WHAT IS ALREADY KNOWN ON THIS TOPIC

Location, sigma of sexual health clinics and lack of pre-exposure prophylaxis (PrEP) awareness limits PrEP access for key groups among whom new HIV acquisitions remain high. Previous research and the UK government suggest PrEP provision via community pharmacies as a potential way of improving PrEP access and health equity.

WHAT THIS STUDY ADDS

This is the first research study to explore the barriers to and facilitators of pharmacy PrEP delivery for pharmacists and community members in the UK. To increase capabilities and motivation, training and awareness raising is needed. To increase opportunities and motivation, environmental and system level changes are needed.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICYIntroduction

Oral pre-exposure prophylaxis (PrEP) became available free-of-charge via National Health Services (NHS) specialist sexual health clinics across England in 2020 after the Impact Trial.1 PrEP is almost 100% effective at preventing HIV acquisition when taken as prescribed.2–4 As such, PrEP use is encouraged for populations at risk of acquiring HIV and has been highlighted as integral to the UK government’s commitment to eliminate new HIV acquisitions in the UK by 2030.

To support client safety, those initiating PrEP must undergo baseline and regular follow-up screening tests for sexually transmitted infections (STIs), HIV and kidney function.5 Consequently, in the UK PrEP is currently primarily accessed via face-to-face clinic-based services.

Data exploring PrEP uptake in the UK shows most PrEP users are white gay, bisexual and other men who have sex with men (GBMSM).6–8 While PrEP use among GBMSM has decreased the number of new HIV acquisitions in the UK,7 the current PrEP delivery model could limit access for key groups among whom new HIV acquisitions remain high and PrEP use low.9 For example, in 2022, 28.4% of new HIV diagnoses were among people of black African heritage (64.1% were black African women), heterosexual men (16.8%) and women (23%). For the first time in over a decade, the number of new HIV diagnoses among heterosexuals in Scotland was higher than that among GBMSM10 and the number of women diagnosed late in England in 2022 was the highest since 2018 (n=239). These findings suggest the current model of PrEP provision may be restricting access for some communities, contributing to health inequalities.11 Individual and system-level barriers including the location of sexual health clinics, ability to access appointments and stigma of attending sexual health clinics have been suggested to inhibit PrEP initiation and continuation.12 This highlights the need to widen PrEP access to those at risk of HIV acquisition who are underserved by the current delivery model.

The UK government and previous research have pointed to PrEP provision via community pharmacies as a potential, effective way of improving access and health equity.6 13–15 Pharmacists are well-positioned to support PrEP delivery due to their accessibility, medication expertise and increasing roles in providing sexual and reproductive health services to the community.16–18 Internationally, community pharmacy PrEP delivery has been associated with improvements in both PrEP initiation and continuation.19 20 Despite this, our previous scoping review highlights barriers to community pharmacy PrEP delivery for pharmacists and pharmacy clients.21 However, most research on these barriers has been conducted in the USA, leaving the acceptability and feasibility of community pharmacy PrEP delivery in the UK unexplored. Additionally, current UK PrEP delivery is complex, dependent on multiple stakeholders and unique commissioning pathways. Consequently, a UK community pharmacy PrEP delivery model would require behaviour change at the pharmacy, client and potentially stakeholder and commissioning levels.

The Capability, Opportunity, Motivation, Behaviour (COM-B) model of behaviour change22 is widely used to explore the barriers and facilitators to healthcare change interventions. COM-B posits that a behaviour (B), for example, PrEP delivery, is influenced by an individual having (1) the capabilities (C) (physically (skills) and psychologically (knowledge)), (2) opportunity (O) (social (societal influence) and physical (environmental resources)) and (3) motivation (M) (automatic (emotion) and reflective (beliefs, intentions)). Informed by the COM-B model, we explored the perceived behavioural barriers and facilitators of community pharmacy (hereafter pharmacies) PrEP delivery for pharmacists and community members at a possible elevated risk of acquiring HIV. These findings will be used to inform the development of an intervention to pilot community pharmacy PrEP provision.

