First it was birth-control pills, then smoking-cessation medications. Now, Colorado is on its way to becoming one of the first states in the country to allow people to skip the doctor’s office and get prescriptions for drugs that prevent HIV infection at the pharmacy.
The move comes as more than 400 Coloradans are diagnosed with HIV each year, even though a once-per-day medication to prevent the virus has been available for nearly a decade. It also comes as public funding for HIV prevention and AIDS treatment has been slashed in Colorado.
“We have prevention and treatment tools to end the HIV epidemic,” said Helen Burnside, director of the Prevention Training Center at Denver Health. “To me, what we really need to think about is expanding access.”
Many of the people most at risk for contracting HIV — which include those who use injectable drugs, as well as people of color, women and men who have sex with men — also are most likely to have difficulty accessing health care or experience stigma at the doctor’s office.
Some of the patients who visit Denver Health’s HIV clinic ride a city bus for two hours to get there, Burnside said, noting that 70% of rural America has a pharmacy within 15 miles and 90% of cities have one within two miles.
“We hear from our patients a lot that they worry they will be seen going into the Denver Health HIV clinic. Everyone knows that it’s the HIV clinic,” she said. “Pharmacies offer a walk-in convenience aspect as well as a non-stigmatizing setting.”
State legislation gathering bipartisan support would allow pharmacists to screen a customer for HIV via a blood test and consultation, and then prescribe either the daily prevention pill, called PrEP, or an emergency pill, called PEP, taken within 72 hours of potential exposure to the virus. The bill, from Rep. Leslie Herod and Rep. Alex Valdez, both Democrats, also requires that insurance plans cover the medication and reimburse pharmacists for the consultation.
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More than 14,000 Coloradans are living with HIV. “People seem to think that it’s cured and it’s gone, but it’s not,” Herod said as she presented her bill to the health committee. If the drugs were available to all, “we would still have so many of our friends and family members sitting here with us.”
If passed, the legislation requires the state Board of Pharmacy to write training requirements for pharmacists following the federal Centers for Disease Control and Prevention guidelines regarding the HIV medications. Some GOP lawmakers want to amend the measure to make sure the Colorado Medical Board also is involved.
The medication to prevent HIV, sold under the brand name Truvada, can cost up to $1,700 per month without insurance. The state Medicaid program spent $6.3 million on Truvada last fiscal year for 1,194 patients, according to data released by the state Department of Health Care Policy and Financing.
A generic form of the drug is expected on the market in the fall. And starting next year, the federal government will consider PrEP a preventative treatment, meaning health plans can no longer charge a copay.
For those who are uninsured but want the HIV prevention drug, pharmacists can offer funding through a state pharmaceutical assistance program.
HIV infection rates were on the rise last year in Colorado. The state health department estimated 455 people were diagnosed with HIV in 2019, up from 409 in 2018. The department notified health professionals last summer that the number of women contracting the virus was increasing.
Nationally and in Colorado, HIV diagnoses have decreased in the last decade, but the CDC says that decline has now plateaued, in part because not everyone has access to prevention medication. Black and Latino men are still disproportionately affected.
Last fall, the state health department notified agencies that provide testing and treatment for HIV and AIDS of budget cuts ranging from 25% to as high as 87% starting last month. The cuts were the result of lost grant funding, past mismanagement of funds and a new legal interpretation about how dollars are spent.
The cuts have meant less HIV testing in the community and fewer treatment and counseling services at Denver Health’s clinic and about a dozen others. It’s frustrating for advocates, who praised Denver a few years ago for joining the international health community in vowing to end the AIDS epidemic by 2030.
Birth control and anti-smoking drugs
Colorado passed a law in 2016 that allowed the state health department, along with the state boards of medicine, pharmacy and nursing, to develop protocol allowing pharmacists to write prescriptions for commonly used medications. First on the list was hormonal contraception, including birth-control pills and patches, that are now available from about 800 pharmacists statewide.
Then last year, protocol was approved for medications to help people quit smoking. Pharmacists who want to prescribe smoking-cessation drugs must take a three-hour online training. Customers must fill out a questionnaire and complete a short consultation with their pharmacist. So far, only 20 or 30 pharmacies are participating.
Colorado could use the 2016 law to enact protocol for HIV medication at pharmacies, but backers of the bill are seeking new legislation because, this time, they want pharmacists to get reimbursed by insurance companies for their time. One Colorado, the LGBTQ advocacy organization that initiated the HIV medication proposal, agreed to add the insurance reimbursement requirement to the bill after consulting with the University of Colorado Skaggs School of Pharmacy and the Colorado Pharmacists Society.
Pharmacists are charging patients from $25 to $45 in cash to screen and consult for birth control. To get buy-in from pharmacies to participate in the HIV medication program, Colorado needs the insurance reimbursement, said Emily Zadvorny, a clinical associate professor at the CU pharmacy school.
The consultations for birth control take 20 to 30 minutes. Under the HIV medication proposals, pharmacists would first test a patient for the virus — possibly through a finger poke — and then talk to the patient about the medication options.
Kroger, which includes King Soopers and City Market stores, already prescribes birth control pills at many of its 147 pharmacies in Colorado and plans to participate in the HIV medication program. Safeway, with 80 Safeway and Albertsons pharmacies in Colorado, also will participate, according to statehouse testimony in support of the measure.
Colorado was only the third state to let pharmacists prescribe birth control, behind California and Oregon.
And if Colorado allows pharmacists to prescribe HIV medication, it will jump to the forefront of prevention efforts nationwide. Only California lets pharmacists prescribe the medications, though Iowa and Washington state are having discussions similar to Colorado’s.
“We’re ready to help, as a public service,” Zadvorny said, noting that some pharmacies in the state already are prescribing HIV medication through collaborations with neighboring physicians. “We want to be that community resource.”