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.
STI screening is a vital component of the Pharm-PrEP clinic and helped identify 4 patients with gonorrhea/chlamydia at baseline and 1 with syphilis after initiation of PrEP. All patients were prescribed antibiotics at the screening. Los Angeles County has high rates of STI transmission;thus implementation of clinic processes allowing the CPP to screen for STIs, interpret test results, and treat patients with STIs is vital to limit spread in the community.17
Selection of PrEP Regimen
The majority of individuals in the cohort received TDF/FTC for PrEP; TAF/FTC was restricted to individuals who had documented renal dysfunction or bone loss (Table 3). 
Six DEXA scans were completed by the end of the evaluation period and 2 had abnormal results. One patient discontinued TDF/FTC and reinitiated with TAF/FTC. The other was switched to TAF/FTC 1 month after initiation.
Follow-Up Visits
The median number of visits per patient was 2. The median time between visits was in accordance with recommended follow-up intervals with 35 days between visits 1 and 2, 60 days between visits 2 and 3, and 88 days thereafter. In all, 10 veterans (20%) stopped PrEP: 4 (8%) were lost to follow-up; 3 (6%) had sustained behavior changes decreasing their HIV exposure risk; 2 (4%) were concerned about ADRs; and 1 (2%) moved out of state. Even after including those patients with a decrease in HIV exposure risk who no longer required PrEP, our 20% discontinuation rate was lower than those reported in other studies that showed a wide variation in PrEP discontinuation rates ranging from 33% to 62%.18-20
Challenges
Some challenges with the implementation of the clinic included logistic and operational barriers, such as developing clinical pathways and managing workflow to facilitate vaccinations or STI treatment for individuals using video or telehealth services, as well as encouraging referrals from PCPs. These challenges were addressed by providing periodic targeted in-service training sessions to primary care teams to increase awareness of the Pharm-PrEP clinic. Collaboration with the ID service and ED allowed implementation of a direct pathway for patients initiated on nonoccupational HIV PEP after a high-risk exposure to be evaluated for transition to HIV PrEP. This PEP-2-PrEP pathway was designed to decrease barriers to follow-up for high-risk individuals who had recently received PEP in the ED. The CPP plays an active, integral role in managing patient care in the PEP-2-PrEP pathway.
Pharmacist-Led PrEP Care
The implementation of the VAGLAHCS Pharm-PrEP clinic demonstrates how CPPs can expand access and manage HIV PrEP with high reliability. Key factors for successfully integrating CPPs as PrEP prescribers include identifying physician champions; using in-services or other training platforms to raise awareness among potential referring HCPs and stimulate referrals; and developing processes to identify high-risk veterans. Also, nontraditional modes of care, such as video or telehealth appointments, can increase access and expand the volume of patient care visits. Such modalities are useful for PrEP management when combined with a well-defined operational process for laboratory specimen collection before appointments. This system is particularly well suited to increasing access to PrEP for patients who live in rural or highly rural areas that are medically underserved or who have difficulty traveling to a clinical facility for an in-person visit.
