18 February 2015
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ASHM has released preliminary advice to HIV clinicians relating to changes to dispensing arrangements for HIV s100 medications which are due to come into effect on 1 July 2015.
Community Pharmacy dispensing of HIV antiretroviral therapy.
This communique is designed to update all HIV clinicians on the progress of the introduction of community pharmacy dispensing of HIV drugs. HIV s100 prescribing clinicians and hospital pharmacies currently dispensing HIV s100 medications are the most important information sources to convey changes in dispensing arrangements to patients with HIV. Any patient who approaches a community pharmacist will need to have obtained a script from a prescribing clinician. Any patient already on therapy will be currently collecting their HIV medications from one of a small number of hospital pharmacies.
Some details are yet to be finalised by the Commonwealth. But we thought it important to convey the information we have now so that you can start communicating changes to your patients. Patients getting a script now will likely be able to have their next, repeat script dispensed in the community. The introduction date is rapidly approaching.
What will this mean for clinicians?
HIV patients will be able to have their HIV s100 medications dispensed in the community from 1 July 2015. This introduces patient choice. Patients who are happy with their existing arrangements, for accessing their HIV drugs, have no need to change them. However, some patients may choose to have their HIV s100 scripts dispensed by a community pharmacy (Chemist) come July 1.
We are releasing this preliminary information now as clinicians have a range of questions and are being asked about these arrangements by patients. As we understand it:
- A hospital script which includes all of the detail required for PBS dispensing will be acceptable in the community. We will provide more information on this as soon as it becomes available. Ideally this should be on a standard PBS script, but if a hospital based clinician does not have a PBS script-pad, a hospital based script should be acceptable.
- The drugs remain s100 and community prescribers will continue to be required to undergo HIV training and maintain their prescribing rights through participating in professional development or continuing medical education.
- You will be required to include a prescriber number on the script. It is currently unclear whether this will be a new or an existing number. But it will not be an authority (s85) process and as far as we can glean you will not be required to phone through for an authority.
- Because the drugs will remain s100, they are outside the 5th National Pharmacy Agreement. In practical terms that means that pharmacists will not be required to supply the drugs within 24hours. But, provided the drugs are distributed by a wholesaler this should be achievable, using their established ordering processes. ASHM is strongly recommending that you advise patients to lodge their script with a community pharmacists one week before their current script runs out.
As soon as the Commonwealth finalises the arrangements (or provides more detail) we will be in contact again to up-date you.
What will this mean for my patients?
Introduction of the scheme will mean that patients have greater flexibility but this will also mean that patients will have greater personal responsibility. Community pharmacies are not required to keep drug in stock. S100 drugs are outside the 5th Community Pharmacy Agreement http://5cpa.com.au/about-5cpa/ between the Commonwealth and the Pharmacy Guild of Australia (PGA) covers registration and claiming and requires pharmacists to be able to access and supply unstocked items usually within 24 hours of a normal order close. It is highly unlikely that pharmacists outside of high volume HIV settings will stock ART. Pharmacists near s100 prescribers, HIV hospital services, sexual health clinics or in key community locations may stock some HIV medications or may stock more common combinations.
- Patients should not be required to pay more in the community pharmacy. Patients having co-payment costs met by a State or Territory Government or by arrangements with a local health authority should continue to have their HIV drugs dispensed by their hospital pharmacy in order to continue to access those arrangements. It is highly unlikely that those types of arrangements will transfer to community pharmacies.
- Dispensing volumes should remain as they are currently. Although some dispensing amounts may come down if patients in remote locations shift to local community dispensing arrangements rather than getting extended supply (under regulation 24) from their hospital pharmacy.
- Patients should be advised to consider where they would prefer to collect their drugs. They will be able to change this, but having a regular relationship with one pharmacy will simplify the process of ordering stock. Some pharmacies may offer to hold patients’ prescriptions and place orders when they are required. But these arrangements will vary from place to place. Community pharmacists are very familiar with ordering high cost drugs and making individual arrangements to accommodate their clients’ needs. They are also very familiar with providing adherence support and discussing side-effects. BUT this is a new set of drugs which they do not have experience with, so a number of educational initiatives are being undertaken by ASHM, the PGA, the Pharmaceutical Society of Australia (PSA) and the Society of Hospital Pharmacists Australia (SHPA), to help familiarise community pharmacists with HIV drugs, their dispensing, side-effects and toxicities.
