide. In Brazil regulation of this practice began in 2013, and the practice remains unexplored as a research topic.

OBJECTIVE

We aimed to explore and gain insights into pharmacist prescribing practices in Brazil and assessing pharmacist's perceptions of their training and preparedness to prescribe medications.

METHODS

A cross-sectional survey was conducted between October 2022 and March 2023 via convenience sampling. Data were collected using an online questionnaire covering sociodemographic issues, academic training, prescribing practices, and perceptions regarding the provision of pharmacist prescribing in ambulatory care. Exploratory descriptive analysis and Poisson regression were performed to estimate the associations between pharmacist characteristics and their practices in prescribing medicines.

RESULTS

Among the 305 valid responses, 58.7% of the outpatient pharmacists stated that they had not prescribed any medication in the previous three years. Over-the-counter medication prescriptions were most common (42.0%). Only 4.6% of respondents had prescribed prescription-only medicines provided through collaborative agreement, with 2.6% reporting that they had adjusted doses, and 2.3% played a role in prescription renewal. Pharmacists living in Northeast regions tended to be more active prescribers (PR = 1.42; 95%CI 1.03-2.18), whereas those in primary healthcare (PR = 0.61; 95%CI 0.39-0.96) and self-declared Black pharmacists (PR = 0.30; 95%CI 0.10-0.97) prescribed less. Respondents strongly believed in the pharmacist's role as a prescriber, although they remained ambivalent regarding their responsibility for patient outcomes. Progress barriers include infrastructure gaps and strained relationships with physicians.

CONCLUSIONS

This study suggests that pharmacists in Brazil predominantly prescribe over-the-counter medications, and variations in setting, region, and race can influence prescribing by pharmacist in ambulatory care.

Preferences for a community pharmacy-based pre-exposure prophylaxis (PrEP) delivery program: A discrete choice experiment

BACKGROUND

Community pharmacies are ideal venues for pre-exposure prophylaxis (PrEP) delivery. Pharmacists and pharmacy-based PrEP delivery programs have the potential to improve access.

OBJECTIVES

This study elicited preferences for attributes of a hypothetical community pharmacy-based PrEP delivery program among US men who have sex with men (MSM) and assessed predictors of their preferences.

METHODS

Data were collected via a cross-sectional anonymous survey of US MSM, who were aged 18-65 years, not transgender, reported HIV status negative/unknown, and PrEP eligible. A discrete choice experiment was conducted with seven attributes of a pharmacy-based PrEP program: initial PrEP eligibility screening mode, location for human immunodeficiency virus (HIV) tests, timing for HIV test results, PrEP decision-making style, location of PrEP consultations, PrEP medication fill method, and mode for ongoing monitoring. Latent class analysis was performed to analyze preference heterogeneity. Multinomial logistic regression assessed predictors of latent class membership.

RESULTS

This study included 390 MSM. Time to receive HIV test results was the most important attribute; receiving results on the same day had the highest preference. The next most important attribute was PrEP screening mode; online questionnaires were the most preferred. Respondents' preferences clustered into four classes: 1) "Same day results and online monitoring" (SDROM) group (63.1%), 2) "Consumerist decision-making" (CDM) group (16.2%), 3) "Self-screening (online questionnaire)" (SOQ) group (11.3%), and 4) "Same day results preferring" (SDRP) group (9.5%). Hispanic MSM (adjusted odds ratio [aOR] =0.31, 95% confidence interval [CI] [0.12-0.84], P = 0.020), MSM of other races (aOR=0.38, 95% CI [0.15-0.97], P = 0.044) vs. White MSM; and those having a sexually transmitted disease recently (aOR=0.37, 95% CI [0.16-0.85], P = 0.018), had lower odds of being in the CDM group vs. the SDROM group.

CONCLUSIONS

MSM's preferences for a pharmacy-based PrEP program are heterogeneous. Same day results for HIV tests and online PrEP screening are key components when designing a community pharmacy-based PrEP program.

HIV Care Continuum and Preexposure Prophylaxis Program in Federal Bureau of Prisons, United States

In 2019, the US Department of Health and Human Services launched the Ending the HIV Epidemic in the US initiative (EHE) with the goal of reducing new HIV infections by 90% by 2030. This initiative identifies 4 pillars (diagnose, treat, prevent, and respond) to address the HIV epidemic in the United States. To advance the EHE goals, the Federal Bureau of Prisons (FBOP) has implemented interventions at all points of the HIV care continuum. The FBOP has addressed the EHE pillar of prevention through implementing preexposure prophylaxis, developing a strategy to decrease the risk of new HIV infection, and providing guidance to FBOP healthcare providers. This article describes the implementation of programs to improve the HIV care continuum and end the epidemic of HIV within the FBOP including a review of methodology to implement an HIV preexposure prophylaxis program.

Leveling Up PrEP: Implementation Strategies at System and Structural Levels to Expand PrEP Use in the United States

PURPOSE OF REVIEW

Despite highly effective biomedical HIV pre-exposure prophylaxis (PrEP) options, suboptimal PrEP uptake impedes progress towards ending the epidemic in the United States of America (USA). Implementation science bridges what we know works in controlled clinical trial settings to the context and environment in which efficacious tools are intended to be deployed. In this review, we focus on strategies that target PrEP use barriers at the system or structural level, exploring the implications and opportunities in the context of the fragmented USA healthcare system.

RECENT FINDINGS

Task shifting could increase PrEP prescribers, but effectiveness evidence is scarce in the USA, and generally focused in urban settings. Integration of PrEP within existing healthcare infrastructure concentrates related resources, but demonstration projects rarely present the resource implications of redirecting staff. Changing the site of service via expanded telehealth could improve access to more rural populations, though internet connectivity, technology access, and challenges associated with determining biomedical eligibility remain logistical barriers for some of the highest burden communities in the USA. Finally, a tailored care navigation and coordination approach has emerged as a highly effective component of PrEP service provision, attempting to directly modify the system-level determinants of PrEP use experienced by the individual. We highlight recent advances and evidence surrounding task shifting, integration, service delivery, and tailoring. With the exception of tailored care navigation, evidence is mixed, and the downstream impact and sustainability of task shifting and care integration require further attention. To maximize PrEP outcomes, research will need to continue to examine the interplay between individuals, clinics, and the healthcare system and associated policies within which they operate.

Facilitators and barriers to community pharmacy PrEP delivery: a scoping review

INTRODUCTION

Pre-exposure prophylaxis (PrEP) is an effective medication to reduce the risk of acquiring HIV. PrEP is available free of charge in the UK from sexual health clinics. Expanding PrEP delivery to community pharmacies holds promise and aligns with UK government goals to eliminate new cases of HIV by 2030. The aim of this scoping review was to describe the existing evidence about the barriers to and facilitators of community pharmacy oral PrEP delivery, for pharmacists and pharmacy clients, as aligned with the Capacity Opportunity, Motivation Behaviour (COM-B) Model.

METHODS

Five bibliographic and five review databases were searched from inception to August 2023. Literature of any study design was included if it discussed barriers and facilitators of community pharmacy PrEP delivery. Trial registrations, protocols and news articles were excluded.

