Willingness to Discuss and Screen for Pre-Exposure Prophylaxis in Pharmacies Among Men Who Have Sex With Men

Abstract

Objective:

To determine the willingness to discuss and be screened for pre-exposure prophylaxis (PrEP) in pharmacies among MSM.

Methods:

Led by Georgia’s Fulton County Board of Health, this study surveyed individuals who attended 2 Atlanta-based Gay Pride events in 2018. This analysis was limited to those who identified as men who have sex with men (MSM) who were not HIV positive and reported never using PrEP. Multivariable regression was used to determine the correlates of willingness to discuss and be screened for PrEP in-pharmacy.

Results:

Most (69%) were willing to discuss PrEP with pharmacy staff and 61.35% were willing to be screened for PrEP in-pharmacy. Those who were interested in PrEP were significantly more willing to discuss PrEP in-pharmacy compared to those not interested in PrEP (prevalence ratio [PR]: 1.65; 95% confidence interval [95% CI]: 1.11–2.48). Race was not associated with willingness to discuss PrEP with pharmacy staff. However, black MSM (BMSM) were less willing to be screened in pharmacies than white MSM, until we accounted for interest in PrEP (PR: 1.27; 95% CI: 1.09–1.48).

Discussion:

Pharmacies may be an optimal setting to expand PrEP access to reach racial minorities who have the highest need but are not being reached. Pharmacy-based PrEP discussions and screening could improve awareness of HIV status and increase PrEP knowledge and uptake. Future studies should determine optimal pharmacy conditions under which PrEP screening and uptake are acceptable for BMSM.

Introduction

Black men who have sex with men (BMSM) suffer from alarmingly high rates of HIV in the United States.^1,2 The most recent statistics indicate that BMSM are 550% more likely to be diagnosed with HIV than white MSM (WMSM).^1,2 Preexposure prophylaxis (PrEP) reduces risk of HIV infection by 92%,³ yet profound racial disparities in the uptake of PrEP persist. In 2015, among those offered PrEP, only 10% of blacks compared to 75% of whites used PrEP.^4,5

Several barriers contribute to lower PrEP uptake among racial minorities. Lower insurance rates among blacks compared to whites⁶ is an important factor. However, evidence of comparable insurance rates among BMSM and WMSM,⁷ as well as prescription payment programs that cover most or all of the costs of PrEP, do not entirely explain significant disparities in PrEP uptake.⁸ Indeed, limited access to PrEP including inconvenient locations of PrEP-prescribing physicians^9–14 and distrust of physicians and stigma that limit communication about PrEP and its side effects^10,15 are critical barriers to PrEP that must be improved to reduce racial inequities in HIV.^9,16

A growing body of literature has highlighted the ability of pharmacies to (1) improve access to health services since pharmacies are conveniently located and most Americans live within just 5 miles of a pharmacy and (2) provide a neutral, nonstigmatizing setting to obtain HIV-related services where many other health services are offered (eg, vaccinations,¹⁷ medication dispensing, blood pressure screening¹⁸) from pharmacists who are highly trusted medical professionals. Recent studies also have shown that pharmacies can effectively provide HIV prevention services and reach populations at high risk for HIV, including men who have sex with men (MSM).^19–22 For example, Amesty et al showed that pharmacy-based HIV testing effectively reached racial minorities who use drugs, particularly when they had not recently tested for HIV. Moreover, Tung et al implemented a pharmacist-led HIV PrEP clinic called “One-step PrEP” in Seattle where 251 mostly WMSM were evaluated for and initiated PrEP.²³ Importantly, only 23% of the customers who obtained PrEP had a primary care provider, highlighting how critical a pharmacy model can be for reaching populations who are disconnected from our current health-care system.

Recent studies have also provided a strong basis for implementing PrEP in pharmacies for white,^23,24 MSM^23,24 and Latinx²⁵ populations, but it remains unclear whether this is a viable strategy for BMSM, the highest HIV risk population; and a population who faces unique experiences in the health-care system and when obtaining PrEP. In order to prevent incident HIV cases and ultimately end the HIV epidemic, it is critical to engage populations who are often disconnected from HIV prevention services and reach those at the highest risk of HIV transmission—BMSM. Herein, the goal of this study is to examine the correlates of willingness to discuss PrEP with pharmacy staff and screen for PrEP in a pharmacy setting among MSM.

