Pharmacist-Prescribed Medications to Prevent HIV: State Spotlight on Arkansas

To facilitate the successful passage of this bill, lawmakers:

Framed the bill as a practical, non-controversial way to address a health care access problem and focused on provider shortages

Engaged multiple stakeholders (e.g., physicians groups, pharmacist organizations, existing HIV care providers)

Focused on economic arguments and cost savings associated with preventing HIV infections

Limited media coverage until the bill pass

In 2023, Arkansas became the first Southern state to authorize pharmacists to prescribe medications to prevent HIV directly to patients. Arkansas had already authorized pharmacists to prescribe nicotine replacement therapy, naloxone, and oral contraceptives in past legislative sessions. Act 314 expanded the definition of “practice of pharmacy” to include initiating pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) under a statewide protocol developed by the state boards of medicine and pharmacy.

PrEP is available as a long-acting injection or a daily pill and is a highly effective medication that decreases the risk of getting HIV if exposed to the virus. PEP consists of a 28-day course of oral medications that a person can use after a known or potential exposure to HIV. PEP is intended for emergency use and must be started as soon as possible within 72 hours of the HIV exposure. For this reason, people who are at risk of repeated HIV exposure should use PrEP instead of PEP. When taken as prescribed, PrEP is up to 99 percent effective at preventing HIV infection, and PEP is more than 80 percent effective.

The 2019 “Ending the HIV Epidemic” (EHE) initiative identified Arkansas as one of seven priority states with a disproportionate number of HIV diagnoses in rural areas. Arkansas also has a significantly greater unmet need for PrEP compared to the United States as a whole. Increased PrEP use is associated with fewer HIV diagnoses and is a key EHE strategy for decreasing HIV infections by 90 percent by 2030.

There are many reasons why people who could benefit from these medications do not use them, so leveraging policy to increase the uptake of PrEP and PEP requires a comprehensive and nuanced approach. Authorizing pharmacists to prescribe these medications is one of the more straightforward policies that can expand access.

Expanding access to prescribers is especially important in Arkansas because, in 2022, more than one-third of Arkansas residents lived in an area identified as having a primary care health professional shortage. Additionally, a 2023 report found that six counties had only one full-time primary care provider. Yet only 3.84 percent of the adult population lived in a low pharmacy access area in 2022.

Policy Process

Introduced by Rep. Aaron Pilkington in November 2022, Act 314 began as HB1007 and moved through the legislature swiftly. After passing out of committee with two minor amendments, it received 95 “yeas” and zero “nays” during the House vote. Slightly more than one week later, it passed the Senate unanimously. By the end of March 2023, Gov. Sarah Huckabee Sanders had signed the bill into law.

There was minimal discussion during the floor votes and committee hearings on HB1007. Rep. Pilkington described the bill before the House floor vote on March 9, 2023, and framed it as addressing a public health and health care access issue, especially in rural areas. He also noted that other states have allowed pharmacists to prescribe PrEP and PEP and that both the Arkansas Medical Society and Pharmacists Association supported the bill. No other representatives spoke for or against the bill before the floor vote.

After passing in the House, the Senate Public Health, Welfare, and Labor Committee considered the bill. During their March 15, 2023 hearing, Rep. Pilkington once again described the bill, this time leading with the effectiveness of the medications. Focusing on the health care implications of pharmacist-prescribed HIV prevention medications, he discussed the importance of beginning PEP within 72 hours of a potential HIV exposure, implying the importance of facilitating access to the medication. Finally, Rep. Pilkington briefly discussed why the Arkansas Medical Society supported the bill. The committee members did not ask any questions after Pilkington spoke.

The final hurdle for HB1007 was the Senate floor vote on March 16, 2023. Sen. Clint Penzo spoke briefly in support of the bill before the vote.

Conclusion

Act 314’s passage shows that policies aimed at reducing HIV infections need not be controversial or divisive. Framing the messaging around a bill in ways that will resonate with most lawmakers and emphasizing the practicality of these initiatives can help potentially skeptical lawmakers understand why a policy action could help their constituents. Focusing messaging to address state-specific concerns and engaging important stakeholders early in the legislative process can also help decrease opposition from lawmakers and other interested parties. For other states considering expanding access to PrEP and PEP, especially those with similar access challenges, Arkansas’ success provides an example of how to navigate the legislative process successfully.