Pharmacist-Led Management of HIV PrEP Within the Veterans Health Administration
Background: Uptake and access to HIV preexposure prophylaxis (PrEP) is key to reducing incident HIV infections. Pharmacists are one of the most accessible health care professionals in the United States and are well suited to address this need.
Observations: We describe a model of care at the Veterans Affairs Greater Los Angeles Healthcare System in which clinical pharmacist practitioners developed and implemented a pharmacy-led PrEP clinic colocated within an infectious disease clinic. Veterans Health Administration clinical pharmacists provide direct patient care under a scope of practice that includes ordering and interpreting laboratory tests and providing PrEP prescriptions. To improve access and patient acceptability, we also used novel telemedicine modes of care to ensure flexible appointment scheduling.
Conclusions: This model can be used by other federal and community-based health care organizations to implement interdisciplinary pharmacist-managed PrEP clinics and expand telehealth modalities to deliver outpatient services.
Pharm-PrEP Program Description
The Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHCS) provides health care services at 11 locations in southern California and serves > 86,000 veterans. The VAGLAHCS pharmacy staff includes 33 CPPs who practice in more than 9 clinical service lines. HIV PrEP services are available through the infectious diseases (ID) service for veterans wishing to begin or continue PrEP or for those identified as high risk. HIV PrEP consultations are placed by the referring HCP to the ID service for scheduling and evaluation. Prior to implementation of the pharmacist-managed PrEP clinic, 2 ID physician assistants (PAs) were responsible for PrEP evaluation, initiation, and follow-up. Each PA had 1 half-day face-to-face clinic and 1 PA had an additional half-day telehealth clinic. About 100 PrEP patients were followed by the ID group.
In July 2019, through collaboration with the ID service, a pharmacy PrEP clinic was created to increase access for veterans to initiate or continue PrEP. This clinic included 1 ID-trained CPP and 1 postgraduate-year-2 pharmacy resident. The CPP initiates and monitors veterans for HIV PrEP with prescribing privileges under a defined scope of practice.
Awareness of this novel service was raised through in-service training sessions for primary care and women’s health clinics. Referrals are generated directly from primary care practitioners (PCPs) or emergency department (ED) visits and are accepted on a continuing basis. Visits with the CPP are conducted in person or through telehealth services based on patient preference. Direct CPP patient care appointments involve a standardized assessment and discussion of patient HIV transmission risk, a review of social and sexual history, sexual practices and HIV risk, clinical evidence of acute HIV or other sexually transmitted infection (STI) symptoms, follow-up PrEP monitoring requirements, and counseling on appropriate PrEP use. CPPs can order laboratory tests, bone densitometry (DEXA scan), immunizations, PrEP, and STI treatment as required. ID service physicians are available during CPP visits for further assessment or consultation. While initially most visits are conducted in person, follow-up visits by telehealth or video have become predominant; most patients prefer these modalities, citing convenience, flexibility, and the ability to obtain laboratory tests in advance. Use of telephone and video is intended to reduce patient loss to follow-up.
All required baseline laboratory panels for PrEP monitoring are ordered and interpreted by the CPP in accordance with CDC guidelines.16 These include screening for syphilis, gonorrhea, and chlamydia; fourth-generation antibody-antigen HIV tests; renal function; viral hepatitis; and pregnancy. After reviewing screening results, the CPP will prescribe tenofovir disproxil fumarate/emtricitabine (TDF/FTC) or tenofovir alafenamide/emtricitabine (TAF/FTC) based on individual patient clinical characteristics, US Food and Drug Administration–approved labeling, and VA Pharmacy Benefits Management Criteria for Use. Initial prescriptions are for a 30-day supply with subsequent prescriptions for 90 days (no refills), providing follow-up HIV testing is completed.
Follow-up PrEP visits are scheduled about every 3 months with some overlap to avoid gaps in medication due to late laboratory testing or delayed receipt of mailed medications. The only laboratory testing strictly required each quarter before PrEP renewal is HIV and pregnancy testing. Other screenings, including STIs and renal function are completed at least every 6 months or more frequently, if indicated, based on individual risk factors. Hepatitis C antibody testing is conducted annually if the patient has ongoing risk factors. Treatment of gonorrhea/chlamydia and syphilis for patients with positive test results is also initiated by the CPP, including recommending antimicrobial regimens. Additional interventions conducted as part of the clinic include indicated vaccinations (meningococcal, human papillomavirus, hepatitis A and B), and DEXA scans. Collaboration with ID service attendings and PAs is conducted on an as-needed basis via direct consultation in the colocated clinic or through email or messaging.
Periodic surveillance of a local dashboard of veterans eligible for HIV PrEP is conducted to re-engage veterans in care who may have been lost to follow-up, along with periodic review of a local STI dashboard. These dashboards capture population-based data to identify patients who may benefit from additional STI screenings as well as potential candidates for HIV PrEP. Clinicians can review their patient panel to target individuals who may be due for specific actions. Patients are identified as needing cotesting if they screen positive for ≥ 1 STIs but have not had a concurrent or subsequent full screening panel (gonorrhea, chlamydia, syphilis, and HIV). Cotesting for bacterial STIs and HIV at the time of an encounter has been promoted to expedite STI identification and treatment and limit community transmission. These reports also identify patients who may be potential candidates for HIV PrEP, based on a history of positive screenings, frequent STI testing, recent prescriptions for postexposure prophylaxis (PEP) or encounters with specific International Classification of Diseases codes associated with high-risk practices.