Methods

Fulton County Board of Health in 2018 conducted a cross-sectional, venue-based survey of individuals who attended the Black Pride pure heat festival and Gay Pride weekend events in Atlanta, Georgia. The Institutional Review Boards of the Georgia Department of Public Health and Emory University approved this study.

Recruitment and Sample

Full details of study design including participant recruitment and data collection have been described previously.²⁶ In short, researchers approached individuals who attended Atlanta Pride events and informed them about a 5-minute survey. Participants were eligible for participation if they were 18 years of age or older and could provide verbal consent for study participation. For this analysis, we further restricted the data to men who reported same-sex behavior, who had not previously used PrEP, and reported being HIV negative or unknown/never testing for HIV.

Data Collection and Survey instruments

All willing and eligible participants completed the survey questionnaire on paper or via electronic tablet. Participants could refuse to answer any question at any time throughout the survey. The survey questionnaire assessed demographics, sex and drug behaviors, HIV status, PrEP knowledge, barriers and willingness, and pharmacy PrEP utilization. Participants received a 5 dollar grocery gift card for completing the survey.

Measures

For this analysis, we assessed 2 outcomes: willingness to discuss PrEP with a pharmacist or pharmacy technician (pharmacy staff) and willingness to be screened for PrEP in a pharmacy. Available responses to both questions were yes and no.

For each outcome, we assessed the impact of various individual-level demographic, sexual and substance use risk behaviors, HIV and sexually transmitted infections, PrEP awareness and interest, and pharmacy patronizing characteristics that may have influenced each outcome. Individual-level demographic characteristics included age (continuous), race/ethnicity (Hispanic, black, white), education (high school or less, college, advanced degree), employed (yes, no), income (less than US$10 000, US$10 000–19 000, US$20 000–49 000, and greater than or equal to US$50 000), health insurance (yes, no), and past 12-month homelessness (yes, no).

Sex and substance use risk behaviors included past 6-month number of male sex partners (0, 1–5 and >5), past 6-month HIV-positive partners (yes, no), past 6-month condom use (never, sometimes, always, no sex), past 6-month anal condom use (yes, no), cocaine use (yes, no), methamphetamine use (yes, no), crack use (yes, no), heroin use (yes, no), and prescription opioid misuse (yes, no). We also combined all of the substances mentioned above to examine any drug use versus none.

HIV status was defined as those who reported being HIV positive, HIV negative, having unknown status, or having never tested for HIV. We also examined sexually transmitted infections (STIs) as having any STI (syphilis, gonorrhea, or chlamydia) in the past 6 months.

Participants were asked if they were aware of PrEP (yes, no), had ever used PrEP (yes, no), and if they were interested in using PrEP (yes, no). Finally, to understand pharmacy utilization, we asked participants how often they visited pharmacies to purchase anything. Based on the distribution of the data, pharmacy visits were categorized as frequently (weekly, monthly, quarterly), infrequently (semi-yearly and yearly), and never.

Statistical Analysis

Descriptive statistics, including medians and interquartile ranges for continuous variables and frequencies for categorical variables, were generated to characterize the sample. Wilcoxon rank tests were performed to determine whether differences in median age were significantly different for those who reported a willingness to discuss PrEP and be screened for PrEP in a pharmacy versus not Chi-square and Fisher’s exact (when sample sizes were small) tests were performed to determine significant differences between categorical variables and each outcome. Significant variables (P < .05) in the bivariate analysis were included in the final adjusted model using forward stepwise regression. Since the prevalence of each outcome was high, adjusted prevalence ratios of the relationship between each outcome and variables of interest were calculated using log-binomial regression. All data were cleaned and analyzed using SAS version 9.4.

