The embarrassment of going to a pharmacy can cause stress for people living with HIV, on pre-exposure prophylaxis (PrEP), or in need of prescriptions for other stigmatized conditions. This can keep many people away from receiving the treatment they need. But Christina Garcia, Pharm.D., and her partner have built a welcoming, creative space for the LGBTQ community to meet these needs in an affirming environment.
Terri Wilder: You and your partner, in life and in business, recently opened a pharmacy to address the needs of the LGBTQ communities in San Francisco and, particularly, in the Castro neighborhood. Can you talk about why you decided to open a pharmacy like this, particularly in a neighborhood that's so well known to the LGBTQ community?
Christina Garcia: I had to make a conscious decision professionally to be out and proud. Because sometimes, people will still, to this day, look down on you as a professional, as a doctor, and say, "Oh, she's gay," or, "He's gay." So, there's definitely that stigma. What we're seeing is actually a huge minority group that's being pushed aside, from a health care perspective.
So, it was a conscious decision for us to say, "Listen. We have been discriminating [against] ourselves." Even just the coming out process was very difficult. Now, as we're seeing the new community, the young kids especially are at big risk as far as getting access to medicine. So, I decided one day to call all of my LGBTQ friends in San Francisco. And I asked them: "How would you guys be if we opened a business that is so specific to the community?"
And they all stopped. And I said, "Is there any business right now in Castro that is even LGBTQ centered?" The answer was no.
So, as we were doing the research, obviously, one of the big ones at the time was the Star Pharmacy. It's been in the community for many, many years; and then, I think, after 15 years ago, it was purchased by Walgreens. So, if you come to Castro, you have pharmacies, but these are national chains. So, obviously, their focus is a lot different than what we're trying to create.
I decided there's a huge need for us to do that. And once we started the traction of our business, I was surprised at the community's help and rallying behind my partner, PJ, and I. So that's when we realized, wow, we're actually doing something so big here. When you think about it, it's logical. Why has no one ever done something like this?
And, obviously, for us, we're doing it from a very personal space. We're doing a business. But creating a business that is very true to your community and this huge need is something that made me realize I have to invest and build something that's lasting.
TW: So, the name of your pharmacy is TIN Rx, and you just recently had an open house so that folks could come and learn more. And, really, the goal is -- like you alluded to -- is to provide patients with culturally competent and inclusive care, in a safe and supportive environment.
Can you talk about some of the things that you and your partner have done to create that inclusive space? I read a little bit about, that you have art from LGBTQ artists. But I'm wondering if you can talk about some of the other things that you've done to make it more of an inclusive, culturally competent space.
CG: If you talk to any other pharmacy owners (or any pharmacy architects, for that matter), they wanted to build a pharmacy that's almost very sterile, right? I had to figure out and hire a different architect group to be able to give me something very retail that is absolutely not health care related.
So it took us a good year and a half to even build, to put the creative folks who have built Victoria's Secret, they built Ulta, Sephora -- just to name a few of these very famous brands. But if you've seen it, it's a very specific retail experience that you have. But that's kind of what I wanted to bring.
Then I also brought in the experts in our industry with automation and how the workflow at the back of the pharmacy is driven. But putting this together, Terri, it was a complete exercise, if I may be honest with you. Because having them to bridge the gap of how the retail works in the world of retail businesses, then you bring in the science behind to it, what's almost two different worlds, clashing. I wanted to bring those two worlds to collide, whereby my community, our patients, our customers that are coming in, have this very welcoming experience.
That took us several interviews, and months and months, to find the right creative brains to bring what I wanted to have, and bring it into a retail space, and create a very warm and welcome experience.
And so, we felt that bringing, actually, art and science together was the most, kind of, normal thing. And that's really how it all came together.
TW: Let's talk about the tech side of this. Something really interesting that I actually had never heard about was these automatic drug-dispensing machines that you have, that kind of make it more convenient for your clientele to get their medication. So, can you talk about that a little bit?
CG: Absolutely. In any business, you would have to have a certain financial backing. But I know that even [with] my backer, and in pharmacy and health care, you have to be able to compete with the national chains. So, I have to invest heavily in the automation and technology, so that my staff are able to actually focus on the patient.
Last year, the state of California finally approved [for pharmacies] to be able to dispense medicines with an automatic dispensing machine. So, for those who are not familiar with this, it's pretty much, after hours, the goal was for pharmacies to be able to have patients pick up their medications even when the pharmacy's closed. And in the state of California, for many of you who are not familiar; it's a very difficult state to have anything passed like that.
Being able to move and adapt to a new technology -- and I don't have any board of directors in my company -- I was so compelled to really invest and have the right team in place and to get this done in this brand-new store in Castro.