- Any new drug added to the HIV pharmacopeia will be treated the same as the existing drugs. It will not be required to be dispensed through a hospital pharmacy for the first supply. Likewise when patients are starting treatment or moving to a new combination this will be able to be dispensed by the community pharmacy. HIV specialist services which have a dedicated HIV pharmacist may choose to continue to direct patients to this service for some or all of their prescriptions, especially if the HIV pharmacist is providing drug education to the patient as part of a care-team approach or if the patient is starting or changing therapy. But from 1 July 2015, the patient will ultimately be the one who elects where they get their prescriptions filled. Community pharmacists with high volume could become increasingly important as part of the holistic care team.
Summary of current state of the transition:
HIV medications will be able to be dispensed in the community from 1 July 2015. The Commonwealth has contracted the PSA, which represents qualified pharmacists, to coordinate a project to introduce the changes to community pharmacists. ASHM, the PGA, which represents pharmacy owners, (many of whom are also pharmacists) and the SHPA are working with the PSA on this project. People living with HIV are also represented on this group. It involves the development of written resources and a webinar which will explain the process to community pharmacists. The SHPA and ASHM are putting on three training courses for Pharmacists with an interest in HIV, one will be recorded and available on-line. Some preliminary materials will be circulated at the Australian Pharmacy Professional Conference in March and there will be an educational session run at that as well. ASHM is also encouraging community pharmacists to take up ASHM membership.
Dispensing arrangements vary across Australia:
A number of sexual health services have in-house pharmacies and some provide drugs free or at a reduced price. Some jurisdictions waive co-payments on HIV medications supplied through existing hospital arrangements. Positive Life NSW has been developing patient resources and will be getting this material out through their networks. In NSW the Expanded Medication Access scheme which has been mailing HIV ART to patients will be rolled back, though we hope a reduced service may remain. The Bobby Goldsmith Foundation, in NSW, will continue to assist people living with HIV to meet their ongoing medication costs. We are unsure of activities in all jurisdictions. If you are aware of any other initiatives in any jurisdiction, please send this information to firstname.lastname@example.org we will are creating a new website page for this. We know many people in community agencies and local health authorities are talking about the changes to dispensing, but we are all waiting to hear what the final arrangements will be.
Resources for pharmacists:
ASHM is working with the PGA on a profession based booklet and single page practical fact-sheet which will be circulated to all pharmacists. It will cover HIV basics for the community pharmacist and also be useful for hospital based pharmacists and pharmacists in training.
The SHPA “Introduction to HIV workshop” is designed to assist those pharmacists who have an interest in HIV. It will be particularly useful for pharmacists who are in high prevalence areas or close to HIV community s100 prescribers, sexual health centres or HIV services. Workshops will be held in Melbourne on 9 May, Brisbane on 23 May and in Sydney on 30 May. The program is accredited for 5 hours of Group 1 CPD and 2 hours of Group 2 CPD credits. Registration is available at http://cpd.shpa.org.au/Seminars-and-Symposiums
What can you do to help?
It is important that we identify those pharmacists who are likely to have a high number of HIV patients wanting to use their services. Can you please email email@example.com with the name of any pharmacist, their pharmacy name and any contact details you might have so that we can include them on a specific invitation list and try and encourage them to attend training and get more involved in HIV medicine. ASHM will provide all of these pharmacists with a complementary membership for the 2015-2016 membership year. We will also look to actively engage community pharmacists in any local training. We will also try and link community pharmacists with their local hospital based HIV pharmacists.
The former Minister for Health the Hon. Peter Dutton, announced on 7 July 2014 http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2013-dutton049.htm that from 1 July 2015 HIV medications would be able to be dispensed at the patients pharmacy of choice. This came after many years of advocacy with the Commonwealth from ASHM and community agencies.
A pilot of community dispensing was run in NSW in 2002 and the Pharmaceutical Benefits Advisory Committee (PBAC) recommended the change to the Department in 2013. The PBAC considered a number of options and settled on quite a radical change which would for the first time allow scripts originating from a hospital to be dispensed in the community as well as scripts from community based prescribers. The rational for this was to minimise the number of pharmacies a patient would need to visit to collect their s100 and non-s100 drugs.
While the long lead time was criticised, there has needed to be much change to quite complex systems to facilitate this access. Clozapine (an antipsychotic drug used long-term in the community) is also being moved to this new dispensing mechanism. Clozapine dosing is regulated by clozapine drug level monitoring. Clozapine, like HIV ART, had been subject to a previous community dispensing pilot and we can only assume that is why these two s100 treatments were selected to be transitioned first. We hope that hepatitis B drugs might also be transitioned to these arrangements in the not too distant future, along with some other s100s.
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