Materials and methods

Participants and sampling

Community Pharmacy Avon contacted community pharmacists with patient-facing roles, working in the Bristol, North Somerset, South Gloucestershire area to gauge interest in participating in an interview and initiate recruitment. Pharmacists were purposefully recruited in relation to working in areas of high or low HIV prevalence. Community members were recruited purposefully via adverts through social media and in community settings (eg, community centres, universities) targeting different individuals/communities at elevated risk of acquiring HIV. These subgroups included non-black African cisgender women, black African cisgender women, transgender people, young people aged 18–25 years and female street sex workers recruited via a community organisation.

All participants interested in participating were contacted with more information and invited to an interview from July 2023 to November 2023. Participants provided written/verbal informed consent and were reimbursed for their time.

Semi-structured interviews

Interviews were carried out face-to-face, via phone or online (Zoom, MS Teams) by CH. They explored participants’ awareness of HIV and PrEP, and discussed how PrEP is traditionally provided in the UK and how community pharmacy could widen PrEP provision. For example, whether community pharmacists could raise awareness of PrEP, deliver PrEP via a collaborative practice agreement with other services (eg, sexual health clinics), deliver PrEP autonomously including carrying out all the necessary screening tests or community pharmacies being a point of contact for PrEP dispensing only. Topic guides were informed by COM-B and our aim to identify the barriers/facilitators of pharmacy PrEP delivery, were adapted according to community members or pharmacist participants and reviewed by two public contributors from our target population to ensure question appropriateness (see online supplemental material 1).

Data management and analysis

Interviews were audio recorded, transcribed, imported into NVivo software and analysed using thematic analysis23 within the COM-B framework. Initially, familiarisation with the data was undertaken by listening to and reviewing each interview transcript. Then, in an iterative process, data was coded line by line, with all data relevant to each code collated. Codes were deductively allocated to the appropriate COM-B thematic framework domain, where they were deemed to fit conceptually. Community member and pharmacist transcripts were analysed separately before being triangulated to compare similarities and differences. Data was coded and aligned to the COM-B by CH and reviewed by HF. Any disagreement was resolved through discussion.

ResultsRecruitment outcome

17 interviews with community pharmacists and 24 with community members, each lasting on average 40 min, were conducted. Pharmacists were pharmacy owners (n=7), employed pharmacists (n=6) and locums (n=4). All pharmacies that participated were independent private businesses rather than belonging to a chain, The socio-demographic characteristics of the community members are presented in table 1. Age ranged from 19 to 48 years, most identified as female, were heterosexual, white or black African American and had never used PrEP.

Table 1

Socio-demographic characteristics of community members

Barriers of and facilitators to community pharmacy PrEP delivery

The barriers and facilitators identified are presented in figures 1 and 2, respectively, and the main ones synthesised narratively below according to the COM-B with illustrative quotes in table 2 (see online supplemental tables 1,2 for further illustrative quotes). Within illustrative quotations the use of […] indicates part of the quotation was not presented because it was not relevant, whereas (text) indicates additional text added for clarity. Quotes are followed by participant identifier and number.

Table 2

Illustrative quotes for some of the barriers and facilitators identified according to COM-B

Figure 1

Barriers of community pharmacy PrEP delivery identified from the interviews with pharmacists and community members presented according to COM-B. CM, community member; COM-B, Capability, Opportunity, Motivation, Behaviour; GP, General Practitioner; pharm, pharmacist; PrEP, pre-exposure prophylaxis.

Figure 2

Facilitators to community pharmacy PrEP delivery identified from the interviews with pharmacists and community members presented according to COM-B. CM, community member; COM-B, Capability, Opportunity, Motivation, Behaviour; PGD, patient group direction; pharm, pharmacist; PrEP, pre-exposure prophylaxis.

