Senate Bill 159 Implementation California Pharmacists’ Perspectives on Opportunities and Challenges

Pharmacies are increasingly recognized for their critical role in expanding access to health care. They are well-positioned to offer expert advice and provide essential products and services in an environment that is more accessible than traditional health clinics or hospitals. As nearly 90% of Americans live within five miles  of at least one pharmacy, community pharmacies are logical venues for preventative care services, including immunizations, blood sugar monitoring, blood pressure checks, smoking cessation, HIV prevention, hormonal contraception, and more.

In California, pharmacists’ expanding role in HIV prevention was formalized through state legislation. California Senate Bill 159 (SB 159), passed in 2019, allows pharmacists in the state to prescribe HIV post-exposure prophylaxis (PEP) and 60 days of HIV pre-exposure prophylaxis (PrEP) to patients without an outside provider’s prescription. In 2021, Senate Bill 409 (SB 409) was passed. It authorizes pharmacists to conduct CLIA-waived tests, including HIV testing which is required under SB 159. By removing access barriers associated with clinic- based provision of HIV prevention, PEP and PrEP initiation by pharmacists has the potential to expand the reach of these highly effective yet underutilized HIV prevention tools. To evaluate the current status of policy adoption and implementation and understand pharmacists’ perspectives on prescribing PrEP under SB 159, we conducted a survey of California pharmacists in late 2022.

The mean age of respondents included in the analytic sample (N=919) was 39 years, and 64% were cisgender females. The majority of respondents (84%) were currently practicing licensed pharmacists; 9% were pharmacy students and 7% were non-practicing pharmacists. Just over half of respondents currently or most recently worked at pharmacies located in Los Angeles County (29%) or the San Francisco Bay Area (23%). Most respondents reported working in community pharmacies (43%), hospitals (28%), or clinic or ambulatory care settings (16%). Among those who worked in community pharmacies, 55% worked at a national chain pharmacy and 38% worked at an independent pharmacy.

Key Findings

• Only 11% of those surveyed indicated that pharmacists at their pharmacy initiate PrEP as authorized by SB 159; similarly, 13% reported providing PEP under SB 159.
• While 92% of respondents had heard of PEP and PrEP, only 72% had heard of SB 159. Even fewer respondents had heard of SB 409 (62%) which authorizes pharmacists to conduct the HIV testing required under SB 159.
• Respondents reported feeling that pharmacy-based PEP and PrEP provision is important (96%), yet significantly fewer respondents reported being confident in their knowledge of PrEP (50%) and ability to prescribe PrEP (41%).
• Less than a third of currently practicing licensed pharmacists (29%) reported receiving training on PEP and PrEP, as required to prescribe medications under SB 159.

Key Barriers

• Half of respondents (53%) classified allocating staff time for PrEP services as difficult given that only the PrEP medication is covered by insurance.
• More than a third of respondents (37%) from pharmacies that do not initiate PrEP selected inadequate staff/time to add new services as the main barrier to implementation.
• The second most cited barrier to implementation was the lack of insurance coverage for pharmacy-based PrEP services (17%).
• A significant number of respondents (42%) believed that the 60-day limit is not enough to ensure successful referral to a primary care provider for PrEP continuation.

We observed differences in the main barriers to implementation reported by those practicing in chain community pharmacies and those practicing in independent community pharmacies. For example, 53  of those at chain pharmacies selected insufficient staff/time as the main barrier to pharmacist-prescribed PrEP compared to 18% of those at independent pharmacies. Independent pharmacies more often selected lack of insurance coverage for the service (33%) and low demand among clients (24%) as the main implementation barrier. Findings were similar for PEP.

• Enact law and regulations ensuring payment for pharmacist-delivered services (e.g., eligibility assessment, consultation, required HIV testing, interpretation of test results) in addition to reimbursement for medication
• Evaluate and reconsider the 60-day limit imposed by law
• Promote and incentivize training programs for pharmacists seeking to implement SB 159
• Address knowledge gaps related to SB 409 which authorizes pharmacists to conduct CLIA-waived tests
• Develop resources pharmacists can utilize to refer patients to follow-up care as needed

Despite California’s concerted efforts to expand access to PrEP and PEP through pharmacies, implementation continues to lag, hindering efforts to prevent HIV. In our survey of more than 900 California pharmacists, we find that pharmacists believe that these HIV prevention services are important and the majority are willing to provide them. Yet respondents indicate that gaps in training and knowledge hinder the delivery of needed HIV prophylaxis. Nearly three years after permissive legislation was adopted, only 11% of survey respondents reported working in a pharmacy where PrEP is provided without an outside provider’s prescription. Pharmacists shared key implementation barriers that span various implementation domains: from problems with the law as drafted to organizational barriers related to training, payment for services, and workflows. Consistent with prior research conducted in California in 2019, 2020, and 2022, this study documents how such barriers persist. Specific findings identify key opportunities to address these challenges, including potential changes to law and implementing regulations. Greater attention must be paid to removing implementation barriers faced by pharmacists given their potential to shift the PrEP/PEP landscape and to prevent the transmission of HIV.