RESULTS

A total of 649 records were identified, 73 full texts were reviewed and 56 met the inclusion criteria, predominantly from high-income/westernized settings. Most of the included literature was original research (55%), from the United States (77%) conducted during or after the year 2020 (63%). Barriers to PrEP delivery for pharmacists included lack of knowledge, training and skills (capability), not having the necessary facilities (opportunity), concern about the costs of PrEP and believing that PrEP use could lead to risk behaviours and sexually transmitted infections (motivation). Facilitators included staff training (capability), time, the right facilities (opportunity), believing PrEP could be a source of profit and could reduce new HIV acquisitions (motivation). For clients, barriers included a lack of PrEP awareness (capability), pharmacy facilities (opportunity) and not considering pharmacists as healthcare providers (motivation). Facilitators included awareness of PrEP and pharmacist's training to deliver it (capability), the accessibility of pharmacies (opportunity) and having an interest in PrEP (motivation).

DISCUSSION

To effectively enhance oral PrEP delivery in UK community pharmacies, the identified barriers and facilitators should be explored for UK relevance, addressed and leveraged at the pharmacy team, client and care pathway level.

CONCLUSIONS

By comprehensively considering all aspects of the COM-B framework, community pharmacies could become crucial providers in expanding PrEP accessibility, contributing significantly to HIV prevention efforts.

A survey of South Carolina pharmacists' readiness to prescribe human immunodeficiency virus pre-exposure prophylaxis

Introduction

HIV pre-exposure prophylaxis (PrEP) is largely underutilized in the Southern United States. Given their community presence, pharmacists are well positioned to provide PrEP within rural, Southern regions. However, pharmacists' readiness to prescribe PrEP in these communities remains unknown.

Objective

To determine the perceived feasibility and acceptability of prescribing PrEP by pharmacists in South Carolina (SC).

Methods

We distributed a 43-question online descriptive survey through the University of SC Kennedy Pharmacy Innovation Center's listerv of licensed SC pharmacists. We assessed pharmacists' comfort, knowledge, and readiness to provide PrEP.

Results

A total of 150 pharmacists responded to the survey. The majority were White (73%, n=110), female (62%, n=93), and non-Hispanic (83%, n=125). Pharmacists practiced in retail (25%, n=37), hospital (22%, n=33), independent (17%, n=25), community (13%, n=19), specialty (6%, n=9), and academic settings (3%, n=4); 11% (n=17) practiced in rural locales. Pharmacists viewed PrEP as both effective (97%, n=122/125) and beneficial (74% n=97/131) for their clients. Many pharmacists reported being ready (60% n=79/130) and willing (86% n=111/129) to prescribe PrEP, although over half (62% n=73/118) cited lack of PrEP knowledge as a barrier. Pharmacists described pharmacies as an appropriate location to prescribe PrEP (72% n=97/134).

Conclusions

Most SC pharmacists surveyed considered PrEP to be effective and beneficial for individuals who frequent their pharmacy and are willing to prescribe this therapy if statewide statutes allow. Many felt that pharmacies are an appropriate location to prescribe PrEP but lack a complete understanding of required protocols to manage these patients. Further investigation into facilitators and barriers of pharmacy-driven PrEP are needed to enhance utilization within communities.

Examining pharmacies' ability to increase pre-exposure prophylaxis access for black men who have sex with men in the United States

BACKGROUND

Pre-exposure prophylaxis (PrEP) has not effectively reached black men who have sex with men (BMSM). Using innovative, nontraditional health care settings-such as community pharmacies-may improve PrEP uptake among BMSM.

OBJECTIVE

To examine correlates of patient willingness to be screened for PrEP (via human immunodeficiency virus [HIV] testing and risk assessment) in pharmacies among BMSM in the United States.

METHODS

Data from the 2020 American Men's Internet Survey were analyzed. Using a modified Poisson regression method with robust variance estimates, we examined differences in willingness to screen for PrEP in pharmacies among BMSM. A 95% confidence interval (95% CI) was calculated for each estimated prevalence ratio (PR).

RESULTS

Of 826 respondents, 637 (77%) were willing to be screened for PrEP in pharmacies. Having a high school degree (PR 0.76 [95% CI 0.62-0.95]), willingness to use PrEP (1.70 [1.41-2.05]), and comfort speaking with pharmacy staff about PrEP (2.5 [1.86-3.51]) were significantly associated with willingness to screen for PrEP in a pharmacy setting. Importantly, there were no observed differences in willingness by age, employment status, annual household income, or insurance status.

CONCLUSION

Pharmacy-based PrEP access may be an effective strategy to end inequities in HIV, given that our results indicate that most BMSM are willing to be screened for PrEP in pharmacies. Future studies should examine whether willingness to use pharmacy-based HIV prevention services is associated with subsequent uptake of these services among BMSM.

Understanding HIV Pre-Exposure Prophylaxis Questions of U.S. Health Care Providers: Unique Perspectives from the PrEPline Clinical Teleconsultation Service

Introduction: Fewer than a quarter of people considered to have factors associated with HIV acquisition are prescribed pre-exposure prophylaxis (PrEP) in the United States. Prior studies demonstrate disparities in provider comfort and knowledge regarding PrEP, suggesting a need for provider capacity building to support widespread PrEP availability. This study examined real-world PrEP clinical questions/cases from providers to a teleconsultation service to identify knowledge gaps and improve PrEP-related training materials and clinical guidelines. Methods: The National Clinician Consultation Center (NCCC) PrEPline provides educational teleconsultation services on clinical decision-making related to PrEP for U.S. health care providers. The NCCC PrEP consultation data collected between 2017 and 2020 were reviewed and systematically categorized by clinical topics, subtopics, and complexity levels (low, moderate, and high). Results: Within the study period, the PrEPline provided 1,754 teleconsultations. More than three quarters came from advanced practice nurses and physicians. The topics of questions commonly focused on medication-based HIV prevention strategies (22.7%), PrEP laboratory ordering/monitoring (17.4%), and side effects and contraindications (14.6%). The majority of teleconsultations (57.9%) involved sharing information that was directly available/addressed in the Centers for Disease Control and Prevention (CDC) 2017 PrEP Guidelines (i.e., low complexity). Discussion: The low frequency of consultations from nonphysician and non-nurse practitioner providers may suggest a need for increased training and collaborative opportunities for other types of providers. The high percentage of low-complexity inquiries may reveal a desire for capacity-building materials specifically designed for practicing providers (e.g., abridged versions of guidelines). This study may inform future research, best clinical practices, and aid in the development of training materials to increase providers' HIV prevention comfort and knowledge.

Predictors of Human Immunodeficiency Virus Pre-Exposure Prophylaxis (PrEP) Uptake in a Sexual Health Clinic With Rapid PrEP Initiation

Background

Improved pre-exposure prophylaxis (PrEP) uptake is essential for human immunodeficiency virus (HIV) prevention initiatives. Offering PrEP at the time of HIV and sexually transmitted infection (STI) testing can improve uptake. We offered rapid PrEP initiation in a sexual health clinic and assessed predictors of PrEP interest, initiation, linkage, and retention.

Methods

Between November 2018 and February 2020, PrEP-eligible individuals who presented to a sexual health clinic were offered a free 30-day supply of PrEP plus linkage to continued PrEP care. Univariable and multivariable analyses of demographic and HIV risk data were conducted to determine predictors of PrEP uptake.