Capability barriers

Capability barriers to pharmacy PrEP delivery for community members and pharmacists included suboptimal knowledge and awareness of PrEP (ie, its purpose, beneficiaries and availability) with some community members and most pharmacists unaware of PrEP prior to the research and associating its use with GBMSM. Consequently, pharmacists felt unequipped with the necessary knowledge or training to deliver PrEP. In addition, if pharmacists were required to administer HIV point-of-care HIV tests, they would require training in sensitively communicating results.

Additional barriers among community members were a lack of knowledge about pharmacy facilities (eg, consultation rooms) and the roles, qualifications and responsibilities of pharmacists in terms of public health service provision. Community members tended to associate pharmacies with access to over-the-counter medication and/or dispensing prescriptions rather than a point of contact for consultations for different health services, including sexual health.

Capability facilitators

To facilitate PrEP delivery, community members and pharmacists highlighted the need to improve PrEP awareness and knowledge among pharmacists and the public through education, training and advertisements. For pharmacists, education and training were perceived to enhance their capability and confidence to deliver PrEP. Similarly, having previous experience of carrying out similar screening tests to those that would be required for PrEP delivery (eg, swabs, finger prick blood tests) was perceived to improve the feasibility of pharmacy PrEP delivery. For community members, particularly those from minoritised communities, knowing pharmacy PrEP delivery would be kept confidential and separate from General Practioner (GP) records was also reported to be facilitative.

Opportunity barriers

Opportunity barriers for pharmacists included lack of staff, high turnover, inability to hire more staff and the perceived added burden of PrEP delivery to workload, and lack of physical space in pharmacies. Pharmacists and community members also highlighted barriers such as having to ask for PrEP on the shop floor, and the perceived lack of privacy offered by consultation rooms due to location, size and appearance. The potential inconsistent service provision between pharmacists and pharmacies was also noted as a barrier to improving access and sustainability of pharmacy PrEP delivery. Similarly, pharmacists and community members highlighted that offering PrEP via already established sexual health services (eg, morning after pill) within pharmacies, could restrict access to communities or demographics among whom these services are mainly sought, for example, young women.

Additional barriers reported by some community members included a preference for an experienced GP or nurse, rather than a pharmacist, to carry out the screening and monitoring tests. This was particularly evident for individuals for whom having blood taken was reported to be triggering due to discomfort with needles or previous drug use. Notwithstanding this, some community members expressed a preference for digital PrEP delivery with pharmacy-based screening and monitoring because they perceived the process and results to be potentially quicker and more reliable than home testing and monitoring.

Opportunity facilitators

Opportunity facilitators for community members and pharmacists include pharmacies’ accessibility, convenience, proximity and walk-in service provision. This was particularly beneficial for community members with complex lifestyles who could not travel to sexual health clinics, individuals living in rural areas or those seeking PrEP ‘on demand’ at short notice and potentially outside of clinic opening hours. Having a pharmacy appointment for PrEP was seen as advantageous, helping to accommodate the additional service and offering convenience and privacy, avoiding the need to request PrEP publicly on the shop floor.

Although PrEP delivery via already established pharmacy sexual health services (eg, c-card, emergency contraception) was reported to restrict access for some demographics, it provides opportunities for pharmacists to raise awareness of PrEP and signpost community members to sexual health clinics. Pharmacists and community members suggested home STI and HIV test kits prior to collecting PrEP could facilitate pharmacy dispensing. However, there were differing opinions on completing tests, with some community members favouring being able to complete all tests at the pharmacy.

Pharmacist-specific facilitators included having screening and monitoring facilities, the use of Artificial Intelligence Patient Medical Record system to assist pharmacists manage and dispense prescriptions, alleviate dispensing responsibilities and free up pharmacists time and training other pharmacy team members to take on some of the pharmacist’s workload. Community member-specific facilitators included the inconvenient location of sexual health clinics and pharmacy PrEP delivery offering easier access with less bureaucracy.

