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HIV services: should community pharmacies be providing PrEP?


By Isabel Shaw
Reporter

30 Nov 2021

Ahead of the publication of the Government’s HIV action plan, reporter Isabel Shaw looks at if the HIV prevention drug PrEP should be made available through community pharmacy and what the expansion of HIV services could mean for the sector.  

At the beginning of this year, the Government confirmed that it was considering expanding access to HIV drug pre-exposure prophylaxis (PrEP) to settings outside of sexual health clinics, including community pharmacies.  

PrEP, a medicine people at risk of HIV can take to prevent transmission from sex or injection drug use, is currently only available through sexual health clinics and hospitals.  

Many within the sexual health field have said an expansion like this could not only mean greater access to the drug, but also better awareness of HIV and ultimately less infections. 

In many areas of the world PrEP is already accessible from community pharmacies, including some states in the USA and countries as close as Ireland.  

Ahead of the HIV action plan, which is expected on 1 December to coincide with World Aids Day, several charities and the National Pharmacy Association (NPA) have called for the initiation of a fully-funded pilot to test the availability of PrEP via community pharmacies. 

But what would this service look like in England? And would pharmacies want to provide it?  

Lack of awareness 

Despite PrEP being 99% effective at reducing the risk of HIV, according to charity Terrence Higgins Trust, much of the public and even some healthcare professionals, are unaware that the medication exists.  

Research into HIV awareness in the UK, which was published in July 2021, found that knowledge and understanding of HIV among the public is often patchy and significant levels of stigma and discrimination remain.   

The research, published by the UK’s HIV rights charity National AIDS Trust, found that only a third of people fully agreed they have sympathy for all people living with HIV, regardless of how they acquired it.  

Similarly, ​​​​only a quarter knew there is medication available to prevent someone from acquiring HIV. 

Community pharmacist in Bristol, Ade Williams, said that perhaps the ‘only reason’ community pharmacists have not been pushing for PrEP to be made available in community pharmacies already is because many do not even understand or know about what this medication, or what it does. 

‘If we did understand, we would have been calling for it,’ he said.  

‘After all, it’s another step towards moving away from being just suppliers of medicines into providing more holistic care and addressing health inequalities in certain groups.’  

Mr Williams told The Pharmacist he has had patients asking for PrEP in his pharmacy. 

‘Sometimes, when patients ask me if they can access PrEP in a pharmacy and I redirect them somewhere else, they say ‘wow at least you know what I’m talking about many healthcare professionals don’t’’.  

Although there is limited research into healthcare professionals’ awareness of PrEP in the UK. Some people have taken to Twitter to express their frustrations over primary care clinicians not knowing what the medication is.  

Mr Williams added: ‘It’s very encouraging when the patient asks can you do something for us, I think it shows that we have crossed a very key barrier.

‘We need to match and surpass the ambition of our patients. It can’t be that our patients have greater ambitions for us than we do for ourselves.’ 

Awareness and accessibility  

Among the public, awareness of the drug remains primarily among gay and bisexual men, according to the THT. Some have suggested this means the potential of PrEP is not being fully realised, and communities that could be benefiting from the drug are missing out.  

But if community pharmacy was to supply the drug, it could increase awareness and help destigmatize HIV, alongside increasing accessibility.  

Mr Williams said: ‘The values and core knowledge of community pharmacy teams are in many ways reflective of the communities and societies we are a part of. 

‘So, if the community pharmacy team had to better understand prevention of transmission of HIV, the treatment and care of HIV patients, that would slip into the community. Community pharmacies are very good at educating their communities,’ he said.  

Hasan Mohammed, a specialist HIV and sexual health pharmacist, who works at the Chelsea and Westminster Hospital, said ‘it is clear’ that many groups are missing out on the vital drug. 

‘The uptake has been really good, which has been great to see. However, not everyone accesses sexual health clinics for various reasons. This could be due to fears around confidentiality, or stigma. Also, some people may not perceive themselves to be at risk or need to get tested,’ he said.  

These groups which can often miss out include women, black and ethnic minority groups and the transgender community, according to Mr Mohammed.  

But greater awareness of the drug and its benefits will help more people access PrEP.  

‘I think having additional routes of obtaining [PrEP] through primary care might tap into more people who would not traditionally access it through a sexual health clinic,’ he added.  