Results

Of 1259 adults who were eligible for PrEP (99.7% male, 42.7% White, 36.2% Hispanic), 456 were interested in PrEP, 249 initiated PrEP, 209 were linked, and 67 were retained in care. Predictors of PrEP interest included younger age (P < .01), lower monthly income (P = .01), recreational drug use (P = .02), and a greater number of sexual partners (P < .01). Negative predictors of PrEP initiation included lower monthly income (P = .04), testing positive for chlamydia (P = .04), and exchanging money for sex (P = .01). Negative predictors of linkage included self-identifying as Black (P = .03) and testing positive for an STI (P < .01). Having health insurance positively predicted both linkage (P < .01) and retention (P < .03).

Conclusions

A minority of PrEP-eligible HIV and STI testers initiated PrEP when offered, suggesting that easy PrEP access in sexual health clinics alone may not improve uptake. Predictors of uptake included established HIV risk factors and markers of higher socioeconomic status, suggesting that those aware of their risk and with the means to utilize health services engaged best with this model.

Effects of knowledge and implicit biases on pharmacy students' decision-making regarding pre-exposure prophylaxis for HIV prevention: A vignette-based experimental study

INTRODUCTION

Men who have sex with men (MSM), especially Black MSM, are disproportionately affected by HIV and experience disparate prescription of pre-exposure prophylaxis (PrEP) for HIV prevention compared to White MSM. While pharmacists are essential in efforts to scale-up PrEP, little is known about the role of knowledge and implicit biases in pharmacy students' decision-making regarding PrEP, which may elucidate mechanisms for improving PrEP access and addressing disparities.

METHODS

A nationwide, cross-sectional study of pharmacy students in the United States was conducted. A fictional White or Black MSM seeking PrEP was presented. Participants completed measures of PrEP/HIV knowledge, implicit racism and heterosexism, assumptions about the patient's behavior (condomless sex, extra-relational sex, adherence to PrEP), and confidence providing PrEP-related care.

RESULTS

A total of 194 pharmacy students completed the study. Compared to the White patient, the Black patient was assumed to be less adherent to PrEP if prescribed. In contrast, assumptions of sexual risk behaviors if prescribed PrEP and confidence providing PrEP-related care did not differ. Additionally, implicit racism was associated with lower confidence providing PrEP-related care, whereas PrEP/HIV knowledge, implicit sexual orientation bias, and assumed sexual risk behaviors if prescribed PrEP were not associated with confidence.

CONCLUSIONS

Pharmacists are essential in efforts to scale-up PrEP prescription, making pharmacy education about PrEP for HIV prevention critical. These findings suggest that implicit bias awareness training is needed. This training may reduce the influence of implicit racial bias on confidence providing PrEP-related care and improve knowledge of HIV and PrEP.

Pharmacist-Involved Antiretroviral Stewardship Programs in People Living with HIV/AIDS: A Systematic Review

People living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS; PLWHA) frequently encounter antiretroviral (ARV) therapy-related problems. Clinical pharmacists with specialized training in ARV stewardship play an important role in managing these problems. However, there is a paucity of evidence to clarify the impact of clinical pharmacists' interventions on managing ARV therapy-related problems in PLWHA. Therefore, we aim to systematically review the literature to determine the nature and impact of pharmacists' interventions on managing medication-related problems in PLWHA. The review protocol was registered on International Prospective Register of Systematic Reviews (PROSPERO; CRD42020173078). Relevant records were identified from six electronic bibliographic databases (PubMed, Embase, EBSCOhost, ProQuest, Scopus, and the Cochrane Central Register) from their inception until September 2022. We included all randomized and nonrandomized interventional studies that were published in English. After the abstract and full-text screening, data were extracted from the selected studies, and the quality of the studies was assessed. The electronic database search and citation tracking identified two thousand and three citations. The review included 21 of these studies, involving 2998 PLWHA, published between 2014 and 2022. Pharmacists' interventions, working alone or in a multi-disciplinary team, comprised ARV medication review, management of adverse drug reactions (ADRs), therapeutic drug monitoring, prevention of drug interactions, and provision of drug information to PLWHA or the health care team. The pharmacist-involved interventions significantly reduced incorrect/incomplete ARV regimens, drug interactions, incorrect dosages, duplicate therapy, polypharmacy, administration errors, missing medication, wrong formulation, ADRs, and prescribing errors. Most studies reported that physicians usually accept more than 90% of the pharmacists' recommendations. ARV medication-related problems remain highly prevalent in PLWHA. Pharmacist-led interventions and stewardship significantly reduce ARV therapy-related problems in PLWHA and are widely accepted by physicians. Dedicated pharmacists with specialized training and credentialing in infectious diseases or HIV/AIDS have a great potential to improve health outcomes in PLWHA.

"Do I want PrEP or do I want a roof?": Social determinants of health and HIV prevention in the southern United States

Scaling up use of Pre-Exposure Prophylaxis (PrEP) among young men who have sex with men and transgender women (YMSM/TGW) is a critical part of the Ending the HIV Epidemic plan. This qualitative study contextualized the social determinants of health (SDOH) that can impede HIV prevention in rural North and South Carolina with 14 key informant interviews with stakeholders and 3 focus groups with YMSM/TGW (N = 23). A deductive-inductive approach with multiple coders was employed to identify themes related to SDOH in rural areas, including economic challenges (e.g., housing and food insecurity), neighborhood characteristics (e.g., lack of transportation), healthcare-related issues (e.g., provider shortages) and educational barriers (e.g., lack of comprehensive and inclusive sexual education). The socio-environmental context of the rural South and prioritization of local, community-based partnerships are necessary to reduce the burden of HIV.

Assessing the use of an infographic on pre-exposure prophylaxis for Wisconsin community pharmacists

BACKGROUND

Pre-exposure prophylaxis (PrEP) treatments reduce the risk of contracting human immunodeficiency virus (HIV). However, despite proven effectiveness, PrEP use remains low among populations at risk of contracting HIV. Successful PrEP uptake includes developing partnerships with health care providers to implement PrEP-related tools and interventions. Pharmacists are uniquely positioned health professionals who can provide PrEP services in the community, such as pharmacy-led PrEP clinics, to increase uptake, adherence, and retention. Unfortunately, prior evidence shows that not all pharmacists have enough knowledge about PrEP to provide effective care, resulting in low confidence and discomfort in PrEP-related patient consultations.

OBJECTIVES

This study aimed to assess Wisconsin community pharmacists' intentions of utilizing an infographic on PrEP for HIV prevention to educate themselves on PrEP and in consultations with patients starting PrEP.

METHODS

An adaptative survey, using the Theory of Planned Behavior, was conducted to assess pharmacists' intentions by measuring their attitudes, subjective norms, and perceived behavioral control. The Fisher exact tests were performed to examine associations between the 3 theoretical constructs against intentions.

RESULTS

Pharmacists reported high intentions of utilizing the infographic to educate themselves (62%) and counsel patients starting PrEP (54%). Their attitudes, subjective norms, and perceived behavioral controls were all significantly associated with their intentions. However, their intentions were reported lower than their attitudes, subjective norms, and perceived behavioral control, suggesting that additional factors may influence intentions that were not measured in this study.

CONCLUSION

The results from this study demonstrate Wisconsin community pharmacists' intentions of using an infographic on PrEP for HIV prevention in practice while measuring their attitudes, subjective norms, and perceived behavioral control. Future research is warranted to explore adapting and using the infographic to better understand its influence in improving pharmacy care among HIV-negative individuals.

Association between the geographic accessibility of PrEP and PrEP use among MSM in nonurban areas

PURPOSE

The US HIV epidemic has become a public health issue that increasingly affects men who have sex with men (MSM), including those residing in nonurban areas. Increasing access to pre-exposure prophylaxis (PrEP) in nonurban areas will prevent HIV acquisition and could address the growing HIV epidemic. No studies have quantified the associations between PrEP access and PrEP use among nonurban MSM.

