If you happen to live in Oregon, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) may soon be a lot easier to get. A bill allowing pharmacists to dispense PrEP and PEP without a doctor’s prescription passed overwhelmingly in the Oregon House of Representatives in late April. If it passes the Senate and is signed into law, which many advocates expect it will, Oregon will be the third state after California and Colorado to allow its residents to get a starter pack—a month’s supply—of HIV-preventive medicine in a single visit to any pharmacist trained in PrEP.
The bill, HB 2958, which passed in a 47 to 7 vote, would remove barriers to obtaining PrEP and PEP by giving pharmacists the authority to perform HIV tests and to counsel people about HIV and the regimen. It also reimburses pharmacists for their time, something advocates say might encourage more pharmacies to opt in. The bill also mandates insurers operating in the state to cover at least one form of PrEP without prior approval.
Removing Barriers to Access
Taken orally, PrEP, whether used daily or on-demand, can prevent up to 99% of HIV infections. It is estimated that 3 million people worldwide are eligible for PrEP, including more than a million in the U.S.—but current data on PrEP use falls short of those goals. Although the regimen was approved almost a decade ago, uptake has been sluggish—and that is particularly true for those most at risk for HIV infection. While Black and Latinx men who have sex with men (MSM) contract HIV at disproportionately higher rates than white MSMs, they were also significantly less likely than were white MSMs to be aware of PrEP, to have discussed PrEP with a health care provider, or to have used PrEP within the past year, according to a 2019 analysis from the U.S. Centers for Disease Control and Prevention (CDC).
Bills like HB 2958, in theory, would remove some major hurdles to access—insurance pre-authorization, need for a doctor’s visit, and a separate trip for an HIV test—and hopefully encourage more people to start PrEP. After all, there are pharmacies in nearly every community—when it comes to HIV testing centers and sexual health clinics, that’s not always the case.
The passage of California’s law in 2019 led other states to consider laws to “de-medicalize” access to PrEP and PEP by letting pharmacists prescribe at least a starter kit, but up until now, Colorado had been the only state to follow through with its own version of the law. And in California, where there are still no data on whether the law is working to boost access to PrEP and PEP in underserved areas and vulnerable communities, there are also no incentives for pharmacists—leading to speculation early on that the law wouldn’t have the desired benefit.
That’s where the Oregon bill differs: Pharmacists would be paid for their time by insurance companies. “The biggest issue with the California law is that it doesn’t allow pharmacists to be reimbursed, so there’s no financial incentive to participate,” said Jonathan Frochtzwajg, public policy and grants manager of the Portland-based nonprofit Cascade AIDS Project, a sponsor of the Oregon bill. He added that, with the Oregon bill, pharmacists would act like doctors, offering screening and counseling for HIV, and would be reimbursed for their time like doctors are. The bill will also require pharmacists who opt in to take a training in PrEP, PEP, and trauma-informed care. Frochtzwajg explained that pharmacists in Oregon, unlike many other states, already have the ability to prescribe PrEP and PEP, but few know what it is or how to assess patients, and none are able to bill for their time, yet.
Some Unknowns Remain
Despite the financial incentive, it’s not clear how many pharmacists will take the training module and choose to provide PrEP and PEP, especially in rural, conservative areas, or how many will be able to provide an HIV test (the bill requires only a rapid oral test in order to receive the starter supply).
It’s also not clear whether obtaining just a 30-day supply would be another hurdle. After the initial starter pack is exhausted, PrEP users would need a doctor’s prescription to obtain more pills, plus an HIV test at a lab. If their initial HIV test is positive, presumably the pharmacist would provide the person with a list of HIV specialists for referral.
“Hopefully, pharmacists will be able to do a warm hand-off to a doctor experienced with HIV,” said Frochtzwajg. “But we are concerned that [the referral] could limit access.” On the other hand, he said, the bill is intended to reach people who are not actively involved in traditional health care and therefore may not have a primary care physician or even insurance. If the law works as expected, a 30-day supply of PrEP would be a stepping-stone to greater health care access. If not, compounding factors like a lack of physicians in the area and the additional cost of lab tests could be barriers.
As for getting the word out to Oregon communities about PrEP’s availability at pharmacies, the Oregon Health Authority, through its End HIV Oregon initiative, will spearhead the effort if and when the bill passes. (TheBody will provide updates on the bill’s progress, as well as the status of similar bills throughout the U.S.)
“We fund the two AIDS service organizations in Oregon [Cascade AIDS Project and HIV Alliance] to provide PrEP navigation services, so we’d plan to really capitalize on their expertise and connections to increase community awareness and also be a bridge between pharmacists, patients, and other medical providers who prescribe PrEP,” an Oregon Health Authority spokesperson said in an email. “All of our contractors for HIV prevention services, including local health departments, Cascade AIDS Project, and HIV Alliance, would be expected to incorporate messaging around the different ways an individual can access PrEP as they are right now under our contracts.”