What is the role of the pharmacist in delivering PrEP (pre-exposure prophylaxis)? For one pharmacy in Seattle, the pharmacist plays multiple roles, doing everything from the HIV testing, to the patient education, to the prescribing of PrEP. Terri Wilder, M.S.W., spoke with Elyse Tung, Pharm.D., at CROI 2017, about this pharmacy and the feasibility replicating a pharmacist-run PrEP (pre-exposure prophylaxis) clinic in a community setting elsewhere.
Terri Wilder: There's a lot of chatter around the country about the role of the pharmacist in pre-exposure prophylaxis [PrEP] delivery. For example, I know in New York state there's a lot of conversations about making sure that pharmacists are educated about PrEP. What is their role in PrEP rollout? Take us through the background of the program that you're involved with.
Elyse Tung, Pharm.D.: We are a traditional community pharmacy site, something that you would normally see on the corner in your neighborhood where you pick up regular prescriptions. We have an over-the-counter section, as well. Patients can come into our clinic and ask if they can get started on PrEP. Then, they'll see one of our pharmacists. We do all the testing, all the patient education, all the prescribing. If they qualify, a lot of our patients can actually leave the pharmacy the same day with medicine in hand. The pharmacist is involved from the very beginning to the very end of the whole process.
TW: You have to find out whether you're HIV negative before you can start PrEP. Some other labs have to be run to make sure that your body is appropriate physically for taking PrEP. Can you talk about how that happens in a clinic setting or a pharmacy setting?
ET: In our pharmacy we have a private patient counseling room. So, all the testing and counseling and the appointments are conducted in that room. We do all the testing there at the pharmacy: HIV testing, sexually transmitted infection testing. Some of the samples are self-collected by the patient and some of the samples are finger stick or venipuncture. Those are collected by the pharmacists. Some of the tests that we utilize are rapid, and some of them are laboratory send-outs.
TW: What about kidney?
ET: Yep. We check that on-site at the pharmacy. That's another rapid test that we use.
TW: My understanding from your presentation is that your pharmacy in your particular state is unique in that you have clinical pharmacists -- which is not widespread across the United States. Can you talk about the advantage of having a clinical pharmacist being part of this?
ET: Really, any pharmacist can be a clinical pharmacist. We're able to do this under a protocol called a collaborative drug therapy agreement (CDTA). Some other states call them collaborative practice agreements. But, from my understanding, most states have some similar form of a protocol or a CDTA that allows a pharmacist to conduct these clinical services with physician oversight. They may be slightly different in legal language under every state's law.
There are definitely some states that don't have that ability. So, we are very fortunate in Washington state that we are allowed to do this. [It] relieves some of the burden on the health care system. It also helps increase access to care.
In my slides, a majority of our patients have not established care. These are patients who don't have a primary care physician [PCP], and they don't know where to go to get their medication or to get on PrEP. The first place they look is, "Oh! I can get it at a pharmacy?" And so, they've sought our services because we're convenient, we're easily accessible, and they find an advantage in coming to a pharmacy, [rather] than going to their doctor, then going to the lab, waiting for the lab results to come back, then going to the pharmacy and getting the prior authorizations approved, and then finally being able to get their medicine. Since we're all in one location, it makes it a lot more efficient for the patient.
TW: How do your folks in the community hear about this? Do you have posters in your pharmacy? Is there kind of a marketing campaign?
ET: It's multiple ways. We definitely have coordinated efforts with a lot of our community-based organizations, or CBOs, who have spread the word about us. We have a really good relationship with our Department of Health, which has also spread the word, and Public Health. We do have our own marketing campaign, as well. And then, also just word of mouth, maintaining a very high level, high quality of care.
As you saw, our retention rate is 75% and patients continue to come to seek our services because they prefer our services. Ensuring that we continue to have that high level of care means that they'll continue to refer their friends and their partners to us.
TW: Do you have multiple locations where this is happening?
ET: Kelley-Ross Pharmacy is an independent pharmacy in Seattle, and we have one community pharmacy site. There are other Kelley-Ross Pharmacy locations, but some of them are closed-door, not in a traditional community setting. So, we have one pharmacy in the area. But, as you can see, our model is replicable and any, really any, pharmacy that's willing to dedicate a little bit of time and energy into the training and implementation can really start up the same thing that we did.
We're really not doing anything that hasn't already been done in a pharmacy. All the skill sets and all the techniques used in our program are everything that's being utilized in other clinic settings, such as anticoagulation, diabetes care, even. We just decided to use that same model and put it onto PrEP.
TW: Do the pharmacists actually identify candidates? Or is it more passive -- the client comes in?
ET: Almost all of our patients are self-referred. They identify with their sexual behavior. They want to get on PrEP. They find us. And they walk in.
A lot of our patients also have primary care providers that they've asked for PrEP, and they don't know how to do it. So, they come to us and say, "My physician doesn't know what PrEP is, doesn't know how to do it. Can you help me?" We're able to continue to take care of them for their PrEP needs while they see their PCP for all their other needs. And we coordinate care with their PCP, as well.
TW: How are these services paid for?
ET: A couple of different ways. There's the clinic service fees that are paid by the patient. There's also insurance that takes care of the medication reimbursement part of it. If someone is uninsured, we give him lots of options on how to access everything.
We have a clinical coordinator that we hired that manages pretty much everything for patients, to ensure that they get the care or the medicine that they need, and to ensure that they can afford it. He helps the patients navigate the whole system to ensure that they get the coverage that they need.
TW: Are all of the pharmacists that work at your location trained on PrEP?
ET: Most of our pharmacists. We have three pharmacists that are trained on it. And they go through a training process that -- I kind of train them, I guess, and my colleague trains them, just to ensure the same kind of level of care and consistency of care.
TW: Great. And then finally, if folks want to hear more about your program or get more information, is there a website that they can go to?
ET: Yeah. They can go to Kelley-Ross Pharmacy and they'll find a link to our PrEP page. They can also go to www.one-step-PrEP.com, as well.
TW: Great. Thank you so much.
This transcript has been lightly edited for clarity.
Terri L. Wilder, M.S.W., is a director of HIV/AIDS education and training in New York City.