METHODS

Using 2020 PrEP Locator data and American Men's Internet Survey data, we conducted multilevel log-binomial regression to examine the association between area-level geographic accessibility of PrEP-providing clinics and individual-level PrEP use among MSM residing in nonurban areas in the United States.

FINDINGS

Of 4,792 PrEP-eligible nonurban MSM, 20.1% resided in a PrEP desert (defined as more than a 30-minute drive to access PrEP), and 15.2% used PrEP in the past 12 months. In adjusted models, suburban MSM residing in PrEP deserts were less likely to use PrEP in the past year (adjusted prevalence ratio [aPR] = 0.35; 95% confidence interval [CI] = 0.15, 0.80) than suburban MSM not residing in PrEP deserts, and other nonurban MSM residing in PrEP deserts were less likely to use PrEP in the past year (aPR = 0.75; 95% CI = 0.60, 0.95) than other nonurban MSM not residing in PrEP deserts.

CONCLUSIONS

Structural interventions designed to decrease barriers to PrEP access that are unique to nonurban areas in the United States are needed to address the growing HIV epidemic in these communities.

Barriers to HIV Pre-Exposure Prophylaxis Uptake and Ways to Mitigate Them: Perspectives of Ghanaian Immigrants in the United States

African immigrants in the United States experience disparities in HIV incidence. Pre-exposure prophylaxis (PrEP) effectively prevents HIV infection, yet uptake is low among racial and ethnic minorities. To better understand PrEP adoption among African immigrants, in March 2020, we conducted interviews with Ghanaian immigrants (N = 40) to explore the barriers and ways to overcome these barriers to PrEP adoption. Participants described several barriers (e.g., low HIV knowledge and risk perception, fear of social judgment, cultural values, and norms), which may impede PrEP adoption. We categorized these barriers according to the levels of the socioecological model (individual, interpersonal, community, and organizational/structural factors). Participants also identified strategies to overcome the barriers, such as providing comprehensive education on HIV and PrEP. Our research provides foundational knowledge that can inform future PrEP research with Ghanaian and other African immigrants and offers important insights into factors that may impact PrEP adoption in this population.

Women's views on communication with health care providers about pre-exposure prophylaxis (PrEP) for HIV prevention

Since the beginning of the HIV epidemic in the USA, effective interventions to reduce HIV risk among cisgender women have been lacking. Although oral HIV pre-exposure prophylaxis (PrEP) is effective in pharmacologically preventing HIV infection, there is a gap between the recommended use of PrEP and PrEP uptake among eligible women. This study aimed to identify the role of patient-provider communication in PrEP decision-making among women considering PrEP. Semi-structured in-depth interviews were conducted with 41 PrEP-eligible women in Philadelphia and New York City. A thematic analysis of the responses was conducted, and a conceptual model developed and confirmed as analysis continued. Of the women interviewed, 53.6% were African American and 29.3% were Latina. Women noted that having a trusting relationship with their health care provider, receiving a tailored recommendation for PrEP based upon their specific needs and using their health care provider as support were crucial facilitators of PrEP decision-making. Lack of provider knowledge about PrEP, perceived health care provider stigma about their drug use and sexual activity, and lack of care continuity were all identified as barriers to effective communication. Study findings can inform future interventions to enhance patient-provider communication about PrEP and increase PrEP uptake among women.

PrEP distribution in pharmacies: a systematic review

INTRODUCTION

Novel mechanisms of service delivery are needed to expand access to pre-exposure prophylaxis (PrEP) for HIV prevention. Providing PrEP directly through pharmacies could offer an additional option for reaching potential users.

METHODS

We conducted a systematic review of studies examining effectiveness, values and preferences of end users and health workers, and cost of PrEP initiation and continuation through pharmacies (pharmacy access). We searched PubMed, CINAHL, LILACS and EMBASE through 2 December 2020. We also searched clinical trial registries and recent HIV conference abstracts. Standardised methods were used to search, screen and extract data from included studies.

RESULTS

No studies met the inclusion criteria for the effectiveness review, for either PrEP initiation or continuation. However, six 'case studies' presenting non-comparative data from PrEP pharmacy programmes demonstrated feasibility of this model in the USA. Eleven studies reported values and preferences of end users and health workers. In the USA, Kenya and South Africa, potential PrEP clients generally supported pharmacy access, although some preferred clinics. One study of PrEP pharmacy clients found all would 'definitely recommend' the programme. Six studies found pharmacists were generally supportive of offering PrEP; one study including doctors found more limited favour, while one study of diverse Kenyan stakeholders found broad support. Three studies reported cost data indicating client willingness to pay in the USA and Kenya and initial sustainability of a clinic financial model in the USA.

CONCLUSION

Provision of PrEP through pharmacies has been demonstrated to be feasible in the USA and acceptable to potential end users and stakeholders in multiple settings. Limited evidence on effectiveness and requirements for laboratory testing and assurance of high-quality services may limit enthusiasm for this approach. Further research is needed to determine if pharmacy access is a safe and effective way to help achieve global HIV prevention goals.

PROSPERO REGISTRATION NUMBER

CRD42021231650.

Pharmacy-Based Interventions to Increase Use of HIV Pre-exposure Prophylaxis in the United States: A Scoping Review

HIV pre-exposure prophylaxis (PrEP) remains underutilized in the U.S. Since greater than 85% of PrEP prescriptions are filled at commercial pharmacies, pharmacists are uniquely positioned to increase PrEP use. This scoping review explores pharmacy-based initiatives to increase PrEP use. We searched PubMed, PsycINFO, CINAHL, and Scopus for peer-reviewed studies on pharmacist-led interventions to increase PrEP use or pharmacy-based PrEP initiatives. Forty-nine articles were included in this review. Overall, studies demonstrated that patients expressed strong support for pharmacist prescription of PrEP. Three intervention designs compared changes in PrEP initiation or knowledge pre- and post-intervention. Commentary/review studies recommended PrEP training for pharmacists, policy changes to support pharmacist screening for HIV and PrEP prescription, and telemedicine to increase prescriptions. Pharmacists could play key roles in improving PrEP use in the U.S. Studies that assess improvements in PrEP use after interventions such as PrEP prescription, PrEP-specific training, and adherence monitoring by pharmacists are needed.

PrEP University: A Multi-Disciplinary University-Based HIV Prevention Education Program

The introduction of emtricitabine/tenofovir diphosphate (FTC/TDF) as pre-exposure prophylaxis (PrEP) for HIV prevention has raised questions regarding which clinicians will serve as prescribers and how providers will be educated about this HIV prevention strategy. We piloted an HIV Prevention Education Program called PrEP University (PrEP U) to address knowledge gaps in HIV prevention among medical trainees. We examined PrEP awareness and assessed learning as a result of the program, measuring knowledge before and after the lectures with an anonymous 5-question multiple choice test. A total of 198 learners participated in PrEP University, which included 127 first year medical students, and post-graduate trainees in internal medicine (n = 23), family medicine (n = 16), OBGYN (n = 13) and pharmacy (n = 19). Prior to PrEP U, 27% of all participants were not aware of PrEP and an additional 8% were unsure if they had heard of it. Knowledge increased significantly after the education program among trainees in OBGYN (2.3 vs 3.8, p < 0.001), pharmacy (1.4 vs 2.5, p = 0.012) and school of medicine (3.3 vs 4.4, p < 0.001), with a trend seen in family medicine (2.7 vs. 3.7, p = 0.067) and internal medicine (2.7 vs 3.4, p = 0.068). Overall, an HIV Prevention Education Program was successfully administered to nearly 200 participants and resulted in improved knowledge of HIV prevention and PrEP across. Pharmacists and OBGYN physicians are two groups with an expanding role in the use of PrEP. Similar programs at other medical schools should be implemented to ensure that future physicians and pharmacists are comfortable with PrEP prescription.

