Pharmacist-Led, Same-Day, PrEP Program
The pharmacist-led, same-day, pre-exposure prophylaxis (PrEP) program in Mississippi was created to address high drop-off rates seen during referral to PrEP. The program targeted those at high risk for HIV, connecting clients with a pharmacist located in the same building as a testing centre for HIV and sexually transmitted infections (STIs). Through a collaborative practice agreement, the program pharmacist could prescribe PrEP outside of a clinical setting and on the same day that clients visited the centre for their initial testing. Baseline PrEP testing (e.g., serum creatinine) was completed during a follow-up clinical appointment with a clinical provider within six weeks. The program was able to provide an initial prescription to all clients who were connected to a pharmacist. Among this high-risk group, 33% of clients who were provided with a prescription went on to attend their first clinical appointment within six weeks.
Clients who attended a walk-in HIV/STI testing centre staffed by two nurses were offered same-day PrEP if they tested negative for HIV through a rapid point-of-care test. Additionally, PrEP was explicitly recommended to those who tested negative for HIV on a rapid point-of-care test and were:
- men who reported having sex with men
- transgender women
- cisgender women who were diagnosed with an STI, who had contact with a partner with HIV or an STI, who had an ongoing sexual relationship with an HIV-positive partner or a partner whose HIV status was unknown, who reported recent injection drug use, or who had an ongoing sexual relationship with men who have sex with men
Clients who were interested in PrEP were connected with the on-site pharmacist or were contacted by the pharmacist within 48 hours if they couldn’t meet that day. During the initial meeting, the pharmacist:
- provided clients with information about the effectiveness and side effects of PrEP as well as the importance of adherence
- took clients’ medical history, including contradictions for PrEP (e.g., kidney disease)
- assessed clients for acute HIV (those showing signs of an acute HIV infection were referred on the same day to a specialist for post-exposure prophylaxis)
- completed paperwork for insurance coverage
For clients who were not showing signs of acute HIV infection and who did not have contraindications for PrEP, a 60-day PrEP prescription was sent to the client’s preferred pharmacy. A collaborative practice agreement allowed the program’s pharmacist to work in partnership with a physician within a defined role: the pharmacist was able to assume responsibility for tasks such as doing assessments, providing referrals, administering medications and prescribing PrEP (prescriptions were billed under a physician’s name). Laboratory tests were not completed during the initial meeting; the pharmacist scheduled an appointment for follow-up within six weeks with a clinical provider, who would complete the client’s baseline PrEP testing (e.g., serum creatinine). If clients did not pick up their initial prescription, the program pharmacist contacted them weekly for one month. Prescriptions were not refilled if the client did not attend their six-week clinical appointment.
Patients with signs of acute HIV infection or contraindications for PrEP were referred the same day to an infectious disease doctor for evaluation.
This observational study took place between November 2018 and May 2019. A total of 69 clients were referred to the program’s pharmacist for same-day PrEP. All of these clients received a prescription for PrEP. Results show that:
- 90% of clients (62) were seen by the pharmacist on the same day as they had their HIV test
- 83% of clients (57) received a PrEP prescription on the same day that they tested HIV-negative
- 77% of clients (53) filled their PrEP prescription
- 43% of clients (23/53) who filled their prescription attended a clinical appointment within six weeks
Therefore, 33% (23/69) of those who were referred to the same-day PrEP program filled a PrEP prescription and were linked to PrEP care.
What does this mean for service providers?
Although this study had a small number of participants (69), it focused on people at high risk for HIV and tried to address some of the challenges associated with the drop-offs normally seen with PrEP referrals. The program was able to prescribe PrEP to all participants, although only 33% of those who were prescribed PrEP attended a clinical appointment for a baseline assessment. Therefore, this approach also highlights the importance of finding ways to retain clients in programs in addition to initiating their use of PrEP.
This study was unique in that it allowed people to start PrEP outside of the clinical setting. This program shows that it is possible to initiate PrEP outside of clinical settings and that pharmacists can play a role in facilitating the process of initiating PrEP.
The Maple Leaf PrEP Clinic – Case Study
Text Message Reminders – Program Element
Khosropur CM, Backus KV, Means AR et al. A pharmacist-led, same-day, HIV pre-exposure prophylaxis initiation program to increase PrEP uptake and decrease time to PrEP initiation. AIDS Patient Care and STDs. 2020;34(1):1-6.