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England is on track to meet the Government’s ambition to reduce new HIV transmissions by 80 per cent in 2025 and end new transmissions completely by 2030, according to the latest update on the HIV Action Plan for England.
Pre-exposure prophylaxis (PrEP) is a key tool in the fight against HIV. PrEP contains the existing HIV treatment drugs tenofovir disoproxil and emtricitabine, and works by stopping HIV from entering the body and making copies of itself, reducing the risk of HIV-negative people acquiring the virus. Taken as a daily pill or on an “event” basis before sexual intercourse, PrEP is available free of charge from sexual health clinics in the UK.
With community pharmacies recognised as key settings for the provision of a wide range of sexual health services, especially for people who do not access healthcare elsewhere, expanding PrEP delivery to community pharmacies could help the Government meet its goal of eliminating new cases of HIV by 2030.
However, despite the Government’s HIV Action Plan in 2021 committing to “develop a plan for provision of PrEP in settings beyond sexual and reproductive health services”, the sexual health charity the Terrence Higgins Trust says there has been “little progress on this commitment” since the plan was launched and that “PrEP is currently missing from plans to make prescription medications more accessible to patients” through pharmacies, via the recently announced Pharmacy First scheme in England, for instance.
It is hoped that a series of positive reports about both the effectiveness of PrEP, and a study looking at its availability from community pharmacies, could change this.
Trial results
The PrEP Impact Trial – funded by NHS England and led by the UK Health Security Agency (UKHSA) with the Chelsea and Westminster Hospital NHS Foundation Trust – took place at 157 sexual health clinics across England between October 2017 and July 2020. The results of the trial, which were published in November 2023, showed the use of PrEP reduced a person’s ‘real world’ chances of getting HIV by around 86 per cent (as opposed to clinical trials, which suggest the medication is up to 99 per cent effective).
Welcoming the evidence of the protective effect of PrEP at scale, the Terrence Higgins Trust nonetheless stressed that there was “more to be done” to increase access for certain communities and individuals such as “many women [who] just don’t know PrEP exists”, and again called for PrEP to be made available in pharmacies and online to widen access.
PrEP in pharmacy
Some people find it difficult to access PrEP because of the stigma associated with using sexual health services, as well as increasing health inequities. A PrEP research project from the University of Bristol/National Institute for Health and Care Research, Applied Research Collaboration West (NIHR ARC West), found that “women born as women, heterosexual men born as men, ethnic minority communities, trans-people and young people are less likely to take PrEP”.
Researchers from the NIHR ARC West project are currently conducting a study to understand the facilitators and barriers to community pharmacies delivering PrEP and have so far conducted a scoping review of the evidence.1
Identifying 56 papers (77 per cent from the US and 63 per cent published during or after 2020), researchers found that barriers to PrEP delivery for pharmacists included lack of knowledge, training and skills in relation to HIV testing and PrEP delivery, and not having the necessary facilities to conduct the tests and consultations. There were also concerns about the costs of PrEP and believing that PrEP use could lead to increased STIs.
According to the review, barriers for patients accessing PrEP in pharmacy included a lack of awareness of PrEP, a lack of pharmacy facilities to conduct tests and consultations, and not considering pharmacists as healthcare providers.
To understand the UK context, Jeremy Horwood, project lead at NIHR ARC West, says the research team is “now conducting interviews with pharmacy staff and with members of the public from communities that may be at increased risk of HIV but not currently receiving PrEP”.
NHS Pharmacy Contraception Service expansion
Thousands of women across England have had their access to the contraceptive pill expanded to their local pharmacy, as part of the Government’s primary care access recovery plan that includes the launch of Pharmacy First.
The new service specification covers initiation of oral contraception and routine monitoring and ongoing supply via a patient group direction, with NHS England saying the aim of the Pharmacy Contraception Service (PCS) is to offer “greater choice from where people can access contraception services and create additional capacity in primary care and sexual health clinics (or equivalent) to support meeting the demand for more complex assessments”.
William Pett, head of policy, public affairs and research at Healthwatch England, said the initiative “will make a real difference to patients and relieve the pressure on hard-pressed services”, but warned that “there could be potential problems, such as pharmacists not being able to see enough of people’s GP records or the ability of different communities and areas to access the new service”.
However, Tase Oputu, chair of the Royal Pharmaceutical Society’s English Pharmacy Board, said that “trials of the scheme showed a widespread welcome for the service and the convenience community pharmacy offers as the front door to the NHS. Pharmacists are perfectly placed to provide relevant health checks and ongoing support for women accessing contraception.”
Barriers and enablers
A further push for community pharmacy access to PrEP comes from research by the Terrence Higgins Trust which found that the average waiting time for a PrEP appointment at a sexual health clinic was 12 weeks.
“Community pharmacies have the potential to make PrEP more accessible and be a critical component of tackling health inequalities and ending new cases of HIV by 2030, especially in towns and rural areas where pharmacies are often more accessible than sexual health services,” says Paul Bates, assistant director of external affairs at the Terrence Higgins Trust.
However, community pharmacies cannot obtain PrEP through the same pathways as sexual health clinics, which poses a challenge when it comes to obtaining the medication. To prescribe PrEP, Bates says, “pharmacists would need to be able to access it from NHS England in the same way that sexual health clinics can, then arrange initial HIV and renal testing, and then annual monitoring and refer patients who test positive for HIV to local services, and finally, support or link in with local HIV promotion activities to increase knowledge and awareness of PrEP”.