HIV PrEP access and affordability: a multidisciplinary specialty pharmacy model

BACKGROUND

Increasing the number of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) providers expands PrEP access to more eligible patients to help end the HIV epidemic. Previous studies have noted providers perceive financial barriers as a limitation to prescribing PrEP.

OBJECTIVE

This study aimed to describe PrEP medication access and affordability in patients seen at a multidisciplinary PrEP clinic.

METHOD

We conducted a single-center, retrospective, cohort study of adults initiating tenofovir disoproxil fumarate/emtricitabine in the Vanderbilt PrEP Clinic between September 1, 2016, and March 31, 2019, with prescriptions filled by Vanderbilt Specialty Pharmacy. Data were gathered from the electronic health records and pharmacy claims. We evaluated 3 different time periods: initial evaluation to PrEP initiation, prescription of PrEP to insurance approval, and insurance approval to initiation. Treatment initiation was considered delayed when > 7 days from initial evaluation, and reasons for delay were recorded. Continuous variables are presented as median (interquartile range [IQR]), and categorical variables are presented as percentages.

RESULTS

We included 63 patients; most were male (97%), white (84%), and commercially insured (94%) with a median age of 38 years (IQR 29-47). Primary indication for PrEP was men who have sex with men at high risk of acquiring HIV (97%). Median time from initial appointment to treatment initiation was 7 days (IQR 4-8). Treatment delays occurred in 25% of patients and were mostly driven by patient preference (50%). Insurance prior authorization was required in 27% of patients; all were approved. Median total out-of-pocket medication costs for the entire study period were $0 (IQR $0-$0). Most patients (86%) used manufacturer copay cards.

CONCLUSION

In this cohort of mostly commercially insured men, the majority were able to access PrEP with low out-of-pocket costs facilitated by manufacturer assistance. Although generalizability beyond this population is limited, these results contradict perceived financial barriers to PrEP access.

The economic impact of pharmacist care for people living with HIV/AIDS: A systematic review

Background and objective

Methods

Results

Conclusions

•

The role of pharmacists in HIV care is expanding, and it is recommended by the World Health Organization and the American Society of Health-System Pharmacists. Therefore, we attempted to find the economic impact of these services.

•

We discovered four such studies, each with minor differences in study intervention, study population, and follow-up duration, making it difficult to generalise their findings.

•

Studies have shown that pharmacist interventions have economic benefits; however, future controlled and real world studies to determine the economic benefits, in the long run, are required to strengthen the evidence.

Health Service- and Provider-Level Factors Influencing Engagement in HIV Pre-Exposure Prophylaxis Care Among Male Sex Workers

Multilevel barriers to pre-exposure prophylaxis (PrEP) care among male sex workers (MSW) include aspects of interactions with health services and providers. We examined relationships between health service- and provider-level factors and PrEP care among MSW. Between 2017 and 2019, we enrolled 111 MSW in the Northeast United States who were not on PrEP, but expressed interest in potentially using PrEP, in a behavioral intervention to promote PrEP uptake and adherence. Using baseline data, we examined whether having a primary care provider, past year frequency of medical visits, comfort discussing sexual practices with providers, and transportation difficulties to accessing general health care were associated with PrEP use self-efficacy, anticipated barriers to PrEP uptake, adherence, and retention (linear regression), and intention to initiate PrEP (logistic regression). Models adjusted for age, race/ethnicity, sexual identity, education, and income. Participants' mean age was 34.2 [standard deviation (SD) = 8.5], and 47% were non-White. Three-quarters (76%) intended to initiate PrEP within the next month. Comfort discussing sexual practices with providers was associated with PrEP use self-efficacy (b = 0.41, p = 0.008). Comfort discussing sexual practices with providers was negatively associated with anticipated barriers to PrEP uptake (b = -0.29, p = 0.006). Transportation difficulties to accessing general health care were associated with barriers to PrEP uptake (b = 0.30, p = 0.007) and barriers to PrEP adherence and retention (b = 0.57, p < 0.001). No health service- and provider-level characteristics were associated with intention to initiate PrEP. PrEP programs targeting MSW may benefit from interventions to foster communication between MSW and providers about sexual practices and should consider structural barriers to accessing care, including lack of access to transportation.

Effect of pharmacist care on clinical outcomes among people living with HIV/AIDS: A systematic review and meta-analysis

BACKGROUND

Pharmacists play a significant role in the multidisciplinary care of people living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (PLWHA). However, there is less evidence to clarify the impact of pharmacist as an individual team member on HIV care.

OBJECTIVE

This study aims to determine the effects of pharmacist intervention on improving adherence to antiretroviral therapy (ART), viral load (VL) suppression, and change in CD4-T lymphocytes in PLWHA.

METHODS

We identified relevant records from six databases (Pubmed, EMBASE, ProQuest, Scopus, Cochrane, and EBSCOhost) from inception till June 2020. We included studies that evaluated the impact of pharmacist care activities on clinical outcomes in PLWHA. A random-effect model was used to estimate the overall effect [odds ratio (OR) for dichotomous and mean difference (MD) for continuous data] with 95% confidence intervals (CIs). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to evaluate the quality of evidence. The review protocol was published on PROSPERO (CRD42020167994).

RESULTS

Twenty-five studies involving 3206 PLWHA in which pharmacist-provided intervention either in the form of education with or without pharmaceutical-care either alone or as an interdisciplinary team member were included. Eight studies were randomized controlled trials (RCTs), while 17 studies were non-RCTs. Pooled-analyses showed a significant impact of pharmacist care compared to usual care group on adherence outcome (OR: 2.70 [95%, CI 1.80, 4.05]), VL suppression (OR: 4.13 [95% CI 2.27, 7.50]), and rise of CD4-T lymphocytes count (MD: 66.83 cells/mm³ [95% CI 44.08, 89.57]). The strength of evidence ranged from moderate, low to very low.

CONCLUSION

The findings suggest that pharmacist care improves adherence, VL suppression, and CD4-T lymphocyte improvement in PLWHA; however, it should be noted that the majority of the studies have a high risk of bias. More research with more rigorous designs is required to reaffirm the impact of pharmacist interventions on clinical and economic outcomes in PLWHA.

Addressing Unhealthy Alcohol Use and the HIV Pre-exposure Prophylaxis Care Continuum in Primary Care: A Scoping Review

Individuals with unhealthy alcohol use are at increased risk for HIV acquisition and may benefit from receiving HIV pre-exposure prophylaxis (PrEP) in primary care settings. To date, literature synthesizing what is known about the impact of unhealthy alcohol use on the PrEP care continuum with a focus on considerations for primary care is lacking. We searched OVID Medline and Web of Science from inception through March 19, 2020, to examine the extent, range, and nature of research on PrEP delivery among individuals with unhealthy alcohol use in primary care settings. We identified barriers and opportunities at each step along the PrEP care continuum, including for specific populations: adolescents, people who inject drugs, sex workers, and transgender persons. Future research should focus on identification of candidate patients, opportunities for patient engagement in novel settings, PrEP implementation strategies, and stigma reduction.

