Pharmacists have more power in some states than patients might realize. They vaccinate, provide overdose-reversal antidotes, and even prescribe birth control, all without the patient seeing a doctor.
Beginning next year in California, giving pharmacists the authority to do more is a strategy coming into play in the battle against HIV, the virus that causes AIDS. Pharmacists will be able to provide highly effective medications to patients to prevent HIV, and influential healthcare leaders and AIDS advocates believe more states should do the same.
The drugs in question, which aren’t well known among the public, are called PrEP and PEP, and they keep people HIV negative. But only 18% of people that health officials think should be on PrEP are taking it, and that’s where pharmacists can help.
Overall, allowing pharmacists more authority isn’t a new idea, but California is the first state that has let pharmacists prescribe HIV medications. States have tapped pharmacists for a long time to get around the fact that pharmaceutical companies haven’t applied with the Food and Drug Administration to make sure drugs are available over the counter. Since states don’t have the power to make a drug available over the counter, they instead turn to the power they do have — to give healthcare providers more authority.
“Pharmacists can do so much more than they do right now,” said Dr. Ashish Jha, Harvard Global Health Institute director. “We in the healthcare system way underutilize pharmacists.”
He and other supporters say states should let pharmacists prescribe the drugs, with proper rules in place, to help end the AIDS epidemic in the United States, where about 1.1 million people have HIV, and nearly 39,000 more are infected every year.
The approach is drawing the attention of the Trump administration, which has set the target of eliminating HIV transmission by 2030, mainly by getting medications to more people. Dr. Jay Butler, deputy director of Infectious Diseases at the Centers for Disease Control and Prevention, called the California example “innovative.” A Health and Human Services representative confirmed the agency was “examining this issue.” In general, the Trump administration has encouraged states to give more authority to medical providers who aren’t physicians.
While there hasn’t been federal legislation on the issue, it’s getting attention elsewhere. In New York, Matt Miller, a candidate for state assembly, is running on the promise to give pharmacists in the state more power to prescribe medications, including those that prevent HIV. Democratic presidential candidate Cory Booker praised California’s law as a “great step in the right direction.”
States that follow California will face some controversy. Doctors are worried about patients taking the drug without regular medical supervision. Further, if patients take the drugs without testing for HIV first, and already have the virus, then their bodies can become resistant to medicines that would help to treat it.
Doctors also want to be able to check in with patients who take PrEP because they can develop problems with their liver, bones, or kidneys. They stress it’s essential to regularly test for other sexually transmitted infections that the drug doesn’t protect against, and they want to know about hepatitis B status, so patients don’t develop more complications.
“You still need that patient-physician relationship,” said Dr. Ada Stewart, president-elect of the American Academy of Family Physicians, who started her career in medicine as a pharmacist. “You need someone to be able to follow up with any labs, and only certain pharmacists will be trained for this … I think it addresses one issue that is part of a bigger picture.”
Dr. Federico Hinestrosa, who works at Orlando Immunology Center in Florida and frequently prescribes PrEP, said he would be more open to nonphysicians prescribing PEP because it’s taken in an emergency. A better way to get more people on the drugs, Hinestrosa said, would be to make more doctors aware of the medicines and how to talk about sexual health with patients.
“Trying to expand more knowledge about these options and targeting primary care centers will help a lot,” he said.
California tried to reach a compromise to address concerns. The California Medical Association, which represents doctor groups, was against the bill at first but recanted when lawmakers changed the legislation so that pharmacists would only be able to prescribe a 60-day PrEP supply. After that, patients would need to go to the doctor. The law also requires patients to present proof that they are HIV-negative.
“It’s not that you’re just going to the pharmacy and just picking up the drug,” explained Carl Schmid, deputy executive director at the AIDS Institute.
Jha said doctors should be more open to states passing these kinds of laws so they could focus on the type of care only they can provide. Doctor opposition, he said, came out of concern that their profession would become irrelevant if other providers are allowed to have similar authorities.
“This is just A protecting your turf kind of thing,” he said. “Every guild does this.”
Dr. Jeffrey Singer, a senior fellow at the libertarian Cato Institute, agrees with the California law. He thinks other states should follow but also believes HIV-prevention drugs should be available entirely over the counter. He suggests it will lower prices and allow patients to have more privacy when they get the drug.
The price tag has been a difficult factor for patients, even when they have insurance. One drug, Truvada, carries a list price of $22,000 a year, though a generic is expected to hit the market next year, and another drug has been approved called Descovy. Still, Singer contends the step of patients having to see a doctor gets in the way of easier access.
“All you’re doing is inconveniencing the patient, and you’re going to have to spend money to take time off work,” he said.