Changes to HIV Pharmacy and Prescribing Practices During the SARS-CoV-2 Pandemic

The SARS-CoV-2 pandemic has affected every stage of the HIV care continuum and has exacerbated barriers to antiretroviral therapy (ART) initiation and adherence, as well as pre-exposure prophylaxis (PrEP) uptake and persistence. Numerous changes have been implemented in clinics to alleviate these barriers. There also have been important changes to pharmacy practices and medication delivery, both of which have been of the utmost importance for supporting ongoing medication access and adherence. These changes include updates to insurance coverage and reimbursement policies, adaptations to workflow, and modifications to methods of ART and PrEP adherence counseling and monitoring. Here, we aim to review some of the beneficial changes to prescribing and pharmacy practices, as well as some under-recognized challenges that we have seen locally, to stimulate discussion about future needs in this arena and which changes should become permanent.

Multimonth Refills
Many important changes to insurance policies were implemented at the federal and state level, as well as with private payers. State responses varied, but many Medicaid, AIDS Drug Assistance Programs, and other payers authorized dispensing of 90-day supplies of ART, which previously was quite difficult. This change has been hugely appreciated by patients, and we hope support for it continues. Although 90-day refills are not appropriate for every clinical situation, the extended refill interval reduces hurdles to medication persistence and lowers the number of potential instances of late refills for many patients. An aspect that has not been discussed as thoroughly, however, is that reimbursement to pharmacies in some areas is lower for 60-day or 90-day refills vs 30-day refills; reimbursement often is based on total number of dispensing tractions per month, and contracts may reimburse pharmacies at lower rates for 60-day or 90-day refills vs 30-day refills. This difference can exacerbate financial strain on pharmacies, especially smaller community pharmacies. We would argue that policies supporting multimonth fills of PrEP or ART can aid with medication access and should be supported for situations that clinicians feel are appropriate, and reimbursement structures need modification to reduce burden on pharmacies.

Medication Delivery
Additional policy changes helped ensure that patients received their medication supply while also supporting social distancing measures and keeping people safe from SARS-CoV-2 infection. For example, some state programs and other third-party payers expanded qualifications for medication delivery by mail, rescinded requirements to obtain signatures from patients to prove receipt of medication, and created an emergency override claims processing procedure to enable patients to obtain early refills when access would be impaired due to the pandemic. All of these changes made medication delivery easier and supported access to ART and PrEP during the pandemic. However, it is unclear which changes will continue, and some are already being retracted. We find that many patients appreciate and benefit from mail-order medication services. This option can reduce hurdles to obtaining medications, such as transportation challenges or stigma concerns with visiting the pharmacy in person, but will not be a viable option for some patients (eg, those without a mailing address).

Electronic Services
Another practice modification implemented by many pharmacies, similar to most clinics, has been the expansion of electronic services, including HIPAA-compliant, secure text messaging, telephonic services, and video visits. Many pharmacy teams began offering these services for ART or PrEP counseling, adherence monitoring and support, and other communications with patients. In our experience, the breadth and scale of implementation of these virtual communications have varied widely among pharmacy practices, but overall they have made a dramatic difference toward supporting adherence. That said, not all patients have the means to access care virtually, so uptake of modalities such as video encounters has been variable. One of the most important communication methods we have found is secure SMS or text messaging, especially for younger clients. Not all pharmacy teams have been able to successfully implement this strategy, however, primarily because of difficulties in identifying methods that are HIPAA compliant. Easy to access, secure, HIPAA-compliant text messaging options would be a boon for many clinics and pharmacies.

Multidisciplinary Collaboration
We are reminded most significantly about the importance of a multidisciplinary, collaborative approach to supporting ART and PrEP initiation and adherence, as well as the importance of teamwork among the provider, pharmacist, case manager, and other clinical team members. These factors have never been so important as during the pandemic. Policy and reimbursement should focus on access to medications, particularly for those with the greatest barriers, and should support options such as multimonth fills and medication delivery by mail for situations that clinicians deem safe and appropriate.

Your Thoughts?
What other changes to prescribing and pharmacy practices have you experienced during the pandemic, and which changes do you think should become permanent? Answer the polling question and join the conversation by posting in the discussion section.