Results

Table 1 shows the descriptive characteristics of the MSM sample who had never used PrEP and were not HIV positive (N = 259). The median age was 32 years. Most participants were black (57.14%) followed by white (33.59%) and Hispanic (9.27%). Most participants had a college degree (62.06%) or advanced degree (12.25%), were employed (89.19%), made US$20 000 per year in income or more, and had health insurance (75.89%). A small proportion experienced homelessness (10.42%) in the past 12 months. In terms of risk behaviors in the past 6 months, most participants had between 1 and 5 male sexual partners (78.88%) and 12.94% reported having at least one HIV-positive partner. Most sexually active participants used condoms during anal sex (62.50%), but inconsistent condom use was high (80.43%). Recent (past 6 months) drug use was reported by about 10% of the sample. Specifically, 5.12% of the MSM reported cocaine use, 3.53% reported methamphetamine use, 1.98% reported crack use, 1.98% reported heroin use, and 3.95 reported prescription opioid use. Only 4.71% reported having any bacterial STI (syphilis, gonorrhea or chlamydia) in the past 6 months.

Table 1.

Descriptive Characteristics and Bivariate Relationships Between Select Characteristics and Willingness to Discuss PrEP With Pharmacy Staff and Screen for PrEP in a Pharmacy Among MSM Who Had Never Taken PrEP in Atlanta, Georgia.^a

			Pharmacy-Based PrEP Discussion			Pharmacy-Based PrEP Screening
			n		%	n		%
			179		69.11	159		61.38
Sociodemographic	Distribution of Characteristics		Yes	No	P Value	Yes	No	P Value
Age (median, IQR)	31.92	(23, 38)	30.72 (23, 35)	34.07 (25, 44)	.0980	30.21 (22, 35)	34.92 (25, 43)	.0062
	n	%	%		P Value	%		P Value
Race
Black, Non-Hispanic	148	57.14	70.42		.8584	57.34		.0692
White, Non-Hispanic	87	33.59	73.81			70.24
Hispanic	24	9.27	70.83			75.00
Education
High school or less	65	25.69	66.67		.4268	62.90		.9337
College	157	62.06	75.00			63.40
Advanced degree	31	12.25	68.97			66.67
Employed
Yes	231	89.19	71.75		.8807	63.84		.6408
No	28	10.81
Income
< US$10K	43	16.80	66.67		.0133	59.52		.8714
US$10K–US$19K	38	14.84	83.33			64.86
US$20K–US$49K	98	38.28	67.02			65.96
≥US$50K	77	30.08	74.67			61.33
Health insurance
Yes	192	75.89	75.00		.0306	64.02		.7191
No	61	24.11	60.34			61.40
Homeless
Yes	27	10.42	69.57		.8203	62.50		.9279
No	232	89.58	71.81			63.44
Risk behaviors, STIs, and HIV Number of male sexual partners
0	23	9.16	61.90		.3646	66.67		.6615
1–5	198	78.88	71.35			61.98
>5	30	11.95	80.00			70.00
Number of HIV+ partners
0	222	87.06	73.83		.1150	64.49		.4426
≥1	33	12.94	60.61			57.58
Anal condom use
Yes	155	62.50	74.50		.3110	67.33		.2093
No	93	37.50
Condom use
Consistent	46	19.57	62.22		.0967	54.35		.1193
Inconsistent	189	80.43	74.59			66.67
Drug use
Cocaine	13	5.12	72.73		.2671	54.55		.2011
Methamphetamine	9	3.53	42.86		.0830	71.43		.2885
Crack	5	1.98	50.00		.2473	50.00		.3260
Heroin	5	1.98	75.00		.4202	50.00		.3271
Prescription opioid	10	3.95	77.78		.2842	55.56		.2370
Any drug	27	10.47	66.67		.5730	54.17		.3345
Any STI	12	4.71	66.67		.2660	87.50		.1131
HIV status
Negative	233	91.02	72.93		.3612	63.32		.9888
Never tested/unknown	23	8.98	63.16			63.16
Heard of PrEP
Yes	216	85.38	72.99		.2187	64.45		.4806
No	37	14.62	62.86			58.33
Interested in PrEP
Yes	148	60.16	88.66		<.0001	93.81		<.0001
No	98	39.84	61.44			43.84
Pharmacy visits
Frequently	111	42.86	71.03		.9411	60.75		.2380
Infrequently	116	44.79	71.43			68.42
Never	32	12.36	74.19			53.33

Abbreviations: IQR, interquartile range; PrEP, pre-exposure prophylaxis; STI, sexually transmitted infection.