While pharmacies’ accessibility means their services are “considered largely free of HIV-related stigma”, according to a British Association for Sexual Health and HIV (BASHH) spokesperson there are still some other pharmacy-specific barriers to implementing PrEP. These include:
- Commissioning pathway: PrEP is currently only commissioned to be supplied from level 3 sexual health clinics, limiting its availability in community pharmacies
- Technology/platform systems: Development of proformas and electronic prescriptions for PrEP supply in community pharmacies through platforms like PharmOutcomes would facilitate its implementation
- Testing from community pharmacies: The possibility of offering HIV (and other) POC tests in pharmacies would require regional or local variations and depend on commissioning agreements
- Financial tariff incentive: A financial incentive for pharmacies would encourage them to provide PrEP services
- National PGD adaptation: A national PGD for PrEP would need local adaptation to reflect the specific pathways and requirements of each area.
One possible solution, says Bates, is that “the Government’s Primary Care Recovery Plan and Pharmacy First ambition should provide an opportunity to take this forward”. As yet, however, there are no plans in place to do so.
The power of switching
OTC switches of products for erectile dysfunction have been useful when it comes to talking to men about sensitive male health issues.
The MHRA reclassified Viagra Connect (sildenafil) from POM to P in 2017, the product becoming available to purchase following a consultation with a pharmacist in the spring of 2018. Sanofi’s Cialis Together (tadalafil) was reclassified as P early in 2023. For customers who prefer not to take a tablet, Eroxon’s erectile dysfunction treatment gel was launched in April 2023.
“The reclassification of medicines from POM to OTC has transformed the ability of patients to take control of their health and manage their self-treatable conditions, and this is particularly true for men’s sexual health,” says Michelle Riddalls, chief executive of PAGB, which represents manufacturers. “This is why we are working with our members, pharmacy organisations, the MHRA, and Department of Health and Social Care via the Reclassification Alliance to widen access to OTC medicines.”
According to Riddalls, when Viagra Connect was launched as a pharmacy medicine in the UK, even though it had been available as a POM for around 20 years at that point, the impact was wide-reaching. “Not only did it have a positive effect on men and their partners, making the brand accessible through pharmacies encouraged more men with erectile dysfunction to visit pharmacies, increasing visits by nearly 60 per cent over 12 months,” she says.2
As a result, more men have felt able to approach pharmacists and have received health education and information around erectile dysfunction as part of the consultation and within the pack itself.
“It is great that men can get over-the-counter treatments for erection problems but it is important too that they see their GP so the underlying causes of those problems can be addressed,” says Jim Pollard of the Men's Health Forum.
“OTC treatments for erection problems have helped us all to understand that these problems are something we can treat, but it is still often something that men keep private. Those interested in men’s health need to continue striving to break the taboo; pharmacists can really help here.”
Enhancing skills
Jeremy Horwood acknowledges that “initiatives are needed” to provide training for pharmacy teams to increase their knowledge of HIV and PrEP. BASHH agrees.
“It is important to note that community pharmacy teams don’t typically have much exposure to antiretroviral drugs [so] PrEP access in community pharmacies presents an opportunity for learning. A comprehensive training package is essential to empower staff to confidently deliver PrEP,” says the BASHH spokesperson.
“Linked to this, as community pharmacies are being asked to deliver a broader range of services, it is important they receive appropriate remuneration for any new services provided.”
In the meantime, the Terrence Higgins Trust’s Can’t Pass It On online training for healthcare professionals aims to increase awareness and understanding of HIV transmission within healthcare settings, enabling pharmacy teams to competently discuss this in practice with patients and colleagues. PrEP information organisation, PrEPster, has a Little Back Pocket Guide to: Talking to Health Professionals about PrEP, which can also offer some useful points of note to healthcare professionals.
According to PrEPster’s guide, patients often encounter health professionals who don’t know as much about PrEP as they would hope and make assumptions about a person’s sexuality or HIV status. The guide offers the following advice to bear in mind when talking to patients about PrEP:
- The reasons someone is using PrEP might not be something they want to discuss – they might be concerned about confidentiality or fear that a partner who doesn’t know about their PrEP use might find out
- Someone using PrEP does not have HIV – although the drugs used in PrEP are some of the ones that are used for HIV treatment. If someone says they are using Truvada, Descovy or their generic versions for PrEP, this does not mean they are living with HIV
- There are very few interactions between PrEP and other medications. A useful guide to checking interactions can be found at hiv-druginteractions.org.
References
1. Facilitators and barriers to community pharmacy PrEP delivery: a scoping review, Harrison et al, 2023. doi.org/10.1101/ 2023.10.06.23296672
2. doi.org/10.1111/ijcp.13849
Further information
‘Accessing PrEP through pharmacies to improve HIV prevention’ project page.
LGBT Hero’s (lgbthero.org.uk) predecessor organisation, the GMFA, co-wrote the Man To Man guide on gay men’s health with the Men’s Health Forum.
PrEPster’s Little Back Pocket Guide to: Talking to Health Professionals about PrEP. Pharmacy staff can sign up for updates on PrEPster training courses and resources.
Practice
In Practice
We know you want to continue to build on your practice, why not hear from others in the sector striving to do the same.