The Role of Pharmacies in the HIV Prevention and Care Continuums: A Systematic Review

The role of pharmacists in the treatment of HIV has expanded beyond medication dispensing to include a host of cost-effective, evidence-based strategies across the HIV prevention and care continuums. However, wide-scale adoption of pharmacy-based HIV prevention and treatment interventions has been slow. We conducted a systematic review to evaluate the evidence on the role of pharmacists across the HIV prevention and care continuums. Thirty-two studies were identified, most of which provided evidence of feasibility of HIV testing and efficacy of non-prescription syringe sale services in pharmacies. However, only two studies implemented an experimental design to rigorously test pharmacy-based strategies. Notably, no pharmacy-based strategies have specifically targeted the highest HIV risk populations such as black and Latinx men who have sex with men, women, or trans populations. Efficacy trials and effectiveness studies should rigorously test existing pharmacy-based strategies to build greater support for wide-scale adoption and implementation. Moreover, in order to integrate pharmacies into the strategy to end the HIV epidemic, studies are needed to ensure that pharmacy-based HIV prevention and treatment services can reach the highest risk populations.

HIV prevention at drug shops: awareness and attitudes among shop dispensers and young women about oral pre-exposure prophylaxis and the dapivirine ring in Shinyanga, Tanzania

BACKGROUND

HIV risk remains high among adolescent girls and young women (AGYW, ages 15-24) in Tanzania. Many AGYW experience stigma and provider bias at health facilities, deterring their use of HIV prevention services. Privately-owned drug shops, ubiquitous in many communities, may be an effective and accessible channel to deliver HIV prevention products to AGYW, including oral pre-exposure prophylaxis (PrEP) and the dapivirine vaginal ring.

METHODS

In July-August 2019, we enrolled 26 drug shops in Shinyanga, Tanzania in an ongoing study to create "girl-friendly" drug shops where AGYW can access HIV self-testing and contraception. At baseline, all shop dispensers were given basic information about oral PrEP and the dapivirine ring and were asked about their interest in stocking each. During the next 3-5 months, we surveyed AGYW (n = 56) customers about their interest in oral PrEP and the ring.

RESULTS

Among dispensers, the median age was 42 years and 77% were female. Overall, 42% of dispensers had heard of a medication for HIV prevention. Almost all dispensers reported some interest in stocking oral PrEP (92%) and the dapivirine ring (96%). Most (85%) reported they would provide oral PrEP to AGYW who requested it. Among AGYW customers, the median age was 17 years; 29% of AGYW were married or had a steady partner and 18% had children. Only 20% of AGYW had heard of a medication to prevent HIV, yet 64% and 43% expressed some interest in using oral PrEP and the dapivirine ring, respectively, after receiving information about the products. PrEP interest was higher among AGYW who were partnered and had children.

CONCLUSIONS

Despite low prior awareness of PrEP among shop dispensers and AGYW, we found high levels of interest in oral PrEP and the dapivirine ring in both groups. Community-based drug shops represent a promising strategy to make HIV prevention more accessible to AGYW.

HIV pre-exposure prophylaxis (PrEP) knowledge, familiarity, and attitudes among United States healthcare professional students: A cross-sectional study

The United States' initiative to End the HIV Epidemic by 2030 includes a primary goal to reduce new HIV infections by 90 percent. One key contributor to this plan is HIV pre-exposure prophylaxis (PrEP). While knowledge and acceptance of PrEP among clinicians is growing, few studies have assessed knowledge and awareness among future healthcare professionals in academic training programs. The present study aimed to assess and compare healthcare trainees' awareness, knowledge, and familiarity with PrEP prescribing guidelines to better understand and prevent gaps in academic training regarding PrEP. A cross-sectional web-based survey of medical, nurse practitioner, and pharmacy students enrolled at two universities was conducted between October 2017 and January 2018. The study assessed participants' awareness, knowledge, and familiarity with PrEP prescribing guidelines and willingness to prescribe PrEP and refer to another healthcare provider. The survey was completed by 744 participants (response rate = 36.2%). Overall, PrEP awareness was high though PrEP knowledge was low. There were significant differences among student groups in domains of interest. Pharmacy students had the greatest PrEP knowledge, awareness, and familiarity with prescribing guidelines. However, medical students reported the greatest comfort with performing PrEP-related clinical activities and willingness to refer a candidate to another provider. Study findings enhance our understanding of healthcare professional students' perspectives of PrEP as a biomedical prevention strategy for HIV. The gaps in students' knowledge offer opportunities for the development of educational strategies to support HIV prevention among future healthcare professionals.

Knowledge, empathy, and willingness to counsel patients with HIV among Indonesian pharmacists: a national survey of stigma

This study aimed to assess the level of HIV treatment knowledge, empathy, and HIV stigma of pharmacy students and pharmacists working with patients as well as potential factors associated with stigma. This survey included 250 hospital pharmacists within 33 provinces and 1013 final-year pharmacy students from Java, the most populated island in Indonesia. The data were collected via Qualtrics® and distributed by WhatsApp. The mean age of the participants was (Mean ± SD) 24.68 ± 5.30 years, and 80.0% were female. The mean knowledge score of students and pharmacists were 14.14 ± 2.01 and 15.39 ± 1.87, respectively, out of the maximum score of 21. The mean empathy score of students and pharmacists was 72.06 ± 5.39 and 77.40 ± 1.35, respectively out of the maximum score of 105. The mean stigma score of students and pharmacists was 21.02 ± 4.65 and 20.66 ± 4.41, respectively, out of a maximum score of 48. Regression analysis showed that knowledge, empathy, and willingness to counsel patients were negatively associated with stigma. Working with patients was positively associated with stigma. A multi-level intervention including education may reduce stigma and strengthen the role of pharmacists in caring for patients.

The case for prescribing PrEP in community mental health settings

Pre-exposure prophylaxis (PrEP) is a biomedical HIV prevention modality that is up to 99% effective in preventing HIV acquisition through sex if taken as directed. People with serious mental illness (eg, schizophrenia and bipolar disorder) are at high risk of acquiring HIV due to sexual behaviours, injection drug use, social factors, and structural discrimination that limits access to all types of preventive health services. We seek to show the importance of prioritising access to PrEP for people living with serious mental illness treated in community mental health settings. We describe barriers to prescribing PrEP, including provider attitudes and provider knowledge gaps, patient attitudes and knowledge, and systems issues. We also address the concerns that community mental health clinic administrators might have about taking on the responsibility of offering PrEP. In summary, despite the barriers to prescribing PrEP in these settings, we believe that there is a unique opportunity for community mental health settings to help address the HIV epidemic by facilitating the prescribing of PrEP to the at-risk populations they currently serve.

Support and perceived barriers to implementing pre-exposure prophylaxis screening and dispensing in pharmacies: Examining concordance between pharmacy technicians and pharmacists

OBJECTIVES

Recent legislation to expand pre-exposure prophylaxis (PrEP) screening and dispensing in pharmacies may significantly improve PrEP access for people at a high risk of human immunodeficiency virus (HIV) transmission. Studies have shown that pharmacists show wide support for PrEP expansion in pharmacies. However, pharmacy technicians are often the first point of contact for patients in pharmacies and are required to implement many of the tasks to ensure patients of a pharmacy receive adequate services. The purpose of this study was to assess pharmacists' and pharmacy technicians' perspectives regarding the implementation of PrEP screening and dispensing.