Motivation barriers

Motivational barriers for pharmacists and community members included perceiving a lack of need for PrEP, personally or within the community, concern about unnecessary use by individuals not in need and the potential financial costs associated with pharmacy PrEP delivery. Personal and systemic stigma was also seen as a potential barrier particularly among sex workers, ethnic minorities and transgender communities who have previously experienced stigma in healthcare settings.

Pharmacist-specific barriers included concerns that increasing PrEP access could lead to riskier sexual behaviours and more STIs, a preference for promoting behaviour modification over PrEP use and worries that conducting screening tests could endanger their safety.

Community-specific barriers included viewing pharmacists as less qualified than sexual health consultants, GPs or nurses to provide PrEP and a preference for accessing PrEP via GP practices due to concerns of being heard initiating conversations about PrEP in pharmacies. Some individuals preferred GP practices for privacy reasons, while others emphasised the importance of being seen accessing sexual health clinics to combat stigma.

Motivation facilitators

Motivational facilitators for pharmacists and community members included a preference for autonomous pharmacy PrEP delivery over other models (eg, in collaboration with GP, sexual health clinic), believing pharmacies were acceptable places to initiate PrEP, that PrEP use reduces new HIV acquisitions, a perceived personal risk of acquiring HIV and feeling comfortable initiating conversations about PrEP. There was also a belief that accessing PrEP via pharmacies would be more discrete and less stigmatising than from sexual health clinics and potentially address medical mistrust issues among marginalised communities.

Pharmacist-specific facilitators included confidence in conducting sensitive conversations, the belief that community members should initiate conversations about PrEP rather than pharmacists opportunistically identifying people who may benefit from PrEP, anticipation of reimbursement or profit from PrEP delivery, and the potential to enhance professional reputation.

Community member-specific facilitators included being confident in pharmacists’ ability to deliver positive STI and HIV results empathically and being able to access PrEP from a pharmacy free of charge.

Discussion

This is the first research study to explore the barriers to and facilitators of pharmacy PrEP delivery for UK pharmacists and community members. The research points to the acceptability of pharmacy PrEP delivery in the UK, and demonstrates commonality with barriers and facilitators identified in other countries, particularly the USA.21 Pharmacy PrEP delivery in the UK could help overcome the current challenges of accessing PrEP via sexual health clinics (eg, location, opening hours). It could also help to minimise stigma and improve health equity for those underserved by the UK’s current model of PrEP provision.

Barriers not previously identified include insufficient knowledge and awareness of community members regarding pharmacy facilities, the services provided by pharmacists and their roles, qualifications and capabilities. These barriers have been acknowledged in relation to other pharmacy sexual and reproductive health services.24 25 However, given the new Pharmacy First initiative enabling patients to be seen by community pharmacy for minor illnesses or an urgent repeat medicine,26 and the expanding roles and increasing responsibilities of pharmacists, particularly since the COVID-19 pandemic. This lack of knowledge highlights the need for further awareness-raising about pharmacy facilities (eg, consultation room), pharmacist’s qualifications and capabilities in addition to the public health services that can be accessed from a pharmacy.

Some barriers identified may be UK-specific. For example, while pharmacists highlighted a willingness to take on more publicly-funded commissioned services, they expressed concern for capacity because of workforce shortages. They also highlighted the potential lack of consistency and subsequent accessibility of service provision between pharmacies due to not all commissioned services being mandatory for all pharmacists to be trained to deliver. This highlights and reiterates previous findings illustrating the current pressures experienced by pharmacists in the UK27 and could represent significant barriers to the feasibility and sustainability of pharmacy PrEP delivery.

