Introduction: Obtaining PEP
Two years ago, the Alachua County Community Support Services, Victim Services and Rape Crisis Center in Gainesville, Florida, contacted me to inquire about Walgreens' partnership in assisting uninsured sexual assault victims to obtain HIV post-exposure prophylaxis (PEP) prescriptions during weekends and holidays. This issue is of great importance because once an individual is sexually assaulted, there is only a 72-hour window to begin PEP. Ideally, it is recommended to start the regimen as soon as possible. I have learned that when a person is sexually assaulted, local emergency rooms only provide a one-day dose of the regimen. As a result, this leaves the victim advocate and patient foraging for medication to cover the remaining days of the typical 28-day regimen. In addition, the problem is further compounded if the assault occurs on a holiday weekend.
I have a bit of insight into this situation because since 2006 I have spent time in Rwanda working with a non-governmental organization (NGO) to build an HIV pharmacy for genocide rape victims and their families. During my visits to the country, I sat in on counseling sessions with trauma counselors and victims. The stories of rape and torture were harrowing and piqued my interest to help even more.
At the time of the initial request from Alachua County Victim Services and Rape Crisis Center, there were two PEP medications: tenofovir/emtricitabine (Truvada) and raltegravir (Isentress). Both required victims to submit patient assistance program forms. In my opinion, the raltegravir program was cumbersome for sexual assault victims because patients have to complete the patient assistance form, get a doctor's signature, fax in the form and optimistically expect a 24-hour turnaround. If a sexual assault occurs over the weekend, patients may not receive the medication until that upcoming Wednesday. Furthermore, the medication could not be processed by the pharmacy but rather the medication would either be mailed to the doctor's office or to the patient's home. As a result, this took the pharmacist out of the treatment process, and made coordination of treatment very difficult. However, when I used the tenofovir/emtricitabine patient assistance program, I supplied key patient information (with patient consent) over the phone and received billing codes shortly thereafter.
A Game Changer
Over the course of many months, the request of the rape crisis center still weighed heavy on my mind. In the interim another pharmaceutical in the class of integrase inhibitors, dolutegravir (Tivicay, DTG), came to market. During this time, I discovered that dolutegravir has a patient assistance program similar to tenofovir/emtricitabine. I contacted dolutegravir's company, ViiV, and discovered that I had the ability to register as an advocate. Registering as an advocate allowed me to call ViiV, and follow up with an application. In addition, I was able to quickly receive applicable billing codes. Now, I had all the pieces of the puzzle in place: two drugs and two ways to bill for the medications.
Implementing the Strategy
The key objective to this strategy is getting patients a three-day supply of prophylactic medications. Execution of this objective is critical. An integral step for the patient assistance program includes obtaining accurate data. In order to get the ball rolling, I initiated a conversation with my boss that went something like this: "I found a way to provide HIV post-exposure prophylaxis medications to uninsured sexual assault victims over the weekend. I will take responsibility for getting the company paid. Done."
Over the last two years, I have continued to communicate with one of the victim advocate counselors, Cassandra Moore. Following my newfound partnership with ViiV's patient assistance program, I have contacted her and updated her on what I had discovered.
Immediately, we agreed to create a pilot program, and started a tradition of weekly meetings over coffee. During these meetings we discussed implementation of the protocol, identifying what information counselors need to supply and the inevitable blips in implementation. We identified all needed initial documentation to be supplied during the victim advocate counselor's initial visit to the emergency room.
Next, we spoke with a doctor and a sexual assault nurse examiner (SANE) on how the prescriptions should be written, and how the patients would access medications. Additionally, Ms. Moore scheduled meetings with other victim advocate counselors to ask questions, and I, along with other pharmacists and technicians in my store, garnered insight about ways to implement the PEP program.
We set out to accomplish two goals with every first encounter: speediness and discretion. During the first visit when the patients come in with counselors, their paperwork goes to the front of the line. When all paperwork is in order, we try to fill their prescriptions within a 10-20 minute window. In addition, the pharmacy staff is discrete in handling these scripts. Furthermore, I have an HIV counseling certification in Alachua County, and I am able to talk with the counselor and patient in the pharmacy's private counseling room.
During the second visit, Walgreens wanted to provide even better service. In one of the pharmacies in this program, we offer next-day shipping, or if they reside in Gainesville, courier service can be provided to the home. Another reason for courier service is to avoid triggering the patient. Offering these service options is increasingly helpful especially when a patient does not have transportation. Since March 2015, we have provided PEP to five patients. While the number of patients served is not high, witnessing the relief on the patients' and the counselors' faces has been priceless.
We currently have this pilot project in two pharmacies: the pharmacy in which I work, and a 24-hour Walgreens pharmacy. The pharmacists and staff in both sites were given an intake orientation to discuss procedures, and the importance of helping sexual assault patients. Subsequently, the pride and professional accomplishment of everyone soon became evident. As a result of tireless effort to initiate this program, two store managers have attended local Coalition Against Sexual Violence (CASV) meetings facilitated by Victim Services and Rape Crisis Center. It was evident that the presence of Walgreens staff was very much appreciated by members of the coalition. The presence of Walgreens staff demonstrated commitment to the PEP program. In my opinion, too often their requests for PEP assistance have been met with, "No," or resulted in no action. However, we at Walgreens continue to do our best to find ways to say, "Yes."
My victim advocate liaison has introduced me to so many organizations in the community that provide assistance and support to victims of sexual assault. These organizations include ER staff, the University of Florida, Alachua County Sheriff's Department, Gainesville Police Department, the state attorney's office, and Peaceful Paths (a local domestic violence agency). I have continued to attend CASV meetings to share information about the program, and gather feedback about how we can improve in the future. We are moving cautiously and carefully to identify ways of expanding other areas of PEP. It is with great hope and planning that other stores will get involved and help fill gaps in PEP care in other underserved parts of the country.