Alternative delivery models for PrEP, including pharmacists as prescribers and mail-in testing, could improve access to HIV prevention for at-risk individuals.
“CDC’s most recent HIV Surveillance Reports showed that only 30% of the 1.2 million people who could benefit from PrEP in the US were prescribed it,” Emiko Kamitani, PhD, says. “Although most people who could benefit from PrEP are Black or Hispanic/Latino, estimates suggest that only 11% of Black people and 21% of Hispanic/Latino people were prescribed PrEP in 2021 compared [with] 78% of their White counterparts.”
Various factors may influence the low rate of PrEP uptake in these individuals, including a low perceived risk for HIV acquisition, social determinants of health, stigma from healthcare providers, family, and friends, or a lack of social support and awareness, according to Dr. Kamitani. “Furthermore, one of the major barriers to PrEP uptake is the lack of access to healthcare providers who are knowledgeable about and willing to prescribe PrEP. This is compounded by the workforce shortage in HIV care.”
Together, these factors have resulted in a “vital need” for innovations in PrEP delivery models that can meaningfully impact HIV transmission rates, she says.
For a study published in AIDS, Dr. Kamitani and colleagues conducted a systematic review of research that assessed the implementation of alternative PrEP care delivery models, as well as an assessment of the various models. These models included the use of alternative prescribers of PrEP (such as pharmacists and nurses), alternative settings for care (such as PrEP delivered via telehealth or in community clinics), alternative settings for laboratory testing (such as self-collection kit mail-in tests), and a combination of these strategies (such as an alternative prescriber of PrEP and an alternative care setting with or without an alternative setting for laboratory screening).
High Applicability Seen for Alternative Models
The review included 16 studies published between 2018-2022 that used alternative prescribers (n=8), alternative settings for care (n=4), alternative settings for laboratory screening (n=1), or a combination of the various approaches (n=3). Most studies were US-based with a low risk of bias.
The results showed high applicability for alternative PrEP prescribers, telePrEP, and mail-in testing based on a modified Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Alternative care delivery models for PrEP demonstrated “the ability to reach the focus population, positive effects on PrEP care delivery, appeal [for] clients and implementation staff, and less challenging implementation procedures,” according to the study results.
“Clinicians can implement a collaborative practice agreement to expand a pharmacist’s scope of practice to initiate PrEP. This could mitigate provider burnout, as pharmacist prescribers may be able to fill the gaps in areas where PrEP providers are in short supply,” Dr. Kamitani says. “More than 90% of Americans live less than 5 miles from a community pharmacy and visit a pharmacy 12 times more often than their primary care provider. By authorizing pharmacists to initiate PrEP, patients may have easier access to PrEP care, which could lead to increased uptake.”
Considerations for Implementation
In addition to improving access, the ability of alternative PrEP delivery models to reduce stigma may be one of the greatest benefits of this approach, she continues.
“Racism, sexism, and homophobia from clinicians can contribute to stigma around accessing HIV prevention and treatment services,” Dr. Kamitani explains. “PrEP users have also reported that clinicians ask about the purpose of a laboratory order in front of others or assume they were HIV-positive. Getting tested for HIV and receiving PrEP care in personal spaces, such as one’s home, removes the barrier of stigma, which in turn may make patients feel more comfortable to continue engaging in PrEP care.”
Importantly, while telePrEP can improve access to the medication and reduce disparities in uptake, “we cannot ignore potential pitfalls such as the digital divide,” Dr. Kamitani continues, including disparities in Internet access and computer skills.
“Providers should apply lessons learned from the COVID-19 pandemic to improve PrEP services,” she says. “During the COVID-19 response, healthcare delivery models were considerably altered with technology and an expanded workforce to adapt to the uncertain periods of restricted access to clinical services. The PrEP care delivery model can similarly be altered by implementing telemedicine, HIV mail-in testing, and pharmacist prescribers. Future research should examine the cost-effectiveness and feasibility of these interventions and identify what additional technical and financial assistance is needed to implement them at a structural level.”
- High applicability was observed for alternative PrEP care delivery models, including alterative prescribers and alternative sites for laboratory testing.
- In addition to improving access, alternative PrEP delivery models may reduce stigma.
- Strategies from the COVID-19 pandemic can help reshape the PrEP care delivery model in a similar way, by implementing telemedicine, mail-in testing, and pharmacist prescribers.