In line with previous research, additional barriers evident among minoritised communities were a concern for confidentiality and stigma28 29 due to culture and/or previous negative experiences accessing healthcare. Although pharmacies were perceived to provide a more discrete less stigmatising environment than sexual health clinics, pharmacists did express unconscious bias and stigmatising attitudes, for example, reporting concern that screening for HIV could jeopardise pharmacists’ safety. Results, therefore, highlight the continued need for education and awareness campaigns to help educate healthcare professionals about HIV to reduce institutional, and societal level, stigma.25 Sexual health champions within pharmacies and the co-development of public health services with users could support the design of services that accommodate access needs and reduce stigma

Despite the barriers identified, there was a general preference among pharmacists and community members for PrEP to be delivered by community pharmacies autonomously from other health services, for example, rather than screening tests being conducted by GP practices. Although some community members and pharmacists preferred the idea of collaborative community PrEP delivery with sexual health clinics or GP practices, this preference tended to be associated with a lack of PrEP awareness, including what PrEP delivery would involve, pharmacists’ roles in service provision and the lack of pharmacy facilities to facilitate the screening and monitoring required.

Moreover, numerous solutions to the identified barriers were readily provided. For example, insufficient awareness and knowledge of PrEP in addition to associating PrEP use with different community groups was suggested to be improved by implementing education, training and advertising. Pharmacists and community members also suggested that pharmacy PrEP delivery could be more feasible if community members were able to do the necessary screening tests at home, accessing the pharmacy for the PrEP consultation/dispensing only.

Pharmacists and community members also highlighted that having an appointment system for PrEP delivery (like influenza vaccinations), could help alleviate or accommodate the addition of PrEP delivery and be facilitative for individuals from minoritised communities, by adding an extra level of privacy. Notwithstanding this, maintaining a ‘walk in’ service for PrEP was also recognised as important for improving access and upholding the pharmacy unique selling point by both pharmacists and community members.

Although pharmacy PrEP delivery is acceptable to pharmacists and community members, there are system and policy barriers that would need to be overcome to make this feasible. If pharmacists were required to conduct point-of-care HIV tests ahead of PrEP delivery, they would require training in managing results and would require close system linkage with sexual health services to manage positive results. Also, in England the distribution of PrEP via the NHS is commissioned and governed by NHS England Specialised Commissioning and currently only allowed to be provided by level 3 NHS sexual health clinics. A change of policy will be needed for community pharmacies to purchase PrEP at NHS list price or hold NHS stock otherwise it could be prohibitively expensive for pharmacies and customers. For community pharmacies to directly dispense PrEP a patient group direction would need to be agreed.

Strengths and limitations

Every effort was made to recruit a diverse sample of participants for interviews. Interviewing PrEP users provided valuable insight into their experiences of current PrEP provision and perceptions of alternative delivery models. Limitations exist in the current research. Due to chaotic lifestyle factors (eg, drug use), the interviews with sex workers were brief, limiting the identification of barriers and facilitators for this group. Findings may also vary for other commercial sex workers (eg, escorts). Further, participants were recruited from one geographical location and as purposeful sampling aimed to recruit a diverse sample, some subgroups are small. Findings should be interpreted in light of this limitation. Although our findings broadly reflect the existing evidence base in this area, future research could explore the relevance of the current findings to other community groups in need of improved PrEP access, and pharmacists working in different areas in the UK.9

Conclusion

The current research, highlights pharmacy PrEP delivery, particularly community pharmacy PrEP delivery autonomous of other services, as acceptable to pharmacists and preferred by underserved community members. Community pharmacy PrEP delivery could therefore offer an important opportunity to expand PrEP delivery and access. To be feasible, a behaviour change intervention should address barriers and leverage facilitators to support implementation. To increase capabilities and motivation, training and awareness raising for pharmacy staff and community members is needed. To increase opportunities and motivation, environmental and system changes (eg, facilities, financial reimbursement) are needed and policy barriers overcome to make this feasible.

Data availability statement

Data are available in a public, open access repository. The data underlying this article are available at data-bris.acrc.bris.ac.uk.

Ethics statementsPatient consent for publication

Not applicable.

Ethics approval

Ethical approval (12833) for the study was awarded by the University of Bristol’s Faculty of Health Sciences Research Ethics committee. Participants gave informed consent to participate in the study before taking part.