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Lawmakers in Georgia, the state with the highest rate of new HIV infections in the country, are moving to allow pharmacists to prescribe and administer HIV prevention drugs.
The bill aims to make the drugs easier to get and lower the costs of care – two challenges that have hampered attempts to stem the number of new cases.
Pharmacists could provide both the pill and long-acting injectable forms of pre-exposure prophylaxis, known as PrEP, which that prevents HIV, as well as PEP, post-exposure prophylaxis, a course of drugs that can prevent HIV after exposure if taken soon enough.
The measure could be “a game changer for shifting the landscape of the epidemic,” said Natalie Crawford, a professor at Emory University’s Rollins School of Public Health.
At eight, Georgia has one of the lowest PrEP-to-need ratios in the country, indicating that people who need the drugs are not getting them. That overall ratio hides deep inequities in how many people are accessing PrEP. The ratio is 32 for white people but plummets to 4 for Black people, according to the latest data from AIDSVu, an online tracking tool based at Emory University.
At least 20 other states allow pharmacists to prescribe the drugs.
Pharmacists said they welcome the legislation – even though some details, especially around payment, still need to be worked out.
Pharmacies are much more accessible to many rural Georgians than doctors’ offices and clinics, said Jordan Khail, a professor at the University of Georgia College of Pharmacy. Pharmacies often also have longer hours than doctor’s offices.
Pharmacies could bring drugs closer to patients
Rural residents often have to travel long distances to a facility that prescribes the drugs, Crawford said.
Even some in urban areas have the same problem. While there are more new HIV cases on the south side of Atlanta, the clinics that provide the drugs are typically on the north side, Crawford said.
“As a PrEP user and Georgia resident, I am in full support of pharmacy-based PrEP, but to be truly effective we must continue to work to protect PrEP coverage for insured individuals and expanding access for uninsured populations through a national PrEP program,” said Michael Chancley, communications and mobilization manager for PrEP4All, a nonprofit that advocates for increasing access to PrEP.
The bill’s sponsors – Sen. Chuck Hufstelter, a Republican anesthetist from Rome, and Rep. Mark Newton, a Republican emergency physician from Augusta – said expanding access to the drugs could lower the number of new infections and save the state money in the long run by reducing the number of patients that need state-funded care.
Lifetime HIV-related costs can range from about $420,000 to over $1 million.
“It’s in the best fiscal interest of the state to prevent HIV transmission,” said Jeff Graham, executive director of Georgia Equality, an LGBTQ advocacy group.
The bill includes several requirements for a pharmacist to administer the drugs:
- Pharmacists need a protocol agreement with a physician, advanced practice registered nurse, or physician assistant.
- Pharmacists would need to complete a qualified training program about the drugs.
- Any drugs for PEP or PrEP that are determined by the state Board of Pharmacy to be approved by the Centers for Disease Control and Prevention for preventing HIV infections will be eligible.
- Pharmacists would have to notify the patient’s primary care provider. If the patient does not have one, the pharmacist would have to provide a list of physicians and clinics to contact for follow-up care.
- The patient would need to provide proof of a negative HIV test within the past seven days, or take a test that proves negative on the spot.
Pharmacists would be able to issue at least 30-day and up to 90-day supplies of the drugs.
Payment models haven’t been determined
Khail and others said pharmacists excel at finding the lowest-cost options for patients. Most American insurers are required to cover the cost of PrEP and PEP, though uninsured people may need to jump through extra hoops to afford them.
While the injectable forms are typically more expensive, pharmaceutical companies’ patient assistance plans can lower the cost for the uninsured.
But the bill also asks pharmacists and pharmacy technicians to do work like counseling the patients and making sure they don’t have any reactions to the drugs.
“We definitely have to talk compensation for pharmacies, and I would even push it further to say pharmacy technicians,” said Dr. Kenric Ware, a professor of pharmacy at Mercer University.
A similar measure in Louisiana included payment provisions for pharmacists, Khail said.
That part still needs to be worked out for Georgia – perhaps through a companion bill or administrative regulations that don’t need legislative approval.
Ware and Khail pointed to the model used for immunizations, in which pharmacists are compensated for the extra work they do in counseling and supervising patients and providing the shots, as a good model for PrEP.
A lack of a plan to reimburse pharmacists could limit how many pharmacists decide to offer the service when it takes effect.
If it passes, the law would take effect July 1, with a Jan. 1, 2027 deadline for the state pharmacy board to designate training programs for pharmacists.
Pharmacists and the bill’s advocates said a range of options are needed to address the state’s high HIV rates. Georgia typically has at least 2,400 new cases each year, amounting to a rate of 26 per 100,000 people, second only to Washington, D.C.
Telemedicine works well for some, but it has downsides.
People who live with others may not want to receive their drugs via mail at home for privacy reasons. Others may lack the internet service or digital literacy needed to access the service, Ware said.
Black and brown communities, especially women, tend to use telemedicine services for PrEP and PEP at rates far below their white counterparts, Crawford said, in part because marketing efforts have left them out.
The bill gained the unanimous support of the Senate last year. The House Representatives overwhelmingly voted for it, with only seven “no” votes.
The measure must now return to the Senate for final approval before it can be sent to Gov. Brian Kemp for his signature.
Rebecca Grapevine is a reporter covering public health in Atlanta for Healthbeat. Contact Rebecca at rgrapevine@healthbeat.org.
