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

Author

Chelsea Boyd

Resident Research Fellow, Harm Reduction

Background

In 2022, 4,606 Floridians received HIV diagnoses. Historically, Florida is among the states with the highest number of new HIV diagnoses per 100,000 residents. Although HIV is not confined by geography, the majority of new HIV diagnoses in Florida occur in a few counties. A Department of Health and Human Services’ initiative, Ending the HIV Epidemic in the U.S. (EHE), which aims to reduce the number of people who get HIV by 75 percent by 2025 and by 90 percent by 2030, designated seven counties in Florida as “priority jurisdictions.” These Florida counties belong to the 48 counties, plus D.C. and Puerto Rico, where more than 50 percent of new HIV diagnoses occurred between 2016 and 2017.

In addition to focusing on priority jurisdictions, the EHE supports expanding access to medications that prevent HIV. Since 2019, an ever-increasing list of states have passed legislation that allows pharmacists to prescribe medications that prevent HIV directly to patients. These laws are intended to help decrease new HIV infections by making it less challenging to access HIV prevention medications. These medications, known as pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), can prevent a person from getting HIV if used properly.

During the 2024 legislative session, Florida State Rep. Gallop Franklin II, a pharmacist by training, introduced HB 159, which became known as the John W. Rheay Act. As filed, the bill aimed to authorize pharmacists to prescribe PrEP and PEP directly to patients by instructing the Board of Pharmacy to establish a statewide protocol that would outline the conditions and procedures pharmacists must follow to prescribe the medications. However, the bill that became law authorized pharmacists to prescribe PEP if they entered a collaborative practice agreement (CPA) with a prescribing physician. This explainer explores how the bill changed throughout the legislative process and provides key takeaways for policymakers interested in proposing similar legislation in their state.

Policy Process

Variations of HB 159 have existed in the halls of the Florida Legislature for years, but these previous versions never received hearings. There were a few factors that made HB 159 different from these attempts. First, Rep. Franklin was a natural choice to sponsor the bill because he is a pharmacist. It also helped that he has good relationships with both chambers and members of both parties. Second, the bill focused on just one aspect of expanding access to HIV prevention medications—allowing pharmacists to prescribe PrEP and PEP—rather than trying to be more comprehensive and address issues like insurance coverage and reimbursement. Third, Rep. Franklin engaged all potential stakeholders early and often in the legislative process, something that other legislators praised during multiple hearings. Fourth, Rep. Franklin’s state Senate sponsor, Sen. Alexis Calatayud, was equally engaged and committed to the bill’s success.

Although all four of these factors were important to the bill’s success, stakeholder involvement was perhaps the most important piece. One indication of how much work went into collaborating with stakeholders is that there was minimal opposition to the bill when the public was invited to comment during the many hearings. Several health care professional associations, major pharmacy chains, health care centers, and private citizens from many different demographics, including the LGBTQ+ community and former physicians, registered their support for the bill at various hearings. It was clear that each stakeholder group felt like their voice had been heard. For example, several advocates for the LGBTQ+ community and health care providers expressed a desire that this or future legislation also include PrEP; however, all of these individuals still vocally supported the version of the bill that only included PEP.

Framing was another component of HB 159’s success. Legislators and individuals giving testimony often talked about how anyone could find themselves in need of PEP. Some of the examples of people who might need to access PEP used at different hearings included victims of sexual assault or rape, health care workers or community members who are accidentally stuck by a needle, and individuals who may be exposed through a sexual encounter or intravenous drug use. This framed the bill as a way to provide better health care options and improve public health. Another point that frequently arose was the 72-hour effectiveness window for starting PEP. One representative who was skeptical of “safety net” interventions even noted that he became supportive of this bill when he heard from medical providers that they supported this bill largely because there are not enough doctors to ensure that someone could get an appointment within 72 hours to start PEP.

Additionally, the bill’s switch to facilitating pharmacist prescribing through CPAs instead of a statewide protocol emphasized the collaborative nature of modern health care. Another component of the bill requires pharmacists to develop “access-to-care” plans for patients who do not have access to primary care, further emphasizing collaborative care.

Finally, it was striking how many legislators shared personal stories of watching as loved ones battled HIV and lost their lives to AIDS. These narratives were moving, relatable, and helped break down the stigma of HIV.

Key Takeaways

Getting HB 159 through the legislature took significant effort and political savvy. It also demonstrated the importance of stakeholder involvement, bipartisanship, and compromise. Although the original version of HB 159 and the enacted version differ significantly, it is clear that the changes resulted in a bill that satisfied most stakeholders and lawmakers and will benefit Floridians.

• Take a “big tent” approach and engage all potential stakeholders early and often and be prepared to negotiate and make compromises.
• If possible, the bill sponsor should have health care experience to add credibility and have the expertise to answer specific questions about the medications and health care practice.
• Find a sponsor in the other chamber who is equally engaged and possibly from the other political party.
• Embrace incremental policy change, especially if similar; more comprehensive versions of the bill have struggled to advance through the legislative process in the past.
• Start a conversation among legislators. It is likely that some of them know someone who is living with HIV or has died from AIDS, which can help decrease stigma.

Conclusion

Getting HB 159 through the legislature took significant effort and political savvy. It also demonstrated the importance of stakeholder involvement, bipartisanship, and compromise. Although the original version of HB 159 and the enacted version differ significantly, it is clear that the changes resulted in a bill that satisfied most stakeholders and lawmakers and will benefit Floridians.