^aN = 259.

About 85% of the sample had previously heard of PrEP and 60.16% reported having interest in PrEP. Only 12.36% never went to pharmacies, and most patronized pharmacies frequently (42.86%) or infrequently (44.79%). Over 69% of the sample was willing to discuss PrEP with pharmacy staff and 61.39% were willing to be screened for PrEP in a pharmacy.

Compared to older participants, younger participants were significantly more willing to discuss PrEP and be screened for PrEP in a pharmacy setting (Table 1). There was no relationship between willingness to discuss PrEP with pharmacy staff and race/ethnicity. However, black participants (57.34%) were borderline significantly less likely to be willing to be screened for PrEP in a pharmacy compared to white participants (70.24%) and Hispanic participants (75%). Individuals who made between US$10 000 and US$19 000 and over US$50 000 were significantly more willing to discuss PrEP with a pharmacy staff compared to those who made less than US$10 000 and between US$20 000 and US$49 000. Participants who had health insurance were more willing to discuss PrEP with pharmacy staff compared to those who did not have insurance. Almost 90% and 94% of participants who reported having interest in PrEP compared to those without an interest in PrEP were significantly willing to discuss PrEP and be screened for PrEP in a pharmacy, respectively.

There were no significant differences in willingness to discuss PrEP with pharmacy staff by age, race/ethnicity, income, or health insurance (Table 2). Compared to those without an interest in PrEP, participants who were interested in PrEP were significantly more likely (PR: 1.65; 95% confidence interval [95% CI]: 1.11–2.48) to be willing to discuss PrEP with a pharmacy staff member. The findings were similar for willingness to be screened for PrEP in a pharmacy. However, black participants were less willing (PR: 0.67; 95% CI: 0.45–1.01) to be screened for PrEP in a pharmacy compared to white participants, until interest in PrEP was accounted for. In the final adjusted model, having interest in PrEP was the only characteristic related to being willing to screen for PrEP in a pharmacy.

Table 2.

Adjusted Relationship Between Select Characteristics With Willingness to Discuss PrEP With Pharmacy Staff and Screen for PrEP.^a

	Pharmacy-Based PrEP Discussion			Pharmacy-Based PrEP Screening
	Prevalence Ratio (95% Confidence Interval)
	Model 1	Model 2	Model 3	Model 1	Model 2	Model 3
Age	1.02 (1.00–1.03)	1.02 (1.00–1.03)	1.01 (0.99–1.03)	1.02 (1.00–1.03)	1.01 (1.00–1.02)	1.00 (0.99–1.01)
Race
White, non-Hispanic	1.00	1.00	1.00	1.00	1.00	1.00
Black, non-Hispanic	0.93 (0.60–1.43)	0.91(0.59–1.41)	0.97 (0.69–1.39)	0.74 (0.51–1.08)	0.67 (0.45–1.01)	0.91 (0.78–1.06)
Hispanic	0.90 (0.44–1.84)	0.90 (0.44–1.83)	0.86 (0.46–1.59)	1.17 (0.54–2.51)	1.14 (0.53–2.47)	0.98 (0.75–1.29)
Income
<US$10K		1.00	1.00		1.00	1.00
US$10K–US$19K		2.19 (0.97–4.97)	1.59 (0.85–2.97)		1.39 (0.80–2.42)	1.11 (0.82–1.50)
US$20K–US$49K		0.98 (0.60–1.59)	0.96 (0.62–1.47)		1.30 (0.85–1.98)	1.08 (0.85–1.37)
≥US$50K		1.34 (0.77–2.35)	1.29 (0.79–2.12)		1.18 (0.77–1.81)	1.09 (0.86–1.37)
Health insurance (yes)		1.34 (0.77–2.35)	1.41 (0.98–2.04)		1.04 (0.72–1.51)	1.00 (0.84–1.20)
PrEP interest (yes)			1.65 (1.11–2.48)			1.27 (1.09–1.48)

Abbreviation: PrEP, pre-exposure prophylaxis.

^aModel 1—adjusted for age and race; model 2—adjusted for age, race, income, and health insurance; model 3—adjusted for age, race, income, health insurance, and PrEP interest.