Richard Angell, head of policy at THT – which is calling for PrEP to be made available in community pharmacies – agreed that this possible expansion would increase the number of people who access the drug.  

As most PrEP services are only available in hospitals and sexual health clinics, which are more easily accessible from cities than more rural areas, HIV services tend to be an ‘urban phenomena’, Mr Angell said.  

He said that community pharmacies would provide an ‘excellent way of people across the whole country having access to a genuinely universal service’. 

‘Community pharmacies, which are generally a lot more accessible, can make sure that people can have a conversation about PrEP, and get their top-up of PrEP in a place that is local and convenient while retaining some anonymity,’ added Mr Angell.  

What would the rollout mean for pharmacies? 

As it stands, community pharmacies in England do not provide any HIV services. This means many within the sector may be unaware of HIV treatments or preventatives and, in the event that the sector is asked to provide PrEP, education and training would be needed.   

Sexual health pharmacist Mr Mohammed, said: ‘HIV is a whole area of medicine that many community pharmacists wouldn’t have had any exposure to before. So obviously a lot of education and training around HIV itself and medication would need to be provided’.

However, Mr Mohammed said a service involving PrEP would be ‘straightforward’ for community pharmacies, compared with services involving other HIV drugs, due to the nature of the PrEP. 

‘In terms of clinical complexity, PrEP is fairly straightforward,’ he explained.  

‘In fact, the delivery service in HIV clinics is mostly nurse-led, with doctors only getting involved with more complex patients who have renal issues or adherence issues or things like that.  

‘So, as far as things go in terms of antiretrovirals and the HIV world, it’s fairly straightforward clinically, certainly for a continuous supply for someone who’s already on it, that would be fairly easy to set up.’  

‘It would still be a big jump for pharmacies, but one that is needed,’ he said. 

People at risk of contracting HIV can take one single pill per day for the treatment to work, guidance on HIV charity Prepster’s website explains. 

PrEP works by preventing HIV from entering their cells and from replicating. This stops HIV from establishing itself and stops the person taking PrEP from becoming infected with HIV. 

For PrEP to be effective, there needs to be high enough levels of drug in the blood to be protective against HIV, that is why the person has to take PrEP regularly.

According to Mr Mohammed, demand for PrEP is at an ‘all-time high’, which puts a lot of pressure on HIV clinics. This could be aided by pharmacists’ involvement. 

‘It would be good to share the workload with community pharmacies,’ he said.  

The first long-acting injection to treat people living with HIV was approved for use by the NHS in England and Wales earlier this month. 

Mr Angell suggested that this long-acting injection could also be launched in community pharmacies alongside PrEP.  

‘The introduction of the long-lasting injectable is going to dovetail brilliantly with the rollout of PrEP — if pharmacists can provide it — because both should be available in pharmacies for accessibility purposes,’ said Mr Angell.   

‘This means there is a double incentive to educate pharmacists on the latest knowledge about PrEP and HIV, ensure that stigma is addressed and reduced in communities and that people across the board know that these services are available.’ 

Professor Claire Anderson, president of the Royal Pharmaceutical Society (RPS), urged the Government to make PrEP available through community pharmacies ‘as soon as possible’.

She said: ‘There is a clear opportunity to drive down rates of HIV infection by expanding provision of pre-exposure prophylaxis (PrEP) to community pharmacies and GP practices as part of the Government’s HIV Action Plan.

‘Community pharmacies are highly trusted and conveniently located, providing a much wider reach than specialist services can on their own. Pharmacies see those who may be reluctant or unable to attend other health services, play a vital role in reducing harm, and provide rapid access to health and care.

‘This highly effective medicine needs to be made as easily accessible as possible to those who need it.

‘We urge the Government to make PrEP available through community pharmacies as soon as possible.’

PreP was made routinely available on the NHS in England in April 2020. This was following the publication of a PHE report which confirmed that transmission of HIV has fallen by more than 70% in England in six years among gay and bisexual men.

There were 800 HIV transmissions in the UK in 2018 among gay and bisexual men – defined as gay, bisexual and other cis or trans men who have sex with men – down from 2,800 in 2012.

In 2018, the Superdrug pharmacy chain became the first high-street retailer to stock a testing kit for the condition.


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