What is the most effective method of positively affecting Pre-Exposure Prophylaxis (PrEP) services in a state where pharmacists cannot furnish HIV PrEP medication?

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Last updated: September 2, 2025 • View editorial policy

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Counseling on PrEP Adherence is the Most Effective Method for Improving HIV Prevention Services

Counseling a patient taking PrEP on the importance of emtricitabine/tenofovir alafenamide adherence for efficacy is the most effective method of positively affecting PrEP services in a pharmacy setting where pharmacists cannot directly furnish PrEP.

Rationale for Adherence Counseling

Adherence is the critical factor determining PrEP effectiveness across all available evidence:

  • The International Antiviral Society-USA Panel guidelines emphasize that adherence counseling is a cornerstone of effective PrEP implementation with an evidence rating of AIa 1
  • Poor adherence is the primary reason for HIV acquisition while on PrEP, making adherence support essential to successful outcomes 2
  • Recent evidence shows that consistently high adherence (4-6 doses/week) results in extremely low HIV incidence rates (0.13/100 person-years) among cisgender women, while low adherence leads to significantly higher infection rates 3

Why Other Options Are Less Effective

Let's examine why the other options would be less effective:

  1. Educating on home administration of long-acting cabotegravir:

    • While injectable cabotegravir is effective, it requires clinical administration and is not designed for home self-administration 1
    • This education would be impractical since cabotegravir injections must be administered by healthcare providers in clinical settings

  2. Educating providers on 2-1-1 dosing for cisgender women:

    • This approach is incorrect and potentially harmful as 2-1-1 dosing (intermittent dosing) is not recommended for cisgender women
    • Guidelines specifically state that "daily dosing of TDF/emtricitabine for PrEP is recommended (evidence rating AIa), and there are currently insufficient data to recommend intermittent dosing" 2
    • Pharmacologic modeling indicates that less than daily dosing may not be effective for vaginal exposures 2

  3. Counseling on drug-drug interaction between rifabutin and emtricitabine/tenofovir disoproxil fumarate:

    • While drug interactions are important, this specific interaction affects fewer patients than those who would benefit from adherence counseling
    • Addressing adherence has broader impact on PrEP effectiveness across all patient populations

Implementing Effective Adherence Counseling

As a pharmacist in a state without pharmacist-furnished PrEP authority, you can still:

  1. Provide structured adherence assessment and support:

    • Evaluate current adherence patterns during medication pickup
    • Discuss barriers to daily dosing and develop personalized strategies
    • Emphasize that adherence is directly linked to protection level 3

  2. Educate on adherence thresholds for protection:

    • For MSM and transgender women: at least 4 of 7 doses per week
    • For cisgender women, people who inject drugs, and heterosexual men: at least 6 of 7 doses per week 2
    • Highlight that consistently daily adherence (7 doses/week) provides maximum protection 3

  3. Integrate adherence counseling into routine pharmacy workflow:

    • Use medication refill patterns to identify potential adherence issues
    • Offer reminder tools, pill boxes, or mobile applications
    • Schedule brief follow-up check-ins during refills

Practical Implementation Tips

  • When counseling patients on PrEP adherence, emphasize that:

    • Daily dosing is crucial for maximum protection
    • Missing doses significantly reduces protection, especially for women
    • Consistent adherence prevents HIV acquisition with nearly 100% effectiveness when taken as prescribed 3

  • Address common adherence barriers:

    • Stigma around HIV prevention
    • Side effect concerns
    • Daily routine disruptions
    • Misconceptions about intermittent use

By focusing on adherence counseling, pharmacists can make the most significant impact on PrEP effectiveness and HIV prevention outcomes, even in states where direct PrEP furnishing is not permitted.

References

1
Guideline

HIV Pre-Exposure Prophylaxis (PrEP) Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

2
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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