Testimony in Support of Delaware Senate Bill 194, Pharmacist Prescribing of HIV Medication
Testimony from:
Chelsea Boyd, Research Fellow, R Street Institute
In SUPPORT of Senate Bill 194: “An Act to Amend Title 24 of the Delaware Code Relating to Practice of Pharmacy”
May 7, 2024
House Sunset Committee (Policy Analysis & Government Accountability)
Chairwoman Walker and members of the committee:
Thank you for considering my testimony in reference to Senate Bill 194. My name is Chelsea Boyd, and I conduct research about integrated harm reduction for the R Street Institute, a nonprofit, nonpartisan public policy research organization. Our mission is to engage in policy research and outreach to promote free markets and limited, effective government in many areas, including harm reduction and sexual health. This is why SB 194 is of special interest to us.
SB 194 will expand the scope of practice for pharmacists by allowing them to prescribe pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) to prevent infections from the Human Immunodeficiency Virus (HIV). This pivotal proposal has the propensity to reduce the risk of contracting HIV, a critical endeavor considering that Delaware routinely ranks in the top 15 for newly diagnosed cases of HIV per 100,000 people.[1] HIV enacts a heavy toll on individual health as well as steep financial consequences. The estimated lifetime cost of one person getting HIV ranges from $326,411 to $490,095 (discounted) in 2019 dollars or $873,402 to $1,205,248 (undiscounted).[2]
The creation and growing use of PrEP and PEP to prevent HIV infections have helped many people decrease their risk of getting HIV. When taken as prescribed, PrEP is 99 percent effective at preventing HIV infection from a sexual encounter and 74 percent effective for preventing HIV infection from injection drug use.[3] Although the number of people who could benefit from using PrEP and have received a prescription for the medication has been increasing, many people who could benefit from using PrEP have not received prescriptions.[4] In Delaware, it is estimated that only 19.4 percent of people who could benefit from using PrEP had been prescribed the medication in 2022.[5] Although this number could be higher, Delaware has made significant progress getting more people who could benefit from PrEP to use the medication, with measures of unmet need for PrEP improving steadily, especially since 2020.[6] Nevertheless, continuing to make PrEP access a priority is vital to improving community health.
Decreasing HIV diagnoses requires a holistic approach that integrates communities and their leaders, healthcare providers, governing bodies, and individuals.[7] Increasing access to PrEP and PEP is one strategy that policymakers can influence directly. Passing legislation, like SB 194, that allows pharmacists to prescribe PrEP and PEP directly to patients is one policy that is gaining traction across the country.
As of September 2023, 17 states had passed legislation that gives pharmacists authority to prescribe PrEP and/or PEP without consulting another health care provider.[8] As the U.S. grapples with a predicted shortage of up to 124,000 physicians by 2034, it is vital that policymakers explore ways to utilize all healthcare providers fully.[9] Pharmacists have doctorial level training in pharmacology, therapeutics, clinical problem solving, medication use, and laboratory monitoring, yet research has shown that they are underutilized.[10] This is particularly unfortunate given that pharmacies are often the most easily accessible health care location.[11]
In Delaware, approximately 254,000 citizens reside in a designated primary care Health Professional Shortage Area (HPSA).[12] This means that these residents may have difficulties securing appointments with the physicians necessary to obtain PrEP and PEP—an issue that can be alleviated by allowing pharmacists to prescribe it.
SB 194 offers Delaware an additional strategy for preventing HIV infections and improving the health of its citizens. SB 194 instructs the Division of Public Health to approve a statewide protocol that directs pharmacists in prescribing PrEP. The bill’s limited requirements for the content of the protocol is a strength of SB 194. Another thing to consider with this bill is how pharmacists will be reimbursed for providing PrEP and PEP services. Without specifying how insurance providers must cover pharmacist-provided services, pharmacists have no guarantee that they will receive payment for services rendered, creating a disincentive to offer these services.[13]
NASTAD (National Alliance of State and Territorial AIDS Directors) recommends, “Statutes should explicitly outline the PrEP and PEP-related services health insurance providers must cover. Additionally, statutes should either define pharmacists as providers or require equitable reimbursement rates between pharmacists and PCPs.”[14]
In summary, allowing pharmacists to prescribe HIV prevention medications is an important component of ending the HIV epidemic in Delaware and the U.S. For this reason, it is critical that you advance SB 194 with a favorable report.
Thank you for your time,
Chelsea Boyd, M.S.
Research Fellow
R Street Institute
(202) 922-6826
[1] Delaware.gov, HIV Surveillance Program Overview. https://www.dhss.delaware.gov/dph/dpc/hivsurveillanceoverview.html.
[2] Adrienna Bingham et al. “Estimated Lifetime HIV-Related Medical Costs in the United States.” Sexually Transmitted Diseases 48:4 (2021) pp. 299-304. https://pubmed.ncbi.nlm.nih.gov/33492100/.
[3] Centers for Disease Control and Prevention, “PrEP Effectiveness,” June 6, 2022. https://www.cdc.gov/hiv/basics/prep/prep-effectiveness.html.
[4] Centers for Disease Control and Prevention, “PrEP for HIV Prevention in the U.S.,” September 29, 2023. https://www.cdc.gov/nchhstp/newsroom/fact-sheets/hiv/PrEP-for-hiv-prevention-in-the-US-factsheet.html.
[5] U.S. Health and Human Services, America’s HIV Epidemic Analysis Dashboard (AHEAD), August 18, 2019. https://ahead.hiv.gov/?location=8&indicator=283&measure=rate.
[6] Patrick Sean Sullivan et al., “Local Data: Delaware,” Oct. 2020. https://aidsvu.org/local-data/united-states/south/delaware/.
[7] Ibid.
[8] Sonya Collins, “Pharmacists Expand Access to PrEP in 17 States,” PharmacyToday 29:9 (September 2023). https://www.pharmacist.com/Publications/Pharmacy-Today/Article/pharmacists-expand-access-to-prep-in-17-states.
[9] Andis Robeznieks, “Doctor shortages are here—and they’ll get worse if we don’t act fast,” AMA, April 13, 2022. https://www.ama-assn.org/practice-management/sustainability/doctor-shortages-are-here-and-they-ll-get-worse-if-we-don-t-act.
[10] Jennifer Kibicho et al., “Are community-based pharmacists underused in the care of persons living with HIV? A need for structural and policy changes,” Journal of the American Pharmacists Association 55:1 (2015) pp. 19-30. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4858315/.
[11] Lucas A. Berenbrok et al., “Access to community pharmacies: A nationwide geographic information systems cross-sectional analysis,” Journal of the American Pharmacists Association 62:6 (November-December 2022) pp. 1816-1822.e2. https://www.sciencedirect.com/science/article/pii/S1544319122002333.
[12] “Primary Care Health Professional Shortage Areas (HPSAs),” Kaiser Family Foundation, Sept. 30, 2022. https://www.kff.org/other/state-indicator/primary-care-health-professional-shortage-areas-hpsas/?currentTimeframe=0&selectedRows={“states”:{“delaware”:{}}}&sortModel={“colId”:”Location”,”sort”:”asc”}
[13] NASTAD, “Pharmacist Authority to Initiate PrEP & PEP and Participate in Collaborative Practice Agreements.” https://nastad.org/sites/default/files/2023-08/PDF-Pharmacist-Authority-Initiate-PrEP-PEP.pdf.
[14] Ibid.