Author: James Morrison (he/him), Pharmacist and Pharmacy Owner, Toronto
I recently had the pleasure of participating in a small group discussion on implementation issues regarding long-acting PrEP (LA-PrEP), at the annual CBRC Summit in Vancouver in November 2023. The discussion group was facilitated by Dr Darrell Tan and comprised a variety of health care providers, including nurse practitioners, social workers, and pharmacists, who practice in a variety of settings across the country.
There was a lot of excitement within the group regarding the expected introduction of LA-PrEP in Canada, with the group strongly feeling that providing more options for people who use PrEP is incredibly positive. We have all met folks who may not feel safe keeping supplies of PrEP tablets for various reasons. We also know that a high level of adherence to tablet regimens is needed to attain maximum efficacy. For some, that level of adherence to a daily medication poses challenges. For these reasons, a bimonthly injection of LA-PrEP is very enticing.
Community pharmacies could be an ideal location for LA-PrEP administration, being accessible and for their capacity to reduce demands on specialist PrEP clinics and family doctors. In our discussion, we identified some barriers to making LA-PrEP available broadly. I will discuss some of these barriers from a primarily pharmacy-focused perspective.
Funding Considerations
When it comes to LA-PrEP drug coverage, the product needs to be covered by all public drug benefit plans and private payers so that folks across the country have equitable access. Local community pharmacists may be called upon to administer LA-PrEP to patients. Ideally there would also be funding to support medication administration as there is a cost associated with that service and the discussion group felt strongly that pharmacies charging an administration fee could create access barriers. Some pharmacies may be willing to absorb the cost associated with administration, although each will need to make its own decision.
Collaboration
With oral PrEP regimens, we have been able to distribute medication widely from urban providers and pharmacies to the patient wherever they are located, but that model may not work with injectable LA-PrEP. Canada is huge and patients will want to receive LA-PrEP close to their home communities. Prescribers will need to rely on a network of administration sites, and the discussion group thought that pharmacies may be well-suited if they have private rooms and willing staff.
Communication
Data systems in the community are, in many jurisdictions, fragmented between pharmacies and clinics. It will be important to have clear communication between prescribers and participating injection sites so that all parties know whether each dose is missed or given on time. Injection sites should also be encouraged to help individuals using LA-PrEP to schedule their doses on time. Technology could be leveraged to create a central portal to assist clinicians in working together over long distances and send reminders to patients. Prescribers may also need the support of pharmacies to encourage patients to complete their laboratory tests on time to ensure appropriate monitoring. If digital technology isn’t an option, we could rely on phone and fax to communicate.
Education
Many pharmacists outside of urban centres may be unaware of PrEP and clinical considerations such as compliance/timing of injections and routine lab monitoring. HIV prevention and treatment have historically been inadequately covered in undergraduate pharmacy curricula. This may be due to the complexity of the topic and limited time in the curriculum. Furthermore, pharmacy professionals are trained on providing injections but may not have experience providing ventrogluteal injections. If pharmacists become engaged in LA-PrEP they will likely require both clinical education on the therapy and technical education regarding the injection administration itself.
Pharmacies may also need support to become affirming health care centres for LA-PrEP patients. Again, this is an area where pharmacists may not have received training, and some have discriminatory practices. Only pharmacies that provide culturally competent care should be offering LA-PrEP injection services.
Key Takeaway
With a bit of careful planning, pharmacies could be leveraged to make LA-PrEP available widely. Personally, I feel strongly that many pharmacies would be great partners in supporting patients receiving LA-PrEP and I intend to offer the service at my own pharmacies in Toronto.
James Morrison (he/him)