I knew intuitively then that I would want to have the machine as part of the construction. Because even though I'm not there, there is that machine after hours.
And so, if you actually go into the pharmacy, there's an area where I created a letter to my community. So, even after hours, they can really have a sense of connection to what we've done, and what this place is all about. So, yes. That's pretty exciting. And I'm smiling because it has taken me a good six, seven months to work with our legal team and the state Board of Pharmacy to get us to be one of those early adapters for this, for the state of California.
TW: Can you talk about how the automatic drug dispensing machine actually works?
CG: Sure. Take, for example: After hours -- and you're a working mom or a you're a working dad, or you're just really busy here in San Francisco, and you needed to get your medication. And our pharmacy closes at 6. Say your doctor sent us your medication just around 5, 5:30, right? And there's no way that you can Uber to our store.
So, what we end up doing is pretty much, we do our conversation with you, as a patient, and prepare the medication. And you're going to receive a text message, or an email on your phone. It's a very unique QR code, where it's very specific to that patient.
So, after hours, when you come into the pharmacy, it figures out that you've been our patient and you've signed up for the machine that you'd like to be able to avail of this; you will be given this little card that would open the pharmacy after hours for you. And the screen is pretty friendly. You just have to follow the prompts. It's very easy. And then you'll scan the barcodes. And one of the lockers will pop open. And your meds are right there. And that's it.
TW: Got it.
CG: That's what we're trying to do, obviously -- get our patients their medication, but after hours. Because I've seen some of those cases, where they needed emergency meds, and the pharmacy is already closed. And having the pharmacy to transfer that prescription to another 24-hour pharmacy is so difficult. And you can see the anxiety from a patient, where they are.
TW: Let's talk about some very specific services that you offer. I'm curious about your services around pre-exposure prophylaxis and, particularly, how you're handling 2-1-1 PrEP, since it's rolling out in San Francisco.
CG: Once you receive any HIV medication -- Truvada -- it's a very expensive drug. So, this will cost us anywhere between $1,700 to $1,800, to $1,900, for a 30-day supply (which is 30 tablets).
Some companies, this doesn't actually get processed in your regular pharmacy. The patient must receive the package. So, typically, when you receive that package, it comes in this really large, bulky box. And there's lots -- lots and lots -- of paper inside. And you have this list of pretty much all the med guides -- but it's quite thick -- of all the main side effect profiles of the medication … and then the bottle.
So, my partner and I, as we are working with some nonprofit organizations, most of the patients that are receiving this are feeling like, "Why do they have to send it so big? I already feel embarrassed with what I'm taking. I'm not comfortable enough to talk about my sexuality. And I have a roommate! And then it comes in a box. So, what am I going to say? I'm taking a prophylactic drug."
Then, what I did was actually work with some of my great minds of my marketing team. And I said, "Is there a way we can actually make this more hip, where it's very discreet?" It comes in this beautiful box.
So, we also created a med guide. The med guides, for those of you who are not familiar, when you take a medication it's kind of like the instructions. So, I wanted it to be so easy. It took us a good month to create some prototypes to actually have it more easily delivered to the customer. I had several revisions to that. And then, once we got the perfect combo that goes into the box; that's when I realized, "Well, I think it's going to be good." So, we started sending that to our first few PrEP patients. And I wanted to get their feedback.
And that was it. They loved it. And then, every month, we started to include certain vitamin samples for them. But it's a very different way that I'd like them to feel when they open the box, when it's just an extension of yourself. It doesn't define them. I never wanted my patients to feel that your life is over, pretty much -- because you're gay and you're taking Truvada; and you're trying to remove that stigma feeling, especially for the young ones. That's pretty much how; and we have created an appreciation factor in the industry.
And so, the cost of creating that, obviously, was a huge investment for me. But it has changed TIN Rx; it has created a completely different placement in the pharmacy world for me.
TW: Folks have a couple of options in how they get their meds. It sounds like you mail them to them; they can use the drug dispensing machine; or they can come in person to your pharmacy.
CG: Yes. We do delivery with them. So, if you're within San Francisco, you can get your medications delivered at your doorstep. We have a courier that does that. Some patients, you know, they travel quite a bit. We have that option, as well -- to send it to their hotel -- if they're business travelers, we accommodate anywhere they need it. And, obviously, we have your traditional, come-to-the-pharmacy. It's ready for them, as well. And we have the ADS [automated dispensing system] machine for after hours.
What we've seen with some of our new customers here in San Francisco -- they actually kind of started liking the new, mail-it-to-me-overnight-and-I-have-a-new-box-the-next-day. So, we're just kind of listening to what they wanted, and try to customize the services much more than any other pharmacy that I've been, or I've worked for, in the past.
