Building Pharmacy Linkages to HIV Prevention and Care: An Interview with Courage Forward Strategies’ Sara Zeigler and Aliyah Ali

At Safer From Harm, we think of harm reduction as tools and information that allow people to better their health, without expecting abstinence from activities that may carry risk. Given that we now have highly effective medications that can prevent the transmission of HIV, improved access to these medications are a key part of the policy picture. That’s why we were excited to talk with Sara Zeigler and Aliyah Ali at Courage Forward Strategies, a public health strategy firm that serves as the managing partner of the RxEACH Initiative. With support from the Elton John AIDS Foundation, RxEACH is working to expand access to HIV prevention and linkage to care services through community pharmacies.

We asked Zeigler and Ali why pharmacies are important to HIV, where the barriers lie, and how they’re helping advocates succeed. The conversation was so rich that we’re planning a Part 2, so stay tuned! 

This interview was initially conducted via video chat, with additional written input from Zeigler and Ali to ensure clarity and accuracy. Where available, data is hyperlinked to an online source. This interview has been edited for length and clarity. 

Jessica Shortall: What are the basic components of HIV prevention and linkage to care that you want to see in community pharmacies? 

Sara Zeigler: The RxEACH initiative is focused on pharmacy-based access to HIV prevention and linkages to care for HIV or other health conditions. We believe that pharmacies can be an entry point for preventive services. However, we are not suggesting that pharmacists should be managing HIV treatment. When a person is diagnosed, they should work with a doctor to monitor viral load and get on the right treatment.

HIV has a long history of team-based care, and we want to expand the team approach to prevention. That can include:

• HIV Screening: Pharmacists can administer HIV screening and conduct patient consultations. If a screening test is positive, the pharmacist can refer the patient to a doctor for a confirmatory diagnosis and care. But today, pharmacists in a lot of states cannot order and administer HIV screening tests. 

• PrEP/PEP: Pre-exposure prophylaxis (PrEP) is a daily oral pill or long-acting injectable. Taken as prescribed, PrEP can reduce the chances of getting HIV from sex by about 99 percent. Post-exposure prophylaxis (PEP) is taken after a possible HIV exposure, to prevent getting HIV. Pharmacists can safely perform patient assessments and write and fill prescriptions in one visit. PEP has a very short window of opportunity (72 hours after possible exposure), and pharmacies are often closer to where people live, and have evening and weekend hours.

• Linkage to Care: A future where pharmacies are part of the HIV team will require more extensive referral networks and relationships with medical practices, so they can link patients to doctors and other health professionals.

• Medication Administration and Adherence: Pharmacists already play a role in identifying and re-engaging patients who have stopped filling their antiretroviral medications.

• Harm Reduction for People Who Use Drugs: HIV transmission can occur when people who inject drugs share syringes. Pharmacies can distribute sterile injection equipment and naloxone for overdose reversal, and offer safe disposal for used syringes. 

Shortall: You’re collaborating with a research team at Emory University’s Center for AIDS Research that is doing data visualizations of the access landscape across all 50 states. Georgia is one of the first states these researchers have visualized. Can you talk us through that example?

Mapping HIV Cases and PrEP Access in Georgia: Visualizing Current and Potential Points of Care

Map developed by Natalie Crawford, PhD and her team at Emory University’s Center for AIDS Research, based on data from Kristin R. V. Harrington, PhD et al., “Examination of HIV Preexposure Prophylaxis Need, Availability, and Potential Pharmacy Integration in the Southeastern US," JAMA Network Open 6:7 (July 27, 2023). https://dx.doi.org/10.1001/jamanetworkopen.2023.26028.  

Zeigler: This map shows the number of HIV cases per 100,000 people in each county in Georgia, overlaid with where PrEP currently can be prescribed, and where community pharmacies—which cannot currently prescribe PrEP in Georgia—are located. Each yellow triangle represents a single PrEP-prescribing location, while each blue circle represents five community pharmacies. We can see that in communities where HIV prevention services are needed most, there are a lot more pharmacies than PrEP-prescribing locations. This helps us visualize two barriers to HIV prevention that pharmacy access can help address.

The first barrier is access. Fifty-six percent of community pharmacies are located in Medically Underserved Areas, while 80 percent of U.S. counties do not have an infectious disease doctor. People live closer to pharmacies, which tend to have longer opening hours. A study in one state projected that if we can unlock access to PrEP and PEP through pharmacies, we can increase access 20-fold. 

The second barrier is stigma. Walking into a pharmacy might be less stigmatizing than walking into a sexual health clinic or other medical facility, and pharmacies can help normalize HIV prevention as part of routine care. 

Georgia recently passed PEP prescribing by pharmacists as a statewide standing order, so we’re starting to see progress. 

Shortall: What are the potential economic impacts expanding access to prevention and care via pharmacies?

Ali: PrEP and PEP can significantly reduce HIV infections and their lifetime medical costs, which average more than $400,000 per patient, and are often paid by Medicaid. There are 70,000 pharmacies in the United States, which could create a significant opportunity to close access gaps. 

Shortall: You recently launched a state action playbook to help advocates pursue policies to expand pharmacy-based access to these services. Why is this playbook needed?  

Ali: We want to help advocates focus on policies that will work within the policy landscape in their state. Pharmacy processes are complicated, and we sometimes see advocates investing political capital in policy goals that will not change the reality for patients. 

For example, in many states, pharmacists are not allowed to order an HIV test, but a negative HIV test is a prerequisite to starting a patient on PrEP. If advocates back a policy to allow pharmacy prescribing and dispensing, but don’t address screening, PrEP access will not be fully operational.

Additionally, most pharmacists get paid for dispensing medicine, not for providing preventive health services. Any legislation that empowers pharmacists to engage on HIV needs to provide for payment pathways. We were pleased to see Louisiana recently enact such a law. 

Shortall: What have you heard from the public about support for pharmacists providing prevention services?

Zeigler: In one survey, 71 percent of adults supported pharmacists administering HIV screening tests, and 65 percent and 67 percent supported pharmacists prescribing PrEP and PEP, respectively.

We also want to see implementation of HIV prevention services across all community pharmacies. It’s critical as we scale up equitable access to prevention services so that everyone has the opportunity seek services no matter where they live. If we can achieve industry-wide scaling up, we can make much progress in normalizing HIV services and reducing the stigma that too often is associated with HIV.

If you would like to learn more about the RxEACH Initiative, you can reach out here.