Discussion

This study showed that being interested in starting PrEP was significantly related to willingness to discuss PrEP with pharmacy staff and willingness to be screened for PrEP in a pharmacy among MSM who had never taken PrEP and were not HIV positive. Race was also an important correlate of willingness to be screened for PrEP in a pharmacy, where BMSM were significantly less willing to be screened for PrEP in a pharmacy compared to WMSM. However, after adjusting for knowledge and interest in PrEP, race was no longer significant. It should also be noted that despite racial differences, over half of BMSM were willing to be screened for PrEP in a pharmacy, suggesting that pharmacies are a viable option for reaching BMSM and WMSM equally. This is particularly important since BMSM have the highest HIV transmission rates and previous studies have shown that race is a significant barrier to PrEP uptake.²⁷ For example, Cahill et al showed that BMSM compared to WMSM were significantly more likely to report medical mistrust, stigma related to PrEP use, and PrEP access barriers related to lack of insurance and/or transportation that make it difficult to reach a doctor.¹⁰ Pharmacies could help overcome these barriers since pharmacists are perceived as one of the most trusted professionals^28,29 in addition to pharmacies being a neutral, nonstigmatizing setting where multiple health services are obtained.^17,18 Moreover, pharmacies are an easily accessible venue for most Americans.³⁰ Over 70% of our MSM sample was willing to discuss PrEP with a pharmacy staff person—highlighting an opportunity to initiate discussions about PrEP that could increase PrEP knowledge, dispel common misconceptions about PrEP, and provide a resource for individuals who need help determining whether PrEP is appropriate for them.

Being interested in taking PrEP, however, was the most significant correlate of willingness to discuss and be screened for PrEP in a pharmacy setting. Other studies have shown a significant relationship between interest in taking PrEP and PrEP uptake.³¹ However, of those who were interested, many BMSM still did not attend an appointment to initiate PrEP, and when they did, severe delays (16 weeks) in initiation occurred.³¹ This highlights the need for PrEP screening models that can immediately link individuals to PrEP as soon as they express interest, rather than requiring them to make appointments which can be delayed due to schedules or canceled altogether as individuals’ perceived need of PrEP may change before being able to initiate PrEP. Since pharmacies provide same-day services for many primary prevention and screening services, research should test whether pharmacies can also be a same-day source for PrEP. Age, income, and health insurance were also important correlates on the bivariate level but did not remain significant in the final adjusted model.

This study has several limitations. First, given the nature of the research question to understand correlates of willingness to discuss and be screened for PrEP by pharmacy staff, we conducted a cross-sectional analysis of self-reported data. Cross-sectional data preclude us from determining temporality between the correlates and each outcome. Given that many of the correlates examined were time-invariant sociodemographic characteristics, this limitation is minimal. Due to self-report, it is possible that participants over or under-reported willingness to discuss and screen for PrEP. However, given our outcomes, willingness to discuss or be screened for PrEP in a pharmacy, we do not expect self-report bias to be differential by the correlates examined. Therefore, bias would be nondifferential and toward the null. Finally, our small, convenience sample may be a limitation as it limits generalizability and our ability to make inferences when small samples are present. It is possible that individuals who agreed to participate in our study would also be more likely to report willingness to receive PrEP in a pharmacy setting. Moreover, since we recruited at a Gay Pride event, it is possible that this convenience sample may have been more knowledgeable about PrEP and willing to take PrEP. While PrEP knowledge was not statistically significant in our study, interest in PrEP remained an important correlate. Future studies should explore this research question in a representative sample of MSM. In this study, we were able to explore multiple correlates of willingness to discuss PrEP and be screened for PrEP in a pharmacy setting. Moreover, these preliminary data can inform future, representative samples of MSM to understand pharmacy PrEP use.

Conclusion

Pharmacies can be an important part of the strategy to expand access to HIV prevention services and reduce racial inequities in HIV transmission. Since pharmacies are a neutral setting in that they offer non-HIV-related services, they are easily accessible and pharmacists have strong rapport and trust with community members, they could be a venue to overcome many of the racially stratified PrEP barriers. Future research should examine pharmacy-based PrEP screening willingness among a larger sample of MSM and test pharmacy-based PrEP delivery models that are directed toward BMSM specifically to reduce HIV.