(1114) Association Between State Policies Enabling Pharmacist-initiated HIV Preexposure Prophylaxis and Need for HIV Prevention: An Ecological Analysis

Objectives: Human immunodeficiency virus (HIV) remains a major public health issue in the United States (US). Over 36,000 people in the US are newly diagnosed with HIV annually, and more than half of new diagnoses occur in the South. Daily, oral HIV preexposure prophylaxis (PrEP) can prevent up to 99% of HIV infections if taken as prescribed. Yet, inequitable implementation of PrEP has further contributed to the geographic disparities in HIV incidence. Models of pharmacist-led PrEP services have been shown to be able to reach socially disadvantaged populations disproportionately affected by HIV. These models have operated under collaborative practice agreements (CPAs) or favorable policy environments that enable pharmacists to prescribe and manage PrEP for specific patient populations. However, pharmacist prescriptive authority for PrEP varies across states, thereby restricting the ability of pharmacists to provide PrEP services in several states. In this analysis, we aimed to understand whether the states that have the most restrictive policies are also the states that could benefit the most from expanded PrEP coverage.

Methods: Utilizing data from a variety of sources, including state statutes, protocols, and policies and information gathered by the National Alliance of State and Territorial AIDS Directors, we classified 50 states and DC (n=51) into six distinct policy categories of PrEP-prescribing authority from most stringent to least restrictive. The categories are: (1) Patient-specific CPA, (2) Population-specific CPA, (3) Prescribing via a standing order from a primary care provider (PCP), (4) Statewide standing order, (5) Statewide protocol, and (6) Unrestricted category-specific authority or statute. We used the PrEP-to-need ratio (PnR) for each state, the ratio of current PrEP users to new HIV diagnoses in the state, as a measure of PrEP need. Lower PnR values indicated a greater need to increase PrEP coverage in the state. PnRs were obtained for 2022 from AIDSVu, an interactive online mapping tool that visualizes the impact of the HIV epidemic on communities in the US. We applied linear regression to estimate the association between state PrEP prescribing authority category and PnR.

Results: Across the US,12 (23.5%) states allow pharmacist-led PrEP services through patient-specific CPA, 29 (56.9%) allow population-specific CPAs, 2 (3.9%) allow PrEP prescribing via a standing order from a PCP, 0 (0.0%) have a statewide standing order for pharmacist-prescribed PrEP, 4 (7.8%) utilize a statewide protocol, and 4 (7.8%) have an unrestrictive category-specific authority or statute. The average PnR ranged from 13.4 among states categorized as most restrictive with patient-specific CPAs to 19.4 among states categorized as least restrictive with unrestrictive category-specific authority or statute. We found that states with the least restrictive policy (category 6) had, on average, a PnR of 2.72 (95% CI, -12.36–17.81) higher than states with the most restrictive policy (category 1). In other words, states with the least restrictive policy had, on average, 2.72 more PrEP users for every person newly diagnosed with HIV compared to states with the most restrictive policy.

Conclusions: Our research findings affirm that most states have in place restrictive policies that pose obstacles to pharmacists’ ability to initiate PrEP for their clients. Although it could be a viable strategy to enhance the accessibility of PrEP within pharmacy settings, none of the states have enacted a standing order for PrEP, despite it’s use for post-exposure prophylaxis (PEP) in New York and North Carolina. States with the most restrictive policy of patient-specific CPAs are also likely to benefit more from expanded PrEP access compared to states with less restrictive policies. In the absence of a national strategy or policy to expand pharmacist-led PrEP, state-level efforts are needed to improve access to PrEP in pharmacies.