METHODS

We qualitatively examined whether pharmacy technicians' (n = 6) support and perceived barriers to screening and dispensing PrEP in pharmacies were concordant with those of pharmacists (n = 7). Pharmacy staff were recruited from high-risk HIV neighborhoods in Atlanta, GA using AIDSVu (Atlanta, GA). Two independent coders used MAXQDA (Berlin, Germany) and performed thematic data analysis and unitization to determine agreement.

RESULTS

Pharmacists and pharmacy technicians expressed strong willingness and support for screening and dispensing PrEP in pharmacies. Both groups expressed concerns about the time and the resources needed to perform PrEP screening and dispensing. Technicians, however, also reported concerns about privacy for patients, the need for community support and awareness of pharmacy-based PrEP screening, and recommended scheduling of PrEP screening activities during a limited part of the day to facilitate screening. Pharmacists reported fewer barriers but reported a need for more training of pharmacy staff to assist with PrEP screening and dispensing implementation.

CONCLUSION

Pharmacy technicians discussed more barriers compared with pharmacists who were largely centered around practical considerations (i.e., logistics and workflow) that may affect the success of PrEP screening and dispensing. Given technicians' pivotal role in the pharmacy, implementation of pharmacy-based PrEP services should address technicians' perceived barriers in addition to those of pharmacists.

Student Education About Pre-exposure Prophylaxis (PrEP) Varies Between Regions of the United States

BACKGROUND

Daily, oral pre-exposure prophylaxis (PrEP) is an effective and safe prevention strategy for people at risk for HIV. However, prescription of PrEP has been limited for patients at the highest risk. Disparities in PrEP prescription are pronounced among racial and gender minority patients. A significant body of literature indicates that practicing healthcare providers have little awareness and knowledge of PrEP. Very little work has investigated the education about PrEP among health professionals in training.

OBJECTIVE

The objective of this study was to compare health professions students' awareness of PrEP and education about PrEP between regions of the US, and to determine if correlations between regional HIV incidence and PrEP use were present.

DESIGN

Survey study.

PARTICIPANTS

A cross-sectional sample of health professions students (N = 1859) representing future prescribers (MD, DO, PA), pharmacists, and nurses in the US.

KEY RESULTS

Overall, 83.4% of students were aware of PrEP, but only 62.2% of fourth-year students indicated they had been taught about PrEP at any time during their training. Education about PrEP was most comprehensive in the Northeastern US, the area with the highest PrEP to need ratio (4.7). In all regions, transgender patients and heterosexual men and women were least likely to be presented in education as PrEP candidates, and men who have sex with men were the most frequently presented.

CONCLUSIONS

There are marked differences in education regarding PrEP both between academic programs and regions of the USA.

Roles for Pharmacists in the "Ending the HIV Epidemic: A Plan for America" Initiative

In 2019, President Trump announced a new initiative, Ending the HIV Epidemic: A Plan for America (EHE). EHE will use 3 key strategies-diagnose, treat, and prevent-to reduce new HIV infections at least 90% by 2030, as well as new laboratory methods and epidemiological techniques to respond quickly to potential outbreaks. Partnerships are an important component in the initiative's success. Pharmacists and pharmacies can play important roles in EHE, including dispensing antiretroviral therapy and providing HIV screening, adherence counseling, medication therapy management, preexposure prophylaxis, and nonprescription syringe sales. The objective of this report is to discuss potential roles that pharmacists and pharmacies can play under the key strategies of EHE.

Evaluation of human immunodeficiency virus curricular content in schools of pharmacy in the United States

INTRODUCTION

Human immunodeficiency virus (HIV) is an important educational topic for student pharmacists given extended patient life expectancy and expanding pharmacist roles in HIV treatment and prevention. Data are lacking in regard to curricular content and type of training received by faculty to provide didactic and experiential HIV training.

METHODS

A cross-sectional, population-based survey of United States (US) pharmacy schools was conducted using a 15-item questionnaire. HIV content experts were surveyed at 135 four-year, accredited programs.

RESULTS

Thirty-seven responses were received from schools in the Midwestern (34%), Northeastern (26%), Southern (26%), and Western (14%) regions. Time devoted to didactic HIV education ranged from 0.5 to 60 hours. The majority of respondents (78%, n = 29) reported 10 or fewer hours of HIV-related content, with 41% (n = 15) reporting five or less hours of content. Experiential practice sites for HIV training were variable, with a majority (80%) including an outpatient infectious diseases/HIV clinic. Eighty percent of respondents also reported students receiving fewer than 25 encounters with people living with HIV (PLWH) throughout their entire experiential training. Over half (54%) of respondents reported that the primary HIV instructor devoted four hours per week or less to HIV care.

CONCLUSIONS

Diversity in the amount of time devoted to HIV didactic education existed among reporting US pharmacy schools. Few schools have dedicated faculty spending a substantial amount of time in direct care of PLWH. Minimum standards for HIV education in schools of pharmacy should be established.

Attitudes about community pharmacy access to HIV prevention medications in California

OBJECTIVE

Increasing access to human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) is a high priority for the Ending the HIV Epidemic Initiative. Expanding access to PrEP and PEP through a variety of health care settings, including community pharmacies, may increase access in communities most in need. California is the first state to allow community pharmacists to furnish PrEP and PEP directly to consumers. Our objective was to assess attitudes among key stakeholders about a California policy to allow community pharmacists to furnish HIV PrEP and PEP.

METHODS

We conducted a qualitative case study with key pharmacy stakeholders. Semistructured phone interviews were audio-recorded and transcribed verbatim. We generated analytical memos for each interview and working with these analytical memos, we conducted a constant comparison across cases to identify commonalities and differences.

RESULTS

We launched the study in October 2018 and interviewed pharmacists (n = 7) working in a variety of settings, including retail-, clinic-, and community-based pharmacies. We also interviewed medical providers (n = 2) working in high-volume PrEP clinics and sought input from representatives of large retail chain pharmacies (n = 2). Overall, pharmacists and medical provider informants shared similar opinions about the central benefits as well as the key challenges related to pharmacist-delivered PrEP and PEP services. Benefits included: community pharmacists are widely accessible, PrEP and PEP protocols are similar to other preventative medications, policy may lead to efficiencies in the health care workforce, and community pharmacists are authorities on medication adherence. Challenges included: implementation issues may limit pharmacist involvement, and missed opportunities to diagnose and treat other health conditions.

CONCLUSION

This study characterizes the types of benefits and challenges that can be expected when PrEP and PEP prescribing privileges are extended to community pharmacists. This information may be useful to policymakers and other stakeholders considering legislation to permit direct prescription of PrEP and PEP by pharmacists.

Disparities in the PrEP continuum for trans women compared to MSM in San Francisco, California: results from population-based cross-sectional behavioural surveillance studies

INTRODUCTION

Although transgender women (trans women) often are conflated with men who have sex with men  (MSM) in HIV research and services, there are distinct population differences that are important for implementing effective HIV prevention. Our objective was to examine pre-exposure prophylaxis (PrEP) disparities between the two populations and compare individual, social and structural factors that influence differences between MSM and trans women along the PrEP continuum.