TW: In addition to PrEP 2-1-1 being rolled out in San Francisco, the community is really looking forward to preparing for long-acting treatments or additional PrEP options. So, Truvada is going to generic soon. And then we have another drug that's going to come out.
I'm wondering how your pharmacy is preparing for long-acting treatment for people with HIV, and other PrEP options.
CG: I love this question.
Some patients that are on psych meds, for example; we have a different delivery mechanism, which is an injection. So that means the patient doesn't have to take the medication [more than] once a month. And I think our job as pharmacists -- this is particularly why I have prepared TIN Rx; just one of those companies to work hand in hand with some of the top pharmaceuticals in the country, to get other nonprofit organizations, even CDC [the U.S. Centers for Disease Control and Prevention], to provide data. What can we do as far as the adherence of patients that renew medications? Are there better side effect profiles [so] that our patients are able to do that?
We have seen a couple of our patients actually request another drug -- sometimes it's mostly the marketing side of it. But looking at the scientific data, we have seen that they're equally the same as Truvada. And I think the game will obviously change when the insurance companies enter the market. Because, right now, Truvada has obviously [been] the leader in our industry as a prophylactic drug. Once that goes into generic, insurance can change, right? They will cover generics. But some insurance would still want that formulary to be as a brand. Others, on the other hand, would want them to go into the other alternative drugs, which then changes the game altogether.
So, for us pharmacists, what we look at, is each patient can fall into each of the categories. And my job is always to provide patients access to the drugs. If it means they cannot afford the medication and obviously their insurance are going into the generics, we are going to go for that option.
The way I serve as we create our growth strategy, or our financial growth itinerary falls into different fragments of that. So, insurance plays a big role..
But there are factors that we all have to consider; not just them taking the injections. What about their liver function? What about their kidney function? Some patients were not necessarily able to take the injections right away, right? But there are factors we don't know. There may be other disease states. There may be other conditions that may not be a good fit for them for the long-acting injections.
So, these are some of the things that make it very interesting to us to see if certain patients would fall into one category, and the other ones, the other category. So, I think a company like TIN Rx to be able to be part of that to provide data, scientific data, is very important, especially how we do new development of the drugs in the market.
TW: My final question is specifically related to any services that you have that are focused on providing services to the transgender community. I'm wondering if you can talk about: Are there any particular programs or services that you've created for that particular community?
CG: I love this question, Terri. So, the One Card Program actually was very much created to them; it's very close to my heart. Because the trans community, I think, in our community, within the LGBTQ, is getting a lot of the stigma, the discrimination within our community.
I got a call from one of my pharmacists; and we had a patient that's transitioning from female to male. And at one point, the insurance was covering that particular testosterone. And halfway through his treatment, the insurance decided to stop any coverage. So, my staff was asking, "Well, it's very expensive. How are we going to do this?"
The insurance says it is still considered a, quote-unquote, experimental medicine. So, when a [person is transitioning and needs hormones], it is seen as, quote-unquote, experimental medicine.
That really got me to a point where I was pretty upset. So, we were traveling, and I told my partner: "How are we going to expand and provide access to the trans community?"
She said, "Well, why don't we create one card?"
And I said, "One Card? What does that mean?"
And she said, "If you look at the word hormone, you take one; it's for everyone, right?"
So, I took that idea and I called all of our team in Wisconsin who was building our design component. And I said, "I'm going to create pretty much a loyalty program" where, say, for example, I have some trans friends (which I do), and money's very tight, as we all know. They still are pretty much discriminated, even getting a job. So, it's a loyalty program. It's a loadable card that, you know, patients can load their card. And I'm literally giving them a pretty significant discount for them to be able to access their medications. So that is pretty much the development of the trans community, the One Card, for us.
I have provided such support to our pharmacists and our staff that if a patient cannot afford [their prescriptions], we create an accounts receivable for them. I will work anything -- I never want money to be an issue, where the patients are not able to access their meds.
Every quarter, we change the design of the One Card program. It really creates a more inviting, very vibrant expression for my trans patients. So, I just wanted to include them also here in the pharmacy -- what they're feeling and who they are -- that they don't have to feel like they're not welcome whatsoever. They are a huge factor; probably one of the big reasons why I created a certain very vibrant color in our vitamin line was very much from the trans community. So, they are a big part of what TIN Rx has done, or what we're trying to do, as a whole, as a mission, and the mission of my company. So, they are welcome as a huge specialty.
TW: Great. If folks were interested in learning more about your new pharmacy, where could they find information?
CG: Please go to www.tinrx.com. We have all those services for you, including the One Card, your PrEP, your daily vitamins. And then you can also check @TINRx on Instagram.