- Pharmacists assist in screening for and managing medication adherence, drug-drug interactions, adverse drug reactions, laboratory results, and at-risk behavior.
- The PrEP pharmacists have a scope of practice allowing them to order labs, consults, and medications as needed.
To the Editor
Retention in care (RIC) is critical to the safety and efficacy of pre-exposure chemoprophylaxis (PrEP) for HIV and the recently published data from Rusie et al.  within Clinical Infectious Disease provide important insights into this topic. In their report the authors identify insurance status and comorbidities as drivers of RIC, with an overall low rate of 4/4 quarterly visits within the first year of PrEP at just 15%. Suboptimal RIC for PrEP has been reported elsewhere  and has been a topic of considerable interest at the Miami Veterans Affairs Healthcare System (MVAHS). To address the issue locally, clinical pharmacists were incorporated into the PrEP program structure and an antimicrobial stewardship program (ASP) quality assurance (QA) oversight initiative was implemented. We report our experience and describe an innovative PrEP program structure in this letter. The necessary institutional approvals were acquired prior to submission of this work.
The structure of our interdisciplinary model is provided in Figure 1. Through incorporating clinical pharmacists into the program, we have been able to extend the capacity of non-pharmacist providers while still adhering to CDC-recommended screenings . Pharmacists assist in screening for and managing medication adherence, drug-drug interactions, adverse drug reactions, laboratory results, and at-risk behavior. The PrEP pharmacists have a scope of practice allowing them to order labs, consults, and medications as needed. Pharmacist visits are done in-person or via telephone, considering patient preference to improve access. In addition to direct patient care, the pharmacists manage a continuous QA initiative, which serves to enhance continuity of care and provide data for reporting to institutional committees.
Between June 2013 and February 2018, MVAHS saw 79 PrEP patients and 43 patients (54%) were actively on PrEP in February 2018. The most common reasons for discontinuing PrEP were: no longer at-risk (n=11), lost to follow-up (n=9), and adverse reaction (n=10). One patient (1%) seroconverted on PrEP, which is attributed to non-adherence.
Examining RIC, 69 of 79 patients (87%) have had a follow-up encounter with a physician, nurse practitioner, or pharmacist in the first quarter after therapy initiation. There are 32 patients who have received a continuous PrEP course of at least 12 months. For these patients, 29 of 32 (91%) had 3/4 quarters with a PrEP visit and 24 of 32 (75%) had 4/4 quarters with a PrEP visit. Most pharmacist encounters (81%) were completed via telephone.
Models for PrEP programs have been evolving in the United States , but data on the impact of pharmacists and ASPs remains limited. Acknowledging our modest sample size and that our patient population does not directly mirror that of Rusie et al., we do feel these data firmly support the notion that the pharmacist and ASP elements of our PrEP program may improve RIC. Future investigations are needed to further elucidate optimal models for PrEP programs in the United States that adhere to national guidelines focused on safety and efficacy.
1. Rusie LK, Orengo C, Burrell D, et al. PrEP initiation and retention in are over five years, 2012-2017: are quarterly visits too much? Clin Infect Dis [in press].
2. Chan PA, Mena L, Pate R, et al. Retention in care outcomes for HIV pre-exposure prophylaxis implementation programmes among men who have sex with men in three US cities. J Int AIDS Soc. 2016. 19(1): 20903.
3. CDC PrEP Guideline. https://www.cdc.gov/hiv/pdf/prepguidelines2014.pdf
4. Mayer KH, Chan PA, Patel RR, et al. Evolving models and ongoing challenges for HIV preexposure prophylaxis implementation in the United States. J Acquir Immune Defic Syndr.2018; 77(2): 119-27.
Pre-Exposure Prophylaxis (PrEP)
Pre-exposure prophylaxis, or PrEP, is a way for people who do not have HIV but who are at substantial risk of getting it to prevent HIV infection by taking a pill every day. The pill (brand name Truvada) contains two medicines (tenofovir and emtricitabine) that are used in combination with other medicines to treat HIV. When someone is exposed to HIV through sex or injection drug use, these medicines can work to keep the virus from establishing a permanent infection.
When taken consistently, PrEP has been shown to reduce the risk of HIV infection in people who are at high risk by up to 92%. PrEP is much less effective if it is not taken consistently.
PrEP is a powerful HIV prevention tool and can be combined with condoms and other prevention methods to provide even greater protection than when used alone. But people who use PrEP must commit to taking the drug every day and seeing their health care provider for follow-up every 3 months.