METHODS

We analysed data from two population-based studies, one with trans women (Trans*National Study, 2016 - 18) and the other with MSM (National HIV Behavioral Surveillance, 2017). Trans women were recruited via respondent-driven sampling and MSM using time location sampling. Key indicators of the PrEP continuum were evaluated, including awareness, health insurance, provider discussions, recent use and adherence. Associations were also examined for PrEP continuum indicators and structural barriers (e.g. employment, homelessness).

RESULTS

Transwomen were more likely than MSM to be Latino/a (30.4% vs. 25.8%; prevalence ratio (PR)=1.08, 95% CI 1.02 to 1.14) or African American (7.1% vs. 4.5%; PR = 1.12, 1.02 to 1.24), live at or below the poverty limit (70.7% vs. 15.8%; PR = 1.47; 1.41 to 1.53), be unemployed (50.1% vs. 26.3%; PR = 1.18, 1.13 to 1.24), be homeless (8.4% vs. 3.5%; PR = 1.15, 1.06 to 1.25) and to have less than a college degree (PR = 1.41, 1.34 to 1.48). Trans women were more likely than MSM to have health insurance (95.7% vs. 89.7%, PR = 1.17, 1.06 to 1.28), but less likely than MSM to have heard of PrEP (79.1% vs. 96.7%; PR = 0.77, 0.73 to 0.81), talked with a provider about PrEP (35.5% vs. 54.9%; PR = 0.87, 0.83 to 0.91) and less likely than MSM to have used PrEP in the past six months (14.6% vs. 39.8%; PR = 0.80, 0.76 to 0.84). Among PrEP users, trans women were less likely to report being adherent to PrEP than MSM (70.4% vs. 87.4%; PR = 0.80, 0.70 to 0.91).

CONCLUSIONS

We found PrEP disparities for trans women compared to MSM and the need for differentiated implementation strategies to meet the specific PrEP barriers trans women face. Inclusion of trans women's HIV risks is needed in CDC guidance for PrEP. Interventions to increase trans women's awareness of PrEP including at the provider and community level are also needed. Finally, programming that addresses trans women's barriers to housing and income is also needed to reduce PrEP disparities.

Awareness of and attitudes toward pre-exposure prophylaxis among African American women living in low-income neighborhoods in a Southeastern city

African American women in the South are disproportionately affected by HIV but have often been ignored in HIV prevention efforts, including in the rollout of pre-exposure prophylaxis (PrEP). To inform strategies to promote PrEP awareness and access in this population, we conducted a venue-based community survey with 53 African American women living in low-income neighborhoods of a Southeastern city to understand women's knowledge of and attitudes toward PrEP. Awareness of PrEP was very low (37%) with only 16% being aware that PrEP is used for HIV prevention. The vast majority of women (85%) reported that they would use or would consider using PrEP, most frequently citing a general interest in HIV prevention or a lack of awareness of their partners' HIV status as motivations for their interest. Some women expressed concerns about side effects or low perceived HIV risk as disincentives for PrEP use. Information regarding side effects and HIV risk assessments will be needed to ensure the acceptable delivery of PrEP in this population.

A Narrative Review of Continuing Professional Development Needs for Pharmacists with Respect to Pre-exposure Prophylaxis (PrEP) for Human Immunodeficiency Virus (HIV)

Pre-exposure prophylaxis (PrEP) for the human immunodeficiency virus (HIV) is rapidly increasing in use worldwide, with many countries now publicly funding use for high risk populations. Pharmacists, as front-line care providers, must have the necessary knowledge, skills and attitudes to effectively provide care to PrEP patients. The aim of this review was to identify priority areas and key gaps for continuing professional development (CPD) needs relating to PrEP for practicing pharmacists. An electronic search of PubMed, EMBASE, International Pharmaceutical Abstracts and CPD-related journals was supplemented with a manual search of references to identify articles describing pharmacists’ knowledge, perceptions and experience with PrEP. A total of eight articles were identified across four countries. Pharmacists were consistently found to lack knowledge and awareness of PrEP, express low confidence/comfort with patient care practices, report a lack of experience and/or intentions to provide patient care, but overall had positive perceptions of PrEP therapy. Older pharmacists with more experience commonly reported greater knowledge gaps than recently trained pharmacists. CPD should therefore aim to increase pharmacists’ baseline knowledge and awareness of PrEP and treatment guidelines, as well as be directed towards older pharmacists with more experience.

Health Care Provider Barriers to HIV Pre-Exposure Prophylaxis in the United States: A Systematic Review

Increasing prescription of pre-exposure prophylaxis (PrEP) is imperative to ending the HIV epidemic in the United States. The objective of this review was to identify health care provider barriers to PrEP implementation. A systematic review was conducted in February 2019 using PubMed to identify barriers to PrEP prescribing practices in the United States. Targeted search terms surrounding PrEP and providers resulted in 222 original studies, 28 of which were ultimately included in our review, with data collected between 2011 and 2018. Six themes were identified across reviewed studies: (i) a lack of PrEP knowledge, (ii) the presence of the Purview Paradox, which refers to discordance in beliefs between HIV specialists and primary care providers on who should prescribe PrEP, (iii) concerns about PrEP costs, (iv) concerns about behavioral and health consequences, (v) interpersonal stigma, and (vi) concerns about patient adherence. A majority of providers were lacking knowledge regarding PrEP, resulting in discomfort in prescribing PrEP, or limited awareness and understanding of PrEP clinical guidelines. Discrepant opinions were identified regarding whether PrEP was best managed within primary care or specialty clinics. Other barriers included concerns about cost, patient adherence, and follow-up maintenance care. Finally, concerns about risk compensation and discomfort discussing sexual activities with patients who would benefit most from PrEP were apparent. Additional work is needed to prepare providers to prescribe and manage patients on PrEP, optimize PrEP delivery, and reduce provider bias. Future research is needed to identify providers' attitudes and beliefs regarding innovations in PrEP dosing, task shifting, and novel strategies for PrEP care.

A Pharmacist-Led, Same-Day, HIV Pre-Exposure Prophylaxis Initiation Program to Increase PrEP Uptake and Decrease Time to PrEP Initiation

Mississippi has one of the highest rates of HIV in the United States, but has low pre-exposure prophylaxis (PrEP) uptake, particularly among black men who have sex with men (MSM) and women. From November 2018 to May 2019, patients at high risk of HIV who tested negative for HIV at a nonclinical testing center in Jackson, Mississippi, were referred to an on-site clinical pharmacist for same-day PrEP initiation. The pharmacist evaluated patients for medical contraindications to PrEP, but no baseline labs were obtained. The pharmacist provided a PrEP prescription and scheduled a clinical appointment for patients within 6 weeks, at which time they were evaluated by a clinician and completed baseline labs. The pharmacist evaluated 69 patients for PrEP; 57% were MSM, 77% were black, and 65% were uninsured. All patients received a PrEP prescription; 83% received the prescription the same day and 97% received it within 5 days. Fifty-three (77%) of 69 clients filled the prescription; 87% of whom filled it within 1 week. Only 23 (43%) of 53 clients who filled their prescription attended their initial clinical appointment within 6 weeks of obtaining PrEP. There were no differences in PrEP initiation or retention by patient sex/gender. This pilot program suggests that an on-site pharmacist working in a nonclinical testing center in the southern United States can successfully initiate PrEP among predominately low-income black MSM. Future efforts should seek to better integrate laboratory testing into this demedicalized model of PrEP and to improve retention in care.