Madison A. Cameron, PharmDa; Jenna Kawamoto, PharmD, BCACPa; Troy A. Shahoumian, MPH, PhDb; Pamela S. Belperio, PharmD, BCPS, AAHIVPb
Correspondence: Madison Cameron (madison.cameron2@va.gov)
aVeterans Affairs Greater Los Angeles Healthcare System, California
bVeterans Affairs Palo Alto Health Care System, California
Author disclosures
The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Ethics and consent
The Veterans Affairs Greater Los Angeles Healthcare System Institutional Review Board determined that this quality improvement study was exempt from review.
Background: Uptake and access to HIV preexposure prophylaxis (PrEP) is key to reducing incident HIV infections. Pharmacists are one of the most accessible health care professionals in the United States and are well suited to address this need.
Observations: We describe a model of care at the Veterans Affairs Greater Los Angeles Healthcare System in which clinical pharmacist practitioners developed and implemented a pharmacy-led PrEP clinic colocated within an infectious disease clinic. Veterans Health Administration clinical pharmacists provide direct patient care under a scope of practice that includes ordering and interpreting laboratory tests and providing PrEP prescriptions. To improve access and patient acceptability, we also used novel telemedicine modes of care to ensure flexible appointment scheduling.
Conclusions: This model can be used by other federal and community-based health care organizations to implement interdisciplinary pharmacist-managed PrEP clinics and expand telehealth modalities to deliver outpatient services.
The US Department of Health and Human Services (HHS) Ending the HIV Epidemic framework aims to decrease HIV infections in the United States by 90% before 2030.1 Achieving this goal requires identifying persons at high risk for HIV and ensuring timely and efficient access to HIV preexposure prophylaxis (PrEP).2-5 However, despite its commercial availability since 2012, community uptake of PrEP is low.6 In 2019, < 25% of Americans who could benefit from PrEP were using this preventive therapy.7 Poor uptake of PrEP has also been documented among veterans and US military service members. National data on men in the military and men who have sex with men (MSM) in the military suggest that about 12,000 service members are eligible for PrEP; however, only 2000 service members and their beneficiaries accessed PrEP in February 2017.8
A review of health records of US military service members conducted from 2014 to 2016 indicated that most patients who received PrEP did not receive recommended monitoring in accordance with the Centers for Disease Control and Prevention (CDC) guidelines. Furthermore, 16% of these individuals did not have HIV testing within 14 days of initiating PrEP, and 13% were never evaluated for hepatitis B infection.8
Pharmacists are highly accessible health care professionals (HCPs): More than 90% of Americans live within 5 miles of a community pharmacy.9 Pharmacists play an integral role within the outpatient health care team and have been responsible for improvements in health care outcomes for a variety of chronic conditions and immunization practices.10-13 Additionally, community pharmacists have provided vital access to care during the COVID-19 pandemic.14 The clinical pharmacist practitioner (CPP) is an innovative and advanced role within the Veterans Health Administration (VHA), functioning with a scope of practice and prescribing privileges to provide direct patient care.15
CPPs are well suited to address the need for increased access, capacity, and timely provision of PrEP, especially in areas where HIV acquisition rates are high or in areas with reduced access to care. We describe a model for a pharmacist-led HIV PrEP program (Pharm-PrEP) to increase access to PrEP. A similar program could be adapted to further expand the use of PrEP in other